Dangerous Use of Saline Flush Syringes (Feb. 2007)

The Institute for Safe Medication Practices recently alerted health professionals about the danger of using pre-filled saline flush syringes to reconstitute medications. In this process the practitioner first discards any unneeded saline from the syringe, then adds the remaining saline in the syringe to a vial of medication. The practitioner mixes the contents of the vial and draws it back into the syringe, ready to administer.

This could be an accident waiting to happen. A syringe labeled "0.9% saline flush" now contains an additional drug, perhaps even a high-alert medication, with no label. If the syringe leaves the preparer's hands before it is used, another practitioner could pick it up and use it on a patient as a saline flush, possibly with lethal consequences.

ISMP says that practitioners should understand how risky this procedure is. It recommends that medications should be dispensed in ready-to-use form whenever possible. If it is necessary to reconstitute or dilute the medication on the unit, staff should be given blank syringe labels, and these should be applied to the final product immediately.

Additional Information:

ISMP Medication Safety Alert! Safety Brief -- Is It Really Saline? November 16, 2006.
http://www.ismp.org/Newsletters/acutecare/articles/20061116_2.asp

Category:

News & Politics

Tags:

• Saline
• Flush
• Syringes
• FDA
• Patient
• Death
• Medication