Is it Really Saline?

ISMP has long been a supporter of prefilled, labeled syringes for several safety reasons: the syringes are available in typical patient-specific doses, requiring no further manipulation; the syringes do not carry the risk of cross contamination that the use of vials do; and the syringes are labeled with the drug name and dose/strength, thus avoiding the risk of an unlabeled syringe. We recently learned about an unsafe practice with using prefilled saline flushes that obviates some of these safety features, particularly the latter. Medications are being reconstituted using prefilled saline flush syringes, particularly the 5 mL or 10 mL sizes. After discarding any unneeded volume of saline, the practitioner adds the remaining saline to a vial of medication, mixes it, and then draws it back into the syringe.

Herein lies the problem: now the syringe that is labeled “0.9% saline flush” contains an additional drug. If the syringe leaves the preparer’s hands before administering the drug, it might be used by another practitioner as a saline flush. We also learned that some medications, including morphine, are being diluted using the prefilled saline flushes. In this case, the syringe labeled as a saline flush also contains a clear, high-alert medication that could be lethal if used as a saline flush. One company that makes saline flushes has widened the gradations on the syringes from tenths of mL to a full mL to discourage this practice; more precise gradations are typically needed to measure drugs accurately, while an adult flush solution does not require accuracy beyond mL gradations. Unfortunately, this at-risk behavior has persisted despite the change.

Please make sure that professional staff understand the serious risks associated with this practice, which can be even more dangerous than an unlabeled syringe. Medications should always be dispensed in the most ready-to-use form possible, especially highalert drugs such as morphine. If reconstitution or dilution must occur on the unit, staff should be supplied with blank syringe labels (not tape) that can be applied to the final product.