We recently switched back to using mannitol bags in the ED as opposed to the vials.  One issue that has come up is that with the mannitol bags looking very similar to regular IV fluids, we have had some nurses continue the infusions after completed through the pump (example – bags are 100 g total, a patient receiving 80 g would have some remaining in the bag at the end of the infusion that is then continued by the RN as they mistook it for IVF).  We are working on continuous education with the nursing staff but were trying to brainstorm some other ideas to make it stand out a little better as a medication. We are considering "high risk medication" and/or "Mannitol" stickers. What are some strategies other institutions have implemented to prevent this error?

Thank you,

Lauren Gashlin