Medication error can occur at any stage of prescribing, transcribing, dispensing, or administrating drugs.These drugs can have disastrous consequences more so in the field of anaesthesiology. Since a large number of lethal drugs are at the disposal of the anaesthesiologists, mastery over the drugs, knowledge of their effects – both therapeutic and adverse, and administration in the correct doses is of utmost importance.

We present a case report wherein distilled water was used instead of normal saline as irrigation fluid and lead to TURP syndrome in 70years old male.So we have to use the safety strategy advised by the US FDA like do not store these two drugs next to each other;affix name alert sticker in the storage area; clear verbal instructions to avoid confusion; working with drug companies to improve labeling and packaging ;employ independent double check in dispensing and administering; encourage reporting