Errors with prefilled saline syringes when used to reconstitute or dilute medications.

In 2006, ISMP (US) reported that prefilled saline syringes were being used for reconstitution or dilution of medications, with the medication being withdrawn from the vial back into the syringe. 1 ISMP alerted practitioners to the increased risk of medication error if syringes used in this way were not appropriately relabelled. This problem can be of particular concern if a high-alert medication is involved. One example provided in the ISMP report was dilution of an opioid in a prefilled saline syringe. Without relabelling, the syringe containing diluted opioid could be mistaken for a syringe containing saline (as labelled), an error that could have potentially fatal consequences if the contents are erroneously administered to a patient. 1