From the November 2005 issue

The mother of a 9-month-old child recently notified 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; however, despite this, she was 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, this child recovered, but we have reported similar tragic events in the November 2002 issue of this newsletter.

Although parenteral syringes are not designed for oral administration, healthcare 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. However, practitioners may not realize the cap is there or may not inform patients or caregivers of the need for its removal prior to use. 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 not removed before administration, the force of pushing the plunger can eject the cap and cause it to lodge in a child’s trachea. (See diagram)

The recently reported event demonstrates that recommendations for preventing such tragedies are Worth Repeating.

Increase awareness. Share this and previous errors with staff to illustrate why parenteral syringes should never be used for oral liquid medications. Show staff a video from FDA in cooperation with ISMP highlighting this issue (Click here for videos).

Product availability. Ensure that oral syringes (without caps) or other appropriate measuring devices are readily available for distribution or purchase at your practice site. 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, purchase syringes that are not packaged with the translucent caps to minimize the likelihood of this error.

Warning labels. Add warning labels that state, “not for use with oral liquids” to boxes or storage bins containing parenteral syringes.

Educate patients and caregivers. Provide education to patients and caregivers regarding proper use of an oral syringe (or other measuring device). Demonstrate how to measure and administer the dose and inform them about how to clean the device, if it is to be reused.

Several years ago, Becton Dickinson voluntarily elected to package parenteral syringes without the small caps in response to this serious issue. However, since some manufacturers still include a cap on parenteral syringes, the danger of asphyxiation with the cap is still present. We have again contacted FDA to alert them 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 minimum, 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.”

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