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Safer Practice Notice Status Active Updated Archived Zone Application Provincial North Edmonton Central Calgary South Risk of error when using pre-filled normal saline syringes to reconstitute or dilute medications Serious medication errors have occurred in Canada and close calls in AHS because pre-filled normal saline syringes (ISMP Canada, 2012; RLS, 2013): • Have been incorrectly labeled or not labeled when used for reconstitution or dilution of medication. • Volume of normal saline and measurement markings are only approximate and therefore licensed only for flushing. Action • Do not use prefilled saline syringes to reconstitute or dilute injectable medications. • Only use syringes that are in a sealed package. Withdraw normal saline for reconstitution or dilution from a normal saline single use vial with a sterile syringe. • Prefilled normal saline syringes are only indicated for flushing catheters or lines (i.e. Peripheral IVs, Central Venous Catheters, tubes) 28 October 2013 Contact: Jane Prestie Consultant, Health Professions Strategy & Practice jane.prestie@albertahealthservices .ca ISMP Canada (2012) ALERT: Errors with Prefilled Saline Syringes When Used to Reconstitute or Dilute Medications retrieved from http://www.ismpcanada.org/download/safetyBulletins/2012/ISMPCSB201210_ALERT_Errors_with_Prefilled_Saline_Syringes.pdf This material is intended for use only by Alberta Health Services staff/Medical and Midwifery staffs. External readers should review the information in the context of their own environment to determine applicability. Alberta Health Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands or suits arising from such use. Further information about this and other Patient Safety Alerts and Safer Practice Notices can be found at: http://www.albertahealthservices.ca/patientsafety