The mother of a 9-month-old child recently notified the Institute for Safe Medication Practices (ISMP) about a near-fatal experience involving her child. Her community pharmacist gave her a parenteral syringe (without the needle) to help her accurately measure and administer an oral rehydration liquid for her daughter. Unfortunately, the pharmacist's good intention resulted in patient harm. The mother was unaware that the syringe tip held a small, translucent cap; despite this, however, she was still able to withdraw the oral liquid. Then, as she administered the liquid, the cap on the end of the syringe ejected and became lodged in the child's throat, causing airway obstruction. Fortunately, the child recovered, but we reported similar tragic events in the October 2002 issue of Pharmacy Times.
Although parenteral syringes are not designed for oral administration, health care practitioners may provide them to patients or caregivers to measure oral liquids without realizing how dangerous this practice may be. Some syringe manufacturers place the small, translucent caps on parenteral syringes packaged without needles as a protective cover. Practitioners may not realize the cap is there, or may not inform patients or caregivers of the need for its removal prior to use, however. The danger arises due to the fact that the cap does not provide a good seal. Subsequently, medications can be drawn into many of these syringes without removing the caps. If they are not removed before administration, the force of pushing the plunger can eject the cap and cause it to lodge in a child's trachea (Figure).
This recently reported event demonstrates that recommendations for preventing such tragedies are worth repeating.
Increase awareness. Pharmacists should share this and previous errors with their staff to illustrate why parenteral syringes should never be used for oral liquid medications. They can show a video from the FDA and ISMP highlighting this issue; the link can be accessed at www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show=3#6.
Ensure product availability. Pharmacists should ensure that oral syringes (without caps) or other appropriate measuring devices are readily available for distribution or purchase at their practice sites. They should verify that the dosage can be accurately measured using the oral syringe. It may be necessary to keep a few different sizes on hand to ensure proper measurement of smaller doses.
Limit access. If parenteral syringes must be stocked for use with injectable products, pharmacies should purchase syringes that are not packaged with the translucent caps to minimize the likelihood of this error.
Use warning labels. Pharmacy staff should add warning labels that state "Not for use with oral liquids" to boxes or storage bins containing parenteral syringes.
Educate patients and caregivers. Pharmacists can provide education to patients and caregivers regarding proper use of an oral syringe (or other measuring device). They can demonstrate how to measure and administer the dose and inform users about how to clean the device, if it is to be reused.
Several years ago, Becton, Dickinson and Co voluntarily elected to package parenteral syringes without the small caps in response to this serious issue. Since some manufacturers still include a cap on parenteral syringes, however, the danger of asphyxiation with the cap is still present.We have again contacted the FDA to alert officals about this problem. They have stated that they will be following up with each syringe manufacturer with the goal to get the syringe caps removed. At the very least, we believe that the packaging of parenteral syringes should be required to clearly state "Not for oral use" or "Not for use with oral liquids."
Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition.
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