title: Iatrogenic phenol injury: a case report and review of medication safety and labeling practices with flexible laryngoscopy.
abstract: Medication errors can be reduced by following standards in patient identification and medication labeling. We present an investigation of a life-threatening event from medication error: A newborn that received intranasal phenol instead of topical anesthetic prior to flexible laryngoscopy. The patient required urgent intubation for respiratory distress and suffered chemical burns of the face, neck, and upper aerodigestive tract. The hospital course was prolonged and included intensive care, delayed oral feeding with enteral support, and the need for several endoscopies. Current standards of medication labeling are reviewed as well as evidence for and against using topical agents for flexible laryngoscopy.
authors.affiliation: University of Colorado School of Medicine, Department of Otolaryngology, United States; Children's Hospital Colorado, Division of Pediatric Otolaryngology, Aurora, CO, United States.
authors.forename: Valerie
authors.initials: V
authors.lastname: Cote
authors.affiliation: University of Colorado School of Medicine, Department of Otolaryngology, United States; Children's Hospital Colorado, Division of Pediatric Otolaryngology, Aurora, CO, United States. Electronic address: jeremy.prager@childrenscolorado.org.
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Prager
mesh_terms: D000281:Administration, Intranasal; D000779:Anesthetics, Local; D000891:Anti-Infective Agents, Local / Q000008:administration & dosage / Q000009:adverse effects*; D002057:Burns, Chemical / Q000150:complications / Q000209:etiology* / Q000628:therapy; D004348:Drug Labeling / Q000592:standards*; D006801:Humans; D007049:Iatrogenic Disease; D007231:Infant, Newborn; D007442:Intubation, Intratracheal; D007828:Laryngoscopy / Q000009:adverse effects*; D008297:Male; D019800:Phenol / Q000008:administration & dosage / Q000009:adverse effects*
chemical_list: D000779:Anesthetics, Local; D000891:Anti-Infective Agents, Local; D019800:Phenol
keywords: Airway burns; Flexible laryngoscopy; Medication errors; Medication labeling; Phenol; Topical anesthesia