Pharmacists should provide appropriate devices for measuring medications and ensure that the patient or caregiver understands how to properly use the device.
Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition.
In a February 2007 Pharmacy Timesarticle, we shared a report of a9-month-old child who nearly diedafter a cap on a parenteral syringebecame lodged in her throat. In the article,a pharmacist had given the mother aparenteral syringe (without the needle)to accurately measure and administeran oral rehydration solution for herchild. The pharmacist, however, wasunaware that the manufacturer used asmall translucent cap on the syringe tipas a protective cover.
The solution was drawn up with thecap in place and, upon administration,the cap ejected into the child?s throat.Unfortunately, similar reports have previouslybeen received by the Institutefor Safe Medication Practices. To preventsimilar tragedies, we provided severalrecommendations. For example,never use parenteral syringes for oralliquids, and practice sites should stockseveral sizes of oral syringes for distributionor purchase. (For more recommendations,see this article in the March issue.) Recently, wereceived 2 more reports that furthersupport our recommendations.
In one case, a radiologist prescribedoral acetylcysteine (Mucomyst) for a69-year-old man to help prevent worseningof his renal impairment due toradiographic contrast media that wasto be administered during a diagnosticprocedure. A community pharmacistprepared each of the 4 prescribed dosesin separate parenteral syringes. Eachwas correctly labeled with the dose,route, and frequency of administration;however, the syringes were dispensedwith needles attached.
Unfortunately, neither the physiciannor pharmacist explained howthe medication was to be taken orallyafter appropriate dilution. As a result,the patient self-administered one of thedoses subcutaneously. The patient wasunharmed, and the additional doseswere administered correctly becausehis daughter read the labels and noticeda sticker on the syringes that said, "Notfor injection."
In another report, a mother shared anexperience she had after picking up anantibiotic liquid at her pharmacy for her2-year-old child. After speaking with thepharmacist about the medication, themother looked around the pharmacy fora measuring device to accurately measurethe 5-mL dose. Unable to find one,she asked a pharmacy technician if theyhad something. A pharmacist located a1-mL and a 20-mL syringe and gave herthe 20-mL syringe that was marked in1-mL increments.
When the mother later tried to administerthe medication, she discoveredthat the barrel of the syringe was toolarge to fit into the antibiotic bottle. Sheconsidered several options: (1) using adose cup provided with another product;(2) delaying the start of the antibioticuntil the next day when she couldget a new device; and (3) using a kitchenteaspoon. Fortunately, the mother wasable to figure out a way to accuratelymeasure each dose, but not all patientsor caregivers could do so.
In each of these cases, practitionersintended to assist their patients by premeasuringthe dose or providing a measuringdevice. They incorrectly assumedthat patients or caregivers, however,would know how to properly use thedevices. Therefore, in addition to providingpatients with appropriate devicesfor measuring doses, practitioners mustensure that the patient or caregiverunderstands how to properly use thedevice with the medication. This is bestaccomplished with education and a demonstrationperformed by the practitionerfollowed by a return demonstration bythe user. If this had been done in eachof these cases, the problems or hazardsencountered by the users would likelyhave been discovered and correctedbefore leaving the pharmacy.
Pharmacy Times and the Institute for Safe Medication Practices (ISMP) would like to make community pharmacy practitioners aware of a publication that is available.
The ISMP Medication Safety Alert! Community/Ambulatory Care Edition is a monthly compilation of medication-related incidents, error-prevention recommendations, news, and editorial content designed to inform and alert community pharmacy practitioners to potentially hazardous situations that may affect patient safety. Individual subscriptionprices are $48 per year for 12 monthly issues. Discounts are available for organizations with multiple pharmacy sites. This newsletter is delivered electronically. For more information, send an e.mail message to
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