Bag of unsterile saline solution that were meant to be used to train healthcare workers were used in real patients. One death, to a patient being treated in a hospice, is believed to be related to using the unsterile solution.
The bags were intended to be used in simulations at schools, but were sent to about 50 medical clinics, surgical centers, and urgent care centers around the country.
The U.S. Food and Drug Administration says that at least 40 patients were administered the fluids. Many patients have been hospitalized after developing fevers, chills, headaches, and tremors. The symptoms developed almost immediately after receiving the unsterile fluid intravenously.
Cases of patients receiving the unsterile intravenous fluids have been reported in seven states: Florida, Georgia, Idaho, Louisiana, North Carolina, New York and Colorado.
The maker of the bags of fluid, Wallcur of San Diego, recalled bags of simulated saline solution and distilled water on Jan. 7 when it learned that the products were being used incorrectly. It had started shipping the training bags last May, labeling them "for clinical simulation."
Wallcur makes and sells products to nursing schools. The bags were intended to be used on dummies or in demonstrations of how to administer intravenous fluids, not to be infused into real patients. The company does not sell products to hospitals or clinics, according to a spokesman. However, it does sell to separate distribution companies. All the misused bags of fluid were linked to shipments ordered through a distributor and not directly from Wallcur.
The U.S. Centers for Disease Control and Prevention has traced the bags of fluid to a distributor, Dr. Alexander J. Kallen, a medical officer at the CDC. It is unclear if the bags were shipped in error, or whether clinic workers used the bags without understanding that they were never to be used in patients.
There has been an extreme shortage of bags of sterile saline in hospitals nationwide for several months. It is not known if the mistaken use of the unsterile saline is linked in some way to this shortage.