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Emptying injectable solutions into basins:
another fatality

Pouring injectable solutions into a basin carries the risk of contamination, and of mixing up different products. Some simple measures would help prevent potentially fatal errors.

Injectable solutions are sometimes poured into a basin before being drawn into the syringe, which speeds things up. This practice carries the risk of contamination by micro-organisms or by particles of glass from the ampoules.

It can also create confusion between colourless products, leading to accidental injections which can have serious and sometimes fatal consequences. Several cases of mix-ups resulting in death or serious disability have been described in medical literature. One fatal case was reported in the USA in 2004. A similar fatal accident occurred in France a few years ago, without provoking a public reaction on the part of the health authorities.

A few simple proposals to reduce the risk of errors: do not transfer injectable solutions to basins, demand that manufacturers make the drug available in suitable packaging, and think about the conditions and the organisation of care to prevent similar errors.

©Prescrire July 2005

Source: "Déconditionnement de liquides dans des cupules : encore un décès" Rev Prescrire 2005 ; 25 (263) : 509.

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