Providers Should Ensure Only Diluted Forms of Acetic Acid are Used, ISMP Warns

The Institute for Safe Medication Practices (ISMP) has issued a National Alert Network (NAN) notice (PDF) advising that health care organizations should take immediate steps to ensure that only diluted acetic acid solutions are used in patient care. ISMP advises that the use and purchase of glacial acetic acid, the most concentrated form of acetic acid available, should be eliminated. Several cases of severe burns, scarring, and other permanent damage to skin or mucous membranes due to the inadvertent application of glacial acetic acid have been reported to the National Medication Errors Reporting Program operated by ISMP. ISMP provides the following steps for preventing further such events:

• Remove glacial acetic acid, which has no use in its current form in clinical medicine, from the pharmacy and replace with vinegar (5% solution) or commercially available diluted acetic acid 0.25% (for irrigation) or 2% (for otic use).
• Restrict purchasing so that pharmacy staff is purchasing acetic acid for all procedural areas.
• Restrict choices for purchasing so that glacial acetic acid is not selected by mistake.
• Ensure the correct strength is ordered.
• Educate staff about the differences between glacial acetic acid and diluted forms of acetic acid.
• Order 5% as “vinegar,” which reduces the potential for confusion with glacial acetic acid.
• Verify the product by requiring an independent double-check of acetic acid solutions before dispensing or applying the product.

Information on the cases reported and common reasons for the cases are included in the NAN alert.