Patient injected with acid instead of saline earns undisclosed settlement

A routine procedure at a fertility clinic in Pennsylvania turned into a life-altering medical error when a patient was accidentally injected with a corrosive acid instead of saline. 

Said to be a mistake, the incident caused severe internal and external burns, leaving a woman with permanent internal and external scarring. A malpractice lawsuit would later expose the chain of failures that led to the injury, which experts classify as a “never event”—meaning it was entirely preventable.

The Philadelphia Inquirer has the full story on the lawsuit and its aftermath, opting to hide the name of the victim for her protection. 

Breaking down the timeline of events, here is what their report shows: At one point in time, a toxic chemical, trichloroacetic acid (TCA), was delivered to the clinic for a nurse practitioner to use during very specific gynecological procedures. Despite the substance being a dangerous acid, it was not properly labeled and was simply placed in an unlocked cabinet alongside routine medical supplies—including saline, which was all that was meant to be used in this case.

Unfortunately, both are clear liquids. Even when poured into a bowl, the difference between them is not immediately obvious. 

According to facts laid out in the malpractice lawsuit, staff was not trained or informed about the presence of the acid, and it’s not clear who was in charge of ensuring it was properly stored. 

On the day of the fateful procedure, an ultrasound technician used a prefilled FemVue device that had been saved from a canceled appointment—a cost-saving practice that violated single-use guidelines. To top it off, the technician then poured liquid from a bottle she assumed was saline into a bowl, failing to pause and check the label—something she may have paused to do if it was necessary for her to fill the syringe on her own. 

Instead some of the FemVue, which did contain saline, was saved and stored as a cost-cutting measure.

The technician revealed that she only checked the label on the poured vial after the patient was in severe pain. By then, the fertility doctor had already unknowingly injected the substance multiple times into the patient, assuming it to be saline. 

Even when the patient expressed intense pain, it was initially dismissed as a normal reaction. No one double-checked to ensure the patient was safe until it was too late. 

The situation only became clear after visible burns appeared, prompting panic among staff and an emergency response. The patient was rushed to a hospital with extreme pain and serious injuries. 

All those involved emphasized after the fact that basic safety practices—proper chemical storage, labeling and verification procedures—could have prevented the incident entirely. Further, one must wonder if the clinic wasn't pinching pennies and had emptied the pre-filled syringe in preparation for a new patient, would the vial of acid have been grabbed from the shelf at all?

The medical malpractice lawsuit was settled out of court with the victim taking an undisclosed sum of cash. 

For more, read the full feature from the Philadelphia Inquirer at the link below.