Training products not intended for actual clinical use may be used inappropriately if certain risk factors are present. In 2014 normal saline for infusion was in short supply due to issues with the plastic bags. Nonsterile solutions intended for training purposes only were inadvertently ordered and infused into patients. The bags were almost identical to normal saline bags intended for clinical use.


Risk factors for clinical use of a demonstration saline solution:

(1) no or limited warning label

(2) warning or product description written in small letters

(3) shortage or other problem in ordering the correct clinical product

(4) failure to recognize that the product was for demonstration by the person ordering the product

(5) failure to recognize as a demonstration product in central supply

(6) clinicians unfamiliar with demonstration products


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