An Eye (Drop) for an Eye, and an Ear (Drop) for an Ear

This is most certainly not a new issue but one that we continue to see rear its ugly head in the world of medication safety: While eye drops are specially formulated for safe and gentle administration into the eyes, ear drops are not, and administration of products intended for the ears into the eyes can lead to significant pain or discomfort at the least, and a visit to the emergency department at worst.

There are many culprits involved in any case of wrong route errors, but one of the usual suspects is misleading or confusing product packaging. In a recent example, a patient was prescribed carbamide peroxide to help with earwax accumulation, and the product was unintentionally administered into the patient’s eyes instead of their ears. The nurse in the case was more accustomed to this medication being dispensed in a bottle with a long tip, more suggestive for use in the ears, but instead received a different brand that was packaged in a container more like those used for eyed drops. While the bottle does state “ear drops,” the container in this cause may have led to confirmation bias blindness for the nurse (confirmation bias is the tendency to filter out, or subconsciously ignore, pertinent information that does not support an already determined belief).

In this case, some other contributing factors included the fact that the dose was scheduled to be administered at the same time as several eye drops, and the lack of a more visually prominent image of an ear on the packaging. The fact that my eye is only 4 inches away from my ear (yes, I measured) adds anatomical proximity to the list of potential causes as well.

While high-leverage tools like barcode scanning can help ensure you are administering the correct medication, we still lack strong strategies for ensuring those medications are administered via the correct route. Our best defense in these situations is relying on human factors engineering concepts to better guide practitioners towards administration via the correct route.

For example, a medication provided by the manufacturer in a prefilled syringe with attached subcutaneous needle is far less likely to be inadvertently administered intravenously than one provided in a vial that needs to be drawn out into a luer-lock syringe that can be connected to a needlefree access site. Similarly, bottles that more clearly indicate a medication should go in the ear, and not the eye, go a long way to prevent these types of mix-ups.

In the distraction-laden, complex, Rube Goldberg machine-esque world that is health care, human factors-friendly packaging with better warnings can go a long way to improving medication and patient safety.

For some other examples, and more safety recommendations, please refer to the full article: https://www.ismp.org/resources/prevent-administration-ear-drops-eyes

Reference:
Institute for Safe Medication Practices (ISMP). Prevent administration of ear drops into the eyes. ISMP Medication Safety Alert! Acute Care. 2022;27(24):1-2. https://www.ismp.org/resources/prevent-administration-ear-drops-eyes