Hospital acquired infections are common and increase morbidity, mortality, and length of stay.1 2 The benefit of hand washing has been highlighted,3 and studies have shown that alcohol hand rub is significantly better than soap in reducing hand contamination.4 5 6 7 In 2004, NHS trusts were advised to introduce “near patient” alcohol based hand rubs (for example, attached beside beds and at entrances to wards) by April 2005.8

With the widespread introduction of these hand rubs, risk assessments were made for the possibility of fire and ingestion. Although alcohol hand rub is flammable, no incidents involving fire have occurred. The risk of ingestion was thought possible in children and confused patients, but little advice was given on reducing this risk.8 Frequent dermal application of alcohol based hand rub has been shown not to raise blood ethanol levels.9 However, no further risk assessment has examined unintentional or intentional ingestion of alcohol rubs.

We report a case of considerable toxicity associated with the deliberate ingestion of alcohol based hand rub, together with data from our poisons unit showing an increase in inquiries related to alcohol rubs.