Stop dangerous practices for giving oral medications
Stop dangerous practices for giving oral medications
Using the wrong type of syringe can result in tragedy
It’s something you probably do almost every day: Drawing up an oral dose of antibiotics. But in one recent case, an ED nurse used a parenteral syringe and accidentally gave the medication intravenously (IV) to an infant, causing the child to go into respiratory arrest. The baby was successfully resuscitated, but after the incident, the nurse was so upset that she resigned.1
Have you ever used a parenteral syringe to prepare doses of oral liquid medication? This practice is dangerous, warns Susan Paparella, RN, MSN, director for consulting services for the Huntingdon Valley, PA-based Institute for Safe Medication Practices (ISMP).
"We are still hearing about these errors happening," she says. "Depending on the medication, it could be very dangerous," she says. "Nobody attempts to do this on purpose. It typically happens in the midst of a very busy ED."
Nurses may prefer to use a parenteral syringe because it makes preparing and administering a dose of liquid medication easier for young children and adults, says Paparella. Unfortunately, EDs often don’t have oral syringes readily available, and many nurses are unfamiliar with this device, she adds.
"At almost every ED we visit, we ask, Are you using oral syringes?’" Paparella says. "Often, ED nurses are preparing their own antibiotics without the pharmacy support that inpatient units have. Thus, they often don’t have the devices they need."
A typical scenario is as follows: The nurse has a parenteral syringe in hand, has drawn up the oral liquid up intending to administer it orally, but is distracted, says Paparella. "The nurse may have other syringes in his or her hand, or may have a couple things to give IV and something else to give orally," she says. "The syringes aren’t labeled, and the next thing you know, they’ve pushed everything."
To ensure the safety of patients when giving oral medications, do the following:
• Use an oral syringe to measure and administer medications.
An oral syringe should be used for all oral liquid medications, says Nancy Blake, RN, MN, CCRN, CNAA, director of critical care services at Children’s Hospital Los Angeles.
"Regulatory agencies also recommend that everything drawn up for use be labeled with the drug name and the patient name wherever possible," she says. "If everything is appropriately labeled, it will eliminate the risk for medication error."
Because oral syringes don’t have Luer-lock tips, they cannot accidentally be used to administer oral medication by the intravenous route, explains Paparella. "An oral syringe will not connect to a needleless port or accept a needle, and thus this wrong route error can never happen," she says.
Because many pediatric medications are liquid doses, this is especially important to consider when administering medications to children, adds Paparella. "We just need to get nurses to understand the danger, and that we have a fix for it, and it’s pretty simple," she says. "If you don’t have any oral syringes in your ED, ask the pharmacy to get you some."
Your ED should develop a policy stating that no oral medications are to be drawn into parenteral syringes, recommends Paparella. She suggests the following wording: "Prepare oral liquid medications in unit-dose oral syringes or facility-supplied measuring devices."
• Avoid sending parents home with parenteral syringes.
"If you are dispensing the medication for a family member to give at home, they should be given an oral syringe and not a parenteral one," says Blake.
In some cases, adverse outcomes have occurred when family members were given parenteral syringes to administer oral liquid medication, which may be packaged with a small plastic syringe tip, Paparella says. "The tip is not easily visible, and especially not to nonpractitioners. So when the antibiotic is injected into the child’s mouth, they also inadvertently inject the tiny tip, which can lodge into the trachea," she says.
When a father was sent home from an ED with a parenteral syringe to administer liquid cefpodoxime to his infant son, the syringe cap accidentally was injected and became stuck in the child’s airway. The child died as a result.1
There have been several reported deaths, reports Paparella. "Obviously, we need to do everything possible to prevent similar events," she says. "Some syringe manufacturers have stopped producing syringes with the plastic tip, but not all have followed suit." She recommends doing the following:
— If parents are routinely sent home with syringes to dose medications for their children, warn them about the dangers of syringe tip shield aspiration.
— Place warnings near the location where parenteral syringes and oral liquid medications are stored, stating, "Do you use oral syringes for proper administration?"
— Work with materials management to purchase syringes without the translucent syringe caps.
At Virginia Commonwealth University Medical Center’s ED, there is a policy that no medications are dispensed home, says Susan Richards, RN, lead transport/trauma nurse for the pediatric ED. "We refer patients to their pharmacy or give them a sheet that they can take to our general pharmacy so that they can receive medications at a much discounted price," she says. "They receive at that time an oral syringe for medication administration."
Reference
- United States Pharmacopeia, Institute for Safe Medication Practices. Medication Error Reporting Program. Reports received 1971 — Present.
Sources/Resource
For more information on syringes and oral medications, contact:
- Nancy Blake, RN, MN, CCRN, CNAA, Director, Critical Care Services, Children’s Hospital Los Angeles, 4650 Sunset Blvd., Mailstop 74, Los Angeles, CA 90027. Telephone: (323) 669-2164. Fax: (323) 953-7987. E-mail: [email protected].
- Susan Paparella, RN, MSN, Director, Consulting Services, Institute for Safe Medication Practices, 1800 Byberry Road, Suite 800, Huntingdon Valley, PA 19006. E-mail: [email protected].
- Susan Richards, RN, Lead Transport/Trauma Nurse, Pediatric Emergency Department, Virginia Commonwealth University Medical Center, P.O. Box 980132, Richmond, VA 23298. Telephone: (804) 828-9111. Fax: (804) 828-0139. E-mail: [email protected].
A video on aspirated syringes can be downloaded at no charge on the FDA Patient Safety News web site (www.fda.gov/psn). Click on "View Broadcasts!" and scroll down to "Show #3, April 2002." Click on "Headline: Article on Preventing Asphyxiation from Aspirated Syringe Tip Caps."
Its something you probably do almost every day: Drawing up an oral dose of antibiotics. But in one recent case, an ED nurse used a parenteral syringe and accidentally gave the medication intravenously (IV) to an infant, causing the child to go into respiratory arrest.Subscribe Now for Access
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