The Joint Commission has just visited our institution and asked about the follow best practice recommendation of eliminating 1000 ml sterile water bags outside of the pharmacy. Our Medication Safety Meeting has been addressing this issue as it relates to the Neonatal ICU use of the 1 liter bags with CPAP machines. Would appreciate any advice on how to best approach this issue as I am told there is no alternative. The notes form our Medication Safety meeting are as follows:

2016-2017 ISMP Targeted Medication Safety Best Practices for Hospitals
BEST PRACTICE 10: Eliminate all 1,000 mL bags of sterile water (labeled for “injection,” “irrigation,” or “inhalation”) from all areas outside of the pharmacy.

Respiratory Therapy stocks 1000 ml bags of sterile water from Carefusion. RT uses for neonatal CPAP.
Safety Strategies
• These bags are not carried by stores and are a direct order.
• The bags are attached to the CPAP machine and are contained in a pressure device for administration. The equipment is set up in the secured storage area preventing the bags from being stored in the NICU patient area.
• They are stored in a locked room with limited access in NICU only.
• High flow oxygen machines in for adults will be changed to 2 liter bags.
• The bags are designed to prevent attachment of a set to the bag and are labeled for respiratory administration only.

Respiratory Therapy contacted Care Fusion for alternatives to the 1000 ml bags of sterile water used for high flow in NICU (sterile water): There is no other option for a bag that can be pressurized for our Infant Flow system in NICU. The sterile water must go into a pressure bag.