Download Risk of error when using pre-filled normal saline syringes to

Safer Practice Notice
Status
Active
Updated
Archived
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

Zone Application
Provincial
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North
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Edmonton
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Central
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Calgary
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South
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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