Don’t Stick that in My Mouth

I’ve read this before, but judging from today’s ISMP Medication Safety Alert! it obviously bears repeating: clinicians should “never use parenteral syringes to prepare or administer small volumes of oral/enteral products.”

ISMP shares several heartbreaking accounts of how nurses or pharmacists who prepared fluids meant to be fed to patients accidentally administered them intravenously. The group says it has offered this advice in SIXTY issues yet continues to have to report such errors.

Oral syringes have been engineered with connections that cannot “be easily or securely connected to standard IV lines and cannot accommodate a needle attachment,” ISMP reports. But this safeguard has been bypassed by clinicians who use parenteral syringes to administer oral/enteral liquids.

“While some healthcare practitioners may believe this type of error would never happen to them, most events occur when knowledgeable staff, intending to administer the product orally/enterally, inadvertently administer it via the wrong route or access port, or when staff mistake the contents of a syringe-often unlabeled-as a parenteral product. Unfortunately, such errors continue to occur far too often,” ISMP reports.

For instance, a baby born to a woman who was the first person in Spain to die of H1N1 flu died itself after “an intermittent feeding prepared in a parenteral syringe was administered intravenously instead of via a nasogastric tube.”

My question to you is, what can you do—or what have you already done—to help prevent such errors? Do drug liquids meant to be distributed orally as well as enteral nutrition products need bigger, more prominent warnings not to use parenteral syringes? Do they need to be prepackaged in oral syringes or enteral fluid bags that cannot be repackaged? Or do these parenteral syringes themselves require warnings?

Given continuing fatal mistakes, your innovation assistance could be a life saver!

Daphne Allen