The mother of a 9-month-oldchild recently notified theInstitute for Safe MedicationPractices (ISMP) about a near-fatalexperience involving her child. Hercommunity pharmacist gave her a parenteralsyringe (without the needle) tohelp her accurately measure andadminister an oral rehydration liquidfor her daughter. Unfortunately, thepharmacist's good intention resulted inpatient harm. The mother wasunaware that the syringe tip held asmall, translucent cap; despite this,however, she was still able to withdrawthe oral liquid. Then, as she administeredthe liquid, the cap on the end ofthe syringe ejected and became lodgedin the child's throat, causing airwayobstruction. Fortunately, the childrecovered, but we reported similartragic events in the October 2002 issueof Pharmacy Times.
Although parenteral syringes are notdesigned for oral administration, healthcare practitioners may provide them topatients or caregivers to measure oralliquids without realizing how dangerousthis practice may be. Some syringemanufacturers place the small, translucentcaps on parenteral syringes packagedwithout needles as a protectivecover. Practitioners may not realize thecap is there, or may not inform patientsor caregivers of the need for itsremoval prior to use, however. Thedanger arises due to the fact that thecap does not provide a good seal.Subsequently, medications can bedrawn into many of these syringeswithout removing the caps. If they arenot removed before administration, theforce of pushing the plunger can ejectthe cap and cause it to lodge in achild's trachea (Figure).
This recently reported event demonstratesthat recommendations for preventingsuch tragedies are worthrepeating.
Increase awareness. Pharmacistsshould share this and previous errorswith their staff to illustrate why parenteralsyringes should never be usedfor oral liquid medications. They canshow a video from the FDA and ISMPhighlighting this issue; the link can beaccessed at www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show=3#6.
Ensure product availability. Pharmacistsshould ensure that oral syringes(without caps) or other appropriatemeasuring devices are readily availablefor distribution or purchase at theirpractice sites. They should verify thatthe dosage can be accurately measuredusing the oral syringe. It may benecessary to keep a few different sizeson hand to ensure proper measurementof smaller doses.
Limit access. If parenteral syringesmust be stocked for use with injectableproducts, pharmacies should purchasesyringes that are not packaged withthe translucent caps to minimize thelikelihood of this error.
Use warning labels. Pharmacy staffshould add warning labels that state"Not for use with oral liquids" to boxesor storage bins containing parenteralsyringes.
Educate patients and caregivers.Pharmacists can provide education topatients and caregivers regardingproper use of an oral syringe (or othermeasuring device). They can demonstratehow to measure and administerthe dose and inform users about howto clean the device, if it is to be reused.
Several years ago, Becton, Dickinsonand Co voluntarily elected to packageparenteral syringes without the smallcaps in response to this serious issue.Since some manufacturers still includea cap on parenteral syringes, however,the danger of asphyxiation with the capis still present.We have again contactedthe FDA to alert officals about this problem.They have stated that they will befollowing up with each syringe manufacturerwith the goal to get the syringecaps removed. At the very least, webelieve that the packaging of parenteralsyringes should be required to clearlystate "Not for oral use" or "Not for usewith oral liquids."
Dr. Gaunt is a medication safetyanalyst and the editor of ISMPMedication Safety Alert!Community/Ambulatory CareEdition.
Pharmacy Times and the Institute for SafeMedication Practices (ISMP) would like to makecommunity pharmacy practitioners aware of apublication that is available.
The ISMP Medication Safety Alert! Community/Ambulatory Care Edition is a monthly compilationof medication-related incidents, error-preventionrecommendations, news, and editorial content designedto inform and alert community pharmacypractitioners to potentially hazardous situationsthat may affect patient safety. Individual subscriptionprices are $45 per year for 12 monthlyissues. Discounts are available for organizationswith multiple pharmacy sites. This newsletter isdelivered electronically. For more information, contactISMP at 215-947-7797, or send an e-mailmessage to email@example.com.