Mishap due to error in labelling-word of caution!

A convenient assembly for drug dilution

“…Furthermore, the use of flush syringes for dilution may be a potential source of drug error. [ 3 4 ] In cardiac operation theatre and intensive care unit, we are using 500-mL self-collapsible NS pouches which are punctured at dedicated site of fluid withdrawal with an 18G needle attached with a 3-way adaptor [ Figure 1a ]. The 3-way adapter is turned on for aspiration after a sterile syringe is connected to it, closed before syringe disconnection and capped [ Figure 1b ].…”