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Necrotising fasciitis following accidental injection of intraoral xylene: a preventable medication error
  1. Sudhagar Eswaran,
  2. Anupriya Ayyaswamy and
  3. Prasanna Kumar Saravanam
  1. ENT, Head and Neck Surgery, Sri Ramachandra Medical College and Research Institute, Chennai, India
  1. Correspondence to Dr Prasanna Kumar Saravanam; sprasannakumar10{at}


The most common cause of preventable mortality and morbidity to the patient in a healthcare system is medication error. Medication errors have got a significant impact on the patient health and healthcare system. These errors are multidisciplinary and can occur at various stages of drug therapy. Physicians, nursing staff, pharmacists, hospital administration all have an important role in preventing medication errors from recurring. The most common causes include wrong patient, wrong drug prescription, look-alike sound-alike drugs, faulty drug administration, wrong dosage, drug storage, delivery problem, lack of staff, patient and physician education and failure to monitor closely. This case illustrates the importance of incorporating protocol and cross-checking before administering a drug during the procedure. Here, we discuss a case of accidental intraoral injection of xylene instead of xylocaine (local anaesthetic agent), which was a sound-alike drug that resulted in significant morbidity to the patient.

  • healthcare improvement and patient safety
  • safety
  • unwanted effects / adverse reactions

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  • Contributors AA contributed for collection of details about the patient, patient consent and writing of case report. SE helped in writing the case report. PKS contributed for final checking of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.