From the September 18, 2003 issue

PROBLEM: In several newsletters (January 22, March 6, March 20, 2003), we've mentioned errors related to the IV administration of sterile water for injection, and the serious patient harm that resulted from hemolysis. Most of these errors involved physicians who prescribed "free water" for patients with hypernatremia, and a generalized knowledge deficit about the hazards of IV administration of this solution. We've since learned of a few ways that bags of sterile water could wind up on patient care units, and be mistaken as IV solutions.

Hospital purchasing (materiels management) departments have sometimes provided patient care units with liter bags of sterile water. One hospital reported that their purchasing department stocks automated dispensing cabinets with plain IV solutions. Recently, a supplier mistakenly sent liter bags of sterile water for injection instead of 5% dextrose solution, which was not noticed when the cabinet was restocked. A nurse accidentally retrieved one of the sterile water bags, expecting to find 5% dextrose in the cabinet. While the sterile water bags (from Baxter) are labeled in red with a warning "For Drug Diluent Use Only," they still look quite similar to IV solution bags. The nurse hung the sterile water, but a physician quickly noticed the error when investigating the patient's complaint of discomfort at the IV site. Sterile water was also found hanging on another patient, but only a small volume had infused. Both patients were fortunate to have suffered no permanent harm. In another hospital, the purchasing department decided to provide units with liter bags of sterile water for injection because the pour bottles of sterile water were on backorder. A pharmacist noticed the bags while working on a pediatric unit and quickly removed them throughout the hospital.

Emergency malignant hyperthermia boxes found in the OR and PACU are another source of sterile water bags. Based on a recommendation from the Malignant Hyperthermia Association (MHA), these boxes are often stocked with liter bags of sterile water for use in diluting DANTRIUM IV (dantrolene). Hospitals have reported concern that any 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 if they are needed for some humidification devices used with ventilators or continuous positive airway pressure (CPAP) devices. Humidification of inspired gases helps prevent cilial damage, heat and water loss, and the encrustation of mucus, which could obstruct the airway. While there are several ways to humidify the gases, a "self-feeding" or "wet" setup may require the use of a sterile water bag, which is attached to a humidification receptacle on the ventilator or CPAP device. For example, one humidification unit made by Fisher & Paykel contains tubing that must be spiked into a water container with a traditional IV-like port. So only bags of sterile water can be used to provide the humidification (see photo in the PDF of the newsletter; additional photos at www.ismp.org). Other manufacturers (e.g., Hudson RCI) offer a "wet" humidification setup with self-contained plastic bottles of sterile water for inhalation, so bags of sterile water are not required. Another option is using heat and moisture exchangers (HMEs), which are self-contained disposable units that do not require a continuous flow of water. While HMEs have less chance of overheating, overhydrating, or causing infection, they may be inadequate for prolonged use with ICU patients, or with dry, thick secretions, hypothermia, or hyperventilation.

For "wet" setups, sterile water for inhalation is available from Baxter in 1, 2, and 3 liter bags, and from B. Braun in 250 mL, 500 mL, and 1 liter (Excel) bags. These are labeled in blue print as a "Respiratory Therapy Solution, Sterile Water for Inhalation" (see photo in the PDF of the newsletter). Unfortunately, some IV solution bags look similar with blue print labeling (B. Braun, Abbott). The sterile water bags also attach easily to IV tubing (and may be listed for purchase as "IV solutions"). One hospital recently reported that a respiratory therapist left a liter bag of sterile water for inhalation unwrapped in the patient's room as the current bag attached to the ventilator was due to run out. A nurse, responding to an IV pump's low volume alarm, replaced the empty IV bag with the sterile water bag, believing it had been left as a replacement. The patient received 500 mL before the error was noticed, but he suffered no harm. We've also seen sterile water for inhalation bags stored on respiratory supply carts, right next to IV fluids, or hanging on an IV pole so the nurse could change the bag at night.

SAFE PRACTICE RECOMMENDATION: Review the list of items that patient care units can order (or those that are automatically stocked) through purchasing to ensure that there are no pharmaceutical products (including sterile water bags) that can be provided without prior pharmacy agreement and supervision. Also develop guidelines so that purchasing staff understand which items should be considered pharmaceuticals." (For example, purchasing staff may not consider plain IV solutions or even over-the-counter medications as "pharmaceutical" products.) Set up a system to ensure that pharmacy is consulted if substitutions that may involve a pharmaceutical product are needed for backordered or discontinued items. Share reports of this error (and other related errors) with purchasing staff to increase awareness of the potential for these kinds of errors.

For emergency malignant hyperthermia boxes, some hospitals have replaced the liter sterile water bags with an adequate supply of 50 mL vials. ISMP has asked MHS to revisit their recommendation for sterile water bags in the emergency box.

Some hospitals have also reported that they use HMEs for most if not all ventilated patients because they have sufficient respiratory staff to change the units frequently (thick secretions will clog the units). If the "wet" setup is needed, consider using humidification units that do not require the use of sterile water bags. If this is not possible, establish guidelines for safe storage and handling of the sterile water for inhalation bags. Alert respiratory staff that the solution should never be left in medication rooms or patient rooms, or hung on an IV pole. Special poles that attach to the ventilator for this purpose are available from some manufacturers and should be used when possible. Store these solutions away from medication supplies. It may be helpful to use a 2 liter bag to differentiate it from more common 1 liter IV bags, and to affix auxiliary warnings to sterile water bags.

Finally, pharmacists and technicians trained in safe drug storage need to make regular rounds on patient care units (and other departments like respiratory where medications may be stored or given) to assess the storage of medications and solutions. Pharmacy oversight of drug storage can reduce the risk of an error.