Adverse Events Associated with Administration of Simulation Intravenous Fluids to Patients — United States, 2014

Details

• Journal Article:
  Morbidity and Mortality Weekly Report (MMWR)
• Personal Author:
  Robyn, Misha P. ; Hunter, Jennifer C. ; Burns, Amy ; Newman, Alexandra P. ; White, Jennifer ; Clement, Ernest J. ; Lutterloh, Emily ; Quinn, Monica ; Edens, Chris ; Epstein, Lauren ; Seiber, Kathy ; Nguyen, Duc ; Kallen, Alexander ; Blog, Debra
• Description:
  On December 23, 2014, the New York State Department of Health (NYSDOH) was notified of adverse health events in two patients who had been inadvertently administered nonsterile, simulation 0.9% sodium chloride intravenous (IV) fluids at an urgent care facility. Simulation saline is a nonsterile product not meant for human or animal use; it is intended for use by medical trainees practicing IV administration of saline on mannequins or other training devices. Both patients experienced a febrile illness during product administration and were hospitalized; one patient developed sepsis and disseminated intravascular coagulation. Neither patient died. Staff members at the clinic reported having ordered the product through their normal medical supply distributor and not recognizing during administration that it was not intended for human use.
• Subjects:
  Disseminated Intravascular Coagulation Drug Contamination Humans Injections, Intravenous Manikins Notes From The Field Patient Simulation Sepsis Sodium Chloride Solutions
• Source:
  MMWR Morbidity Mortal Weekly Rep. 2015; 64(8):226-227.
• Series:
  Weekly Report: Morbidity and Mortality Weekly Report (MMWR)
• ISSN:
  0149-2195 (print) ; 1545-861X (digital)
• Pubmed ID:
  25742384
• Pubmed Central ID:
  PMC4584720
• Document Type:
  Journal Article
• Place as Subject:
  New York ; United States
• Pages in Document:
  2 pdf pages
• Volume:
  64
• Issue:
  8
• Collection(s):
  Morbidity and Mortality Weekly Report (MMWR)
• Main Document Checksum:
  urn:sha-512:912000ab84dae0009143a29d9960a8e26f99a79211eca8fd442d8b69f94094eef7c23e7df4810fd4ff2b5dce3ddb5360e78707c726f71ed3b170dd72f72e24fb
• Download URL:
  https://stacks.cdc.gov/view/cdc/55023/cdc_55023_DS1.pdf
• File Type:
  [PDF - 149.96 KB ]