Acetone in the anaesthetic room - time for a change

Through its core work to review recorded patient safety events the NHSE National Patient Safety Team identified a risk involving a LASA (Look Alike Sound Alike) error involving acetone and sodium citrate.

The incident involved inadvertent ingestion of acetone instead of Sodium Citrate whilst a patient was being prepared for Caesarean birth. The error was immediately recognised, and the acetone removed from the patient’s stomach (via NG tube).

 Bottles of acetone and sodium citrate are both brown in colour and of comparable size. Acetone has traditionally been kept in anaesthetic rooms/operating theatres to remove nail varnish allowing accurate oxygen saturation monitoring.

This issue was discussed with SALG in October 2023 and whilst only one incident relating to this particular LASA error was reported it was acknowledged that potential for the error to be repeated remains, particularly in emergency situations. There was discussion around potential unintended consequences of removing acetone altogether. Although there are conflicting views, the evidence suggests that the risks to the patient of nail varnish/ gels interfering with saturation readings by pulse oximetry are outweighed in the theatre environment by the risks of inadvertent oral administration of acetone/nail varnish removal solution. In conclusion SALG has decided to recommend departments of anaesthesia should remove acetone from anaesthetic rooms.


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