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Topic: Medication
Publication Type: Patient Safety Advisory
Single or Multiple Incident: multiple
Date: 6/1/2008 12:00:00 AM
Country: United States of America
Organization: Pennsylvania Patient Safety Authority (USA)

"This Patient Safety Advisory discusses serious and fatal patient safety incidents that can occur with the use of sterile water for injection and sterile water for inhalation (high alert drugs). Several patient incidents are described and recommendations to reduce risk of occurrence are provided. Contributing factors to the incidents include the following: - failure among healthcare practitioners to recognize the danger of infusing plain sterile water intravenously to treat hypernatremia, - bags of sterile water for injection and inhalation are being mistaken for intravenous (IV) solutions when they are stocked on patient care units, - hospital materials management departments may inappropriately provide patient care areas with liter bags of sterile water, - emergency malignant hyperthermia boxes found in the operating room and postanesthesia care unit can be another source of sterile water bags. These boxes often are stocked with 1 L bags of sterile water to dilute dantrolene sodium for injection, used to treat malignant hyperthermia. Unused or partially used bags of the solution may find their way into IV stock or be hung as an IV solution during emergent treatment. - Respiratory therapy staff may also store or bring bags of sterile water to patient care units for humidification devices used with ventilators or continuous positive airway pressure (CPAP) devices. - sterile water for inhalation is available in 250 mL, 500 mL, 1 L, 2 L, and 3 L bags that can be used for wet setups. Some of these bags not only look similar to other IV solutions, but they can also be attached to IV tubing (and may be listed for purchase as “IV solutions”)."

Additional Details

Medication/Gas/Fluid:
"sterile water for injection, sterile water for inhalation, sodium chloride, saline, dextrose, cefazolin, potassium chloride, dantrolene sodium, sterile water for irrigation, insulin, diuretics"
Medication/IV List:
"sterile water for injection, inhalation, and irrigation (excluding pour bottles) in containers of 100 mL or more, insulin, subcutaneous and IV"


Sterile Water Should Not be Given “Freely”