Caustic eye drops

A patient attending for day case cataract surgery had phenol drops instilled into the right eye instead of bupivacaine local anaesthetic. Although bupivacaine is the only eye drop used in the day case centre in this type of bottle, phenol is used topically by chiropodists. The similarity of the bottles highlights the importance of reading a label before administration of a treatment. This mishap also shows the need for cross specialty risk management when different departments use the same work space. The caustic burn was treated successfully, and the patient eventually achieved good vision after uncomplicated cataract surgery.

We welcome articles of up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied on a disk. Permission is needed from the patient or a relative if an identifiable patient is referred to. We also welcome contributions for “Endpieces,” consisting of quotations of up to 80 words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.