A patient undergoing open-heart surgery was prescribed chlorhexidine gluconate oral rinse (0.12%), dispensed in a 60 mL amber bottle. A surgical skin preparation with chlorhexidine gluconate antiseptic solution (4%) also was prescribed. Spotting chlorhexidine skin preparation at the bedside, the patient's nurse thought that this bottle was the oral rinse. She instructed the patient to swish in his mouth and spit out. Another nurse later discovered the error.

The skin preparation label contains the word "antiseptic" in large letters, but the warning "For external use only" is in small print and placed at the bottom of the label, where it can be easily overlooked. The company has been asked to make the "For external use only" label warning more prominent.