Water, Water, Everywhere, but Please Don’t Give IV: SAFE PRACTICE RECOMMENDATION

Safe Practice Recommendation:

Here are suggestions for avoiding errors in patients with hypernatremia:

• Practitioners should be educated about the danger of infusing sterile water without appropriate additives.
• Clinicians should understand the physiology behind infusing hypotonic, isotonic, and hypertonic solutions in context of a patient’s electrolyte levels.
• Clinicians should recognize that treating severe hypernatremia generally consists of infusions that contain sodium to reduce blood levels slowly. Correcting hypernatremia too rapidly may lead to cerebral edema, seizures, and possibly death. cheap antibiotics
• Protocols should be developed to guide the safe and effective treatment of hypernatremia.
• If there are concerns about using dextrose solutions, elevated blood glucose levels can be treated with insulin.
• If fluid volume is a concern, patients can be given diuretics.
• If an order for sterile water is received, it should trigger an immediate call to the physician and a referral to the facility’s peer review process.
• In the pharmacy, IV compounding products should never be allowed to leave the sterile compounding area. These solutions should be segregated and stored with warnings that they should never leave the pharmacy.
• The pharmacy computer should flash an alert, “Use Only as a Diluent,” when these products are entered, and Sterile Water for Injection, USP should never appear as a choice in prescriber order-entry systems.
• Labels should be placed on the front of IV bags in such a way that they do not obscure important information.

Although the error cited in this article was not avoided, the use of sterile water in 2-liter (or larger) containers for IV compounding might facilitate alerting staff members as to its intended use. The difference in size also reduces the risk of confusing it with other 1-liter IV solutions. The hospital involved in this error has asked the manufacturers of Sterile Water for Injection, USP to place a warning label on both sides of the container.

The Institute for Safe Medication Practices (ISMP) has also found that the current labeling for sterile water products is inconsistent among the various manufacturers. Some containers boldly state, “Pharmacy bulk package. Not for direct infusion” within a red border; others simply state, “For drug diluent use only.”

The U.S. Pharmacopeia also requires a warning stating that these products are suitable for intravascular injection only after they are first made approximately isotonic by the addition of a suitable solute. However, this warning blends in with other label text and is not easily noticed.
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We are aware of additional cases of direct injection of sterile water and have therefore asked the Food and Drug Administration and manufacturers to place stronger, more visible warnings on all large-volume parenteral containers of this product.