Position and safety statements

A joint safety statement was developed in response to reported incidents of accidental injection of chlorhexidine. Typically, the accidental injections are associated with drawing up chlorhexidine from gallipots, rather than following national anaesthetic and user-applied labelling guidelines and standards.

The statement includes recommendations consistent with the National standard for user-applied labelling of injectable medicines, fluids and lines and ANZCA’s PS51 Guidelines for the Safe Management and Use of Medications in Anaesthesia, including the use of dark-tinted chlorhexidine for skin preparation is advocated, as light-tinted chlorhexidine increases the risk of errors.

Internationally, safety organisations have tried to reduce the incidence of erroneous injection through education, storage, and labelling of medicines and devices, including the National standard for user-applied labelling of injectable medicines fluids and lines.

The International Standard ISO 80369-6:2016 Small bore connectors for liquids and gases in healthcare applications – Part 6: Connectors for neuraxial applications was introduced with the aim of reducing the erroneous, harmful administration of fluids via intrathecal, epidural and other neural routes and reducing erroneous administration of substances intended for neural routes to other sites. ISO 80369-6:2016 specifies the design and dimensions of small-bore connectors for neural applications, including neural, peripheral and regional applications.

The Australian and New Zealand College of Anaesthetists (ANZCA) and the Commission have published a joint statement and guidelines with a safety checklist to support the implementation of medical devices with ISO80369-6:2016 compliant neural connectors in Australia.

Identification of neural route medicines, fluids and lines factsheet

2022

Fact sheet or brochure

The Commission recommends established metered dose inhalers are prescribed and communicated by the metered dose, even if the product is labelled with additional information on the delivered dose.

The labelling and packaging of established metered dose inhalers and other metered dose products may state the quantity of active ingredient per metered dose and the quantity of active ingredient in a delivered dose. It is recommended where both doses are described, these products are:

• Prescribed and communicated by the metered dose
• Labelled at point of dispense with metered dose. The delivered dose may also be displayed if clearly described, such as ‘each inhalation contains a metered dose of (X micrograms) which is equivalent to a delivered dose of (Y micrograms)’.

The Paediatric Prescribing Position Statement promotes best practice in prescribing, dispensing and administering of medicines for paediatric patients. This statement includes recommendations to:

• Stop, Think and Check! before prescribing and refer to evidence-based resources
• Review the appropriateness of the medicine for the child and the information required to prescribe safely
• Think about the
  • prescription information for the pharmacist to dispense, nurse and others to administer and patient to use 
  • patient and their carer’s understanding of what is being prescribed
• Check the dose is accurately described on the prescription with appropriate follow up.

Paediatric prescribing position statement

2024

Publication, report or update

This fact sheet provides guidance on the storage and management of concentrated 80% phenol in Australian clinical settings, other than podiatry.

The fact sheet includes recommendations to reduce the risk posed by concentrated 80% phenol so that:

• Concentrated 80% phenol should only be used in health service organisations for the purpose of podiatric nail surgery. 
• Appropriate arrangements should be made for storage of concentrated 80% phenol for podiatric nail surgery. For other purposes, concentrated phenol 80% should only be stored with pharmacy services where appropriate dilutions can be prepared, should they be required. 
• Concentrated phenol 80% should be removed from clinical settings, such as medical imaging, to reduce the risk of harm to patients.

Preventing harm from phenol in medical imaging

2025

Fact sheet or brochure