Confusion between organ preservation solutions and IV containers

Cold storage solutions are used to preserve harvested organs prior to kidney, liver, and pancreas transplantation. Solutions like VIASPAN and SPS-1 contain extremely high amounts of potassium, and are available in plastic bags that resemble IV infusion containers (Figure 1). These solutions are used for organ perfusion, flushing, and cold storage. In 2005 (Organ storage solution. ISMP Medication Safety Alert! June 30, 2005) a pharmacist reported that a plastic liter bag of ViaSpan cold storage solution was among various products and IV bags returned for credit to the hospital pharmacy. Upon investigation, the pharmacist learned that an organ procurement team had just visited the hospital to retrieve organs. The team did not use all the ViaSpan they had brought with them. Somehow, one bag had been inadvertently placed in the pharmacy return bin because it looked so much like an IV solution bag. Last month, the California Department of Public Health heard complaints about this product and passed them on to the California Hospital Association (CHA) Patient Safety Organization (PSO). As a result, the CHA PSO sent California hospitals an alert about these solutions entering hospitals through materials management and bypassing the pharmacy. Inadvertent IV administration of the solution would almost certainly cause cardiac arrest due to the high potassium content (about 125 mEq/L). The bag contains a port that will accommodate IV tubing. We have contacted Teva, the manufacturer of ViaSpan, to ask the company to improve product safety with enhanced label warnings. The label on the bag warns that the solution is not for direct injection, and that the potassium content is high. However, the warning, printed in small black letters, is easily lost in the other information listed on the front label. We have also contacted the Association of Organ Procurement Organizations to enlist its help in getting the word out to transplant staff to never leave unused cold storage solution containers on location after organ harvest. Please alert operating room staff at your hospital of this possibility. While we are not aware of an actual incident, an error is at least possible in any hospital where organs might be retrieved. For hospitals where the products are routinely stored, be sure to sequester the solutions away from other IV solutions. Apply auxiliary warning labels to the outerwrap that reflect the potential danger of IV administration, noting that this concentrated electrolyte solution is to be used only for storage or flushing of harvested organs.