ICU Medical 0.9% Sodium Chloride Injection recalled due to potassium chloride product mix-up
One lot of ICU Medical 0.9% Sodium Chloride Injection (a salt solution) was found to contain 10 mEq Potassium Chloride Injection instead. The vial had the correct outer label but the wrong product inside. This was discovered through a customer complaint.
From the FDA notice · Read the official notice ↗ · All ICU Medical recalls
What to do
- If you work in a hospital, pharmacy, or medical facility, check your inventory for lot 1042188 (NDC 0990-7984-23, expiration 31 October 2027).
- Do not use any units from this lot. Quarantine and set them aside immediately.
- Contact ICU Medical Customer Service at 1-800-258-5361 or customerservice@icumed.com for return instructions.
- Report any adverse events to FDA MedWatch at 1-800-332-1088 or www.fda.gov/medwatch/report.htm.
Is yours affected?
Compare your label or packaging with the recalled product.
- UPC code
- 30309907984231
- Sold in
- Nationwide
- Made for
- All ages (0 months and older)
Photos from the FDA
Details
- Illnesses reported
- None reported
In the FDA's words
September 17, 2026 AUSTIN, TX – Otsuka ICU Medical LLC is issuing a voluntary recall for one lot of 0.9% SODIUM CHLORIDE Injection, USP, 100mL single pack to the user level due to a potential mix-up. The affected lot of 0.9% SODIUM CHLORIDE Injection, USP (NDC: 0990-7984-23 Lot 1042188) may potentially contain the overwrap with labeling indicating it to be 0.9% SODIUM CHLORIDE Injection, USP (NDC: 0990-7984-23) but the actual product within the overwrap may be POTASSIUM CHLORIDE Inj. 10 mEq, (NDC 0990-7074-26) Lot 1035181. The issue has been identified through a customer complaint where a 10 mEq Highly Concentrated POTASSIUM CHLORIDE Injection 100 mL bag was found inside an overwrap of 0.9% SODIUM CHLORIDE Injection, USP 100 mL.
Risk Statement: There is a reasonable probability that inadvertent injection of highly concentrated potassium chloride results in adverse events and potentially fatal outcomes. For populations most at risk, which include premature infants, patients on chronic parenteral nutrition, patients who have a history of cardiac arrhythmias, patients with chronic renal insufficiency, patients who have acute renal failure, and patients on potassium-sparing diuretics, there is a reasonable probability of adverse events such as neuromuscular dysfunction including muscle weakness, ascending paralysis, listlessness, vertigo, mental confusion, hypotension, cardiac dysrhythmias, or death from cardiac arrest. To date, Otsuka ICU Medical LLC has not received any reports of adverse events related to this recall.
Affected Product: The affected product lot was manufactured on 13 November 2025 and distributed in the United States between 30 December 2025 and 22 June 2026. An image of the overwrap and the mixed-up product is provided below. Please note that the incorrect product being overwrapped with a Sodium Chloride overwrap contains its own label and clearly indicates it to be POTASSIUM CHLORIDE Inj. 10 mEq. The affected product information is provided in Table 1 below:
Read the full announcementShow less
Table 1: Affected Product
NDC Number
List Number
Product Description
Lot Number
Expiration Date
Configuration
Label Example
0990-7984-23 07984-23 0.9% SODIUM CHLORIDE Injection, USP 1042188 31 October 2027 100 mL in flexible container See below
DESCRIPTION OF CASES BEING RECALLED:
NDC Number
Barcode Number GTIN
Lot Number
Expiration Date
Configuration
0990-7984-23 (01)30309907984231 1042188 31 October 2027 100 mL in flexible container
Otsuka ICU Medical LLC is notifying its customers, including distributors, of this recall by letter and is requesting the return of all recalled products. All customers, including distributors, should check inventory locations within their institution for the affected product in Table 1, quarantine, and discontinue use.
Upon receipt of the completed response form, ICU Medical Customer Service will contact customers to coordinate a return label and instructions for product return.
For further inquiries, please contact ICU Medical using the information provided below.
ICU Medical Contact
Contact Information
Areas of Support
Global Complaint Management 1-(866)-216-8806 or globalcomplaints@icumed.com Reporting product complaints
Drug Safety 1-844-654-7780 or
Reporting adverse events for IV Solutions & Drugs
Medical Information 1-800-241-4002, option 6 or medinfo_us@icumed.com Medical inquiries
Customer Care 1-(800)-258-5361 or customerservice@icumed.com Product credit Return instructions
Field Action Processing marketaction@mailac.custhelp.com Questions about this action and response forms
The U.S. Food and Drug Administration (FDA) has been notified of this action.
Adverse reactions or quality problems experienced with the use of this product may be reported to the FDA's MedWatch Adverse Event Reporting program either online, by regular mail or by fax.
Complete and submit the report Online: www.fda.gov/medwatch/report.htm
Regular Mail or Fax: Download form www.fda.gov/MedWatch/getforms.htm or call 1-800-332-1088 to request a reporting form, then complete and return to the address on the pre-addressed form, or submit by fax to 1-800-FDA-0178
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