key: cord-0730775-g51vf6uk
authors: Redelmeier, Donald A.; Thiruchelvam, Deva
title: Hand hygiene sprayed into eye
date: 2021-03-27
journal: IDCases
DOI: 10.1016/j.idcr.2021.e01092
sha: 41e1159fde2134572117d6367ca68e6402057302
doc_id: 730775
cord_uid: g51vf6uk

Hand hygiene is a practical, affordable, acceptable, reliable, and effective strategy to mitigate nosocomial infection risks in hospitals. Here we provide an image of clinical medicine that documents a potential error related to hand sanitizer dispenser malfunction. An awareness of this adverse event can lead to immediate modifiable changes in healthcare settings to reduce the risks of nosocomial infections.

A 45-year-old healthcare worker reached for a hand sanitizer dispenser as a routine practice to prevent nosocomial disease. Because the nozzle was partly clogged from congealed additive ingredients (Acrylate Crosspolymer, Aloe Extract), an ejected sidestream of fluid hit the right eye causing immediate pain, redness, and blurred vision [1] . Subsequent irrigation led to improved symptoms within 1 h and full resolution after 3 h. No abnormalities were found on examination the next day. Follow-up testing a week later replicated the hand sanitizer overspray (Fig. 1) .

Hand hygiene is a practical, affordable, acceptable, and reliable strategy to reduce nosocomial infection risks inside hospitals [2] . The COVID-19 pandemic has led to increased numbers of hand sanitizer dispensers in public places [3] . These are retrofitted onto existing infrastructure with typical nozzle heights 5 feet (1.5 m) above floor level. Such positioning tends to be more convenient for taller (DAR) rather than shorter (DT) persons [4] . We suggest a lower dispenser positioning might be another easily addressed form of structural bias that can be modified for less inequity in modern healthcare [5] . 

Belvedere International Inc. Product label for one step hand sanitizer Available

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The authors report no declarations of interest.