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Medication Safety: A Change in Policy

A recent report by the Institute for Safe Medication Practices says that despite past warnings, serious medical errors continue to occur when parenteral syringes are used to administer oral or enteral medications. The underlying problem is that once a parenteral syringe is filled with a liquid intended for oral use, it can be accidentally connected to an intravenous line. That':s why oral syringes should always be used for oral medications because they can':t readily be connected to an IV line and can':t accommodate a needle.

ISMP describes several cases in which oral medications were prepared in a parenteral syringe and accidentally given intravenously. In one case, a week–old infant died after an intermittent feeding was prepared in a parenteral syringe and administered intravenously instead of through a nasogastric tube. In another case, a nurse prepared yogurt in a parenteral syringe, intending to give it through an enteral tube to treat diarrhea. The patient had both an enteral and PICC line, both of them unlabeled, and the nurse accidentally administered the yogurt through the PICC line.

In still another case, Versed and Tylenol liquids were withdrawn into a parenteral syringe, to be given orally to a child being prepared for surgery. When the nurse in charge was called away, a student nurse gave the drugs intravenously. The child was unconscious for nearly an hour and required several days of antibiotics. In these cases and others, it took only a momentary mental lapse to connect a parenteral syringe containing an oral liquid to the wrong line – sometimes with fatal results.

Oral syringes: A crucial and economical risk–reduction strategy that has not been fully utilized.

Using parenteral syringes (one with a Luer lock that can be attached to a needleless IV system) to administer oral/enteral liquids presents a serious danger of misadministration.

After filling a parenteral syringe with an oral/enteral medication, it takes a momentary mental lapse to connect it to an intravenous line and inject it. To prevent this, oral syringes have specially engineered hubs that cannot be easily or securely connected to standard IV lines and cannot accommodate a needle attachment. While some healthcare practitioners may believe this type of error would never happen to them, most events occur when knowledgeable staff, intending to administer the product orally/enterally, inadvertently administer it via the wrong route or access port, or when staff mistake the contents of a syringe—often—unlabeled—as a parenteral product. Unfortunately, such errors continue to occur far too often.

Safe Practice Recommendations: The consistent use of oral syringes for preparation and administration of all small volume oral/enteral liquids is an effective and economical riskreduction strategy that should be employed in all healthcare settings. Table 1 summarizes key actions to ensure widespread and consistent use of oral syringes. Patients are subjected to a substantial and unjustifiable risk of harm when oral/enteral products are prepared and administered in parenteral syringes. It':s time to make the use of oral syringes a standard of practice in every healthcare organization.

Strategies that promote consistent use of oral syringes

  1. Assess medical equipment connectivity
    Examine ports on nasogastric, enteral .and parenteral tubing and catheters to determine which type of connectors they accommodate. Some needleless IV system connection ports unfortunately may accommodate oral syringes (with some manipulation), thereby allowing oral solutions to be injected IV. While some enteral tubes have a port compatible with parenteral syringes, others are available with a port that only accommodates oral syringes. To reduce the risk of wrong route errors, use parenteral tubing with ports that are totally incompatible with oral syringes and enteral devices that only accommodate oral syringes and catheter tip connectors.
  2. Supply all clinical areas with oral syringes
    The client's DME should be accountable for supplying the client with appropriately sized (e.g., 1 mL, 5 mL, 10 mL) oral syringes. If possible, use oral syringes that have a different appearance from parenteral syringes. Judicious use of color and design can help staff distinguish between oral/enteral and parenteral syringes.
  3. Reduce tolerance of risk
    Communicate the potential danger of inadvertent intravenous injection of oral/enteral liquids prepared in parenteral syringes. Include examples of external (and internal) errors that have happened, even if they did not reach the patient, and promote the belief that the error could happen to them. The risks of wrong route errors with oral/enteral liquids should also be identified in medication and enteral feeding policies and procedures. Our policy now contains the language that oral syringes are to be used for the administration of oral and enteral medications.
    1. Recently one of our clients had a near miss with this exact situation. The client has both a central line as well as a GT. When the parent removed the central line injection cap to change it, he discovered a colored liquid inside of the cap and the line. Fortunately, the father acted brilliantly. He used sterile saline to flush out the end of the line, removed blood from the catheter to remove any possible remaining drug, then flushed it with saline. In addition, the client was taken to the hospital where he received multiple tests to check him for any problems. Then he was placed on IV antibiotics just in case.
    2. Fortunately he did not suffer any ill affects. This could have been a devastating incident and it can happen to anyone...yes, even you. Do not be so arrogant to believe that you cannot make a mistake. It is someone who does not believe they can make mistakes that are the most dangerous. For this and many more reasons we have changed our policy.
  4. New Policy
    Our new policy will require staff to use oral syringes only when preparing and administering oral/enteral liquids. Staff are to use oral syringes to prepare and administer all small volume oral/enteral solutions, to avoid placing any non–parenteral products in parenteral (luer lock) syringes. Avoid placing topical products in oral syringes.
  5. Label all access lines
    Place labels (indicating what the port line is being used for) on all distal ports and tubing of access lines, includingperipheral and central intravenous lines and feeding tubes. An additional strategy is to place a dead–ender cap on the injection cap of the intravenous line(s). This will prevent access with any type of syringe until the cap is removed adding a check and balance to the administration of any intravenous medication. In addition, if the central line includes a clamp, the clamp should be closed when not in use.



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