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Up to 10 hospital patients in Oregon died from tap water injections instead of fentanyl: report
(www.businessinsider.com)
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Saline inventory is not tracked. Saline bags for use as IV fluids are scanned and tracked because they are ordered by a doctor and considered equivalent with administering a medication. But we also use those bags all the time for things that aren't tracked like priming tubing for "piggyback" administration of something that is ordered with the nearly full bag thrown away at the end, never scanned or tracked. And saline flushes aren't tracked.
There's ample supply of saline that would never be missed in the quantities that would have been used here. There is zero reasoning for using tap water instead of saline.