A warning alert has been issued on the risk of inadvertent intravenous administration of solid organ perfusion fluids.

• Patient Safety Alert – Risk of death or severe harm from inadvertent intravenous administration of solid organ perfusion fluids

Perfusion fluids are mainly used during solid organ transplantation procedures to perfuse and preserve organs. If inadvertently intravenously administered to a patient, the high potassium content of some perfusion fluid can cause cardiac arrest.

Patient safety incidents have been reported where there has been confusion between solid organ perfusion fluids and other fluids intended for administration to patients.

To prevent this risk, hospitals with transplant units are asked to ensure that storage of organ perfusion fluids is reviewed to reduce the chance of confusion with other fluids intended for administration to patients. Other hospitals are asked to remove all solid organ perfusion fluids from clinical areas.

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