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 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 unlabled, 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In still another case, Versed and Tylenol liquids were withdrawn into a parenteral syringe, to be given orally to a child being prepared for surgery.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.
ISMP points out that it is not enough to have the pharmacy dispense oral liquids in a unit–dose cup. In some cases, nurses have withdrawn the liquid from the cup into a parenteral syringe and then administered the dose intravenously.
ISMP stresses that all patient care and procedure units should be supplied with oral syringes, even if they are used infrequently, and nurses need to understand the importance of using them. They should carry an auxiliary label that prominently says, “for oral use only.”
ISMP's alert features a ten–point strategy for promoting the use of oral syringes in healthcare facilities.
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