Corneal injury secondary to silver nitrate stick mistaken for cotton bud

误将硝酸银棒当作棉签而导致角膜损伤

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Abstract

PURPOSE: This case report highlights the potential for error when removing corneal foreign bodies in a shared speciality area in Accident and Emergency (A&E). OBSERVATIONS: This case presents the accidental use of a silver nitrate stick rather than a cotton bud to remove a corneal foreign body. This resulted in a corneal injury requiring ophthalmological referral and management with topical antibiotics, topical steroids and lubricants. CONCLUSIONS: Mistaking a silver nitrate stick for a cotton bud is a tangible risk in a busy A&E and can result in significant corneal injury. Clinicians and departments can greatly reduce this risk by having separate and secure storage of similar consumables, as well as keeping consumables in original packaging and discarding of the remainder after a pack has been opened. Minimizing the risk for error will better safeguard and improve patient safety.

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