Is it really saline?

Eighty-one percent of respondents (mostly nurses) to our 2018 survey reported that they have used a prefilled 0.9% sodium chloride (saline) flush syringe to reconstitute or dilute an IV push medication, particularly the 5 mL or 10 mL flush syringes. This unsafe practice has increased since our 2014 survey, at which time 54% of practitioners said they had diluted medications using a saline flush syringe. When participants in our 2018 survey were asked to describe the process, three methods were reported, resulting most often in a saline flush syringe that also contains a medication (Table 1). Most respondents who described the process did not mention relabeling the flush syringe. Herein lies the problem: the syringe is labeled “0.9% saline flush” but contains an additional medication.

Table 1. Diluting medications using a saline flush syringe (descending order of frequency)
Description of Process 
Waste an appropriate amount of saline from the prefilled saline syringe, draw the proper amount of medication from a syringe (cartridge) or vial directly into the prefilled saline syringe, mix, and administer
Draw the dose of medication into a syringe, waste an appropriate amount of saline from the prefilled saline syringe, add the medication to the saline syringe, mix, and administer (mostly used for low volume doses to aid in measurement)
Draw the appropriate dose of medication into a syringe, add to that syringe the appropriate amount of saline diluent from the prefilled saline syringe, mix, and administer 

If the syringe leaves the preparer’s hands before being administered, it might be used by another practitioner as a saline flush. The result could be lethal if the syringe contains a high-alert medication such as an opioid, which about three-quarters of respondents admitted to diluting even when the medication was provided in manufacturer or pharmacy-prepared syringes.

Some saline flush manufacturers have widened the gradations on flush syringes to a full mL to discourage dilution since more precise gradations are needed to measure medications accurately. Others have added “For Flush Only” to the label to remind practitioners of their intended use. However, this unsafe behavior has persisted.

Please educate staff about the serious risks associated with this practice and that dilution of medications provided in a ready-to-administer form is unnecessary.