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NAN issues medication safety alert

January 24, 2013

The National Alert Network yesterday issued an alert urging health care providers to ensure that only diluted acetic acid solutions are used in patient care. The alert describes cases where "glacial" acetic acid was accidentally applied to skin or mucous membranes instead of a more diluted form, according to the Institute for Safe Medication Practices' National Medication Errors Reporting Program. To prevent medication errors, the alert recommends that providers remove glacial acetic acid from the pharmacy, discard it safely and replace it with vinegar (5% solution) or specific concentrations of diluted acetic acid. The alert also recommends additional steps to ensure that the correct strength of acetic acid is ordered and dispensed. NAN is a coalition of members from the National Coordinating Council for Medication Error Reporting and Prevention that distributes medication safety alerts in cooperation with ISMP and the American Society of Health-System Pharmacists.