Medication errors
Michael R. Cohen ScD, MS, RPH

June 2011 
Volume 41  Number 6
Pages 14 - 14
  PDF Version Available!

In response to a shortage of concentrated sodium chloride (NaCl) 14.6% and 23.4% vials, Ameridose, an outsource I.V. compounding company, is marketing concentrated NaCl in a minibag (other companies may also provide this product). The Institute for Safe Medication Practices (ISMP) warns that despite warnings on the product labeling that the solution must be diluted for I.V. administration and must not be given by direct infusion, practitioners could easily overlook the warnings or confuse the minibag with other drugs intended for direct infusion. For example, placed face down on a counter, the minibag containing concentrated NaCl is virtually indistinguishable from other similar-looking minibags.Concentrated NaCl is a hypertonic solution. Inadvertently infusing it without dilution can cause hypernatremia and serious complications such as fluid volume overload and pulmonary edema.Packaging concentrated electrolyte solutions in vials would be safer, but outsourcing companies are unlikely

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