Preventing Tragedies Caused by Syringe Tip Caps

PROBLEM: The tip caps on syringes pose a potential choking hazard to small children. Without proper disposal, these have been found in the bed covers or on bedside tables within reach of pediatric patients. Similar in size to a small toy piece, the caps may be ingested or aspirated if a child places it in his mouth. The cap, if not removed from the syringe before administration, may blow off into the child's mouth when the plunger is pressed.

In November 1994, the American Pharmaceutical Association (APhA) and ISMP alerted health care professionals about a similar concern with hypodermic syringe caps that are used to administer oral products. Many hypodermic syringe caps are small, translucent and inconspicuous. Further, medications can be drawn into some hypodermic syringes and administered without removing the caps. We are aware of several cases of children swallowing or choking on hypodermic syringe caps. One infant required cardiopulmonary resuscitation and intubation before the cap was removed from his airway. In Australia, a near-fatal accident occurred in 1995. An infant's mother, unaware that the syringe was fitted with a protective cap, drew the first three doses into the syringe and administered the medication without a problem. On the fourth dose, the cap came off and lodged in the infant's throat, causing asphyxiation. After considerable effort, the cap was dislodged from the infant's throat. The presence of the tip cap was not obvious because it was similar in color to the syringe body.

Oral syringe tip caps are usually colored and shaped for visibility. Most caps are extremely difficult to dislodge, yet they pull off conveniently for medication administration. For example, the oral tip cap for the EXACTA-MED ORAL DISPENSER (Baxa) has a pin that inserts into the syringe tip to create a seal. When capping the syringe, a positive action is felt or heard to ensure that the cap is secured. When we tested Baxa syringes, we found that dislodging the cap of a syringe containing soapy water was practically impossible. However, not all syringes are this safe. When we tested an over-the-counter oral syringe, EZY DOSE (Apothecary Products, Minneapolis, MN), the tip explosively dislodged with pressure. No warning about this problem is on the package label of the product.

SAFE PRACTICE RECOMMENDATION: Proper removal and disposal of syringe tip caps before drug administration is essential to prevent accidental ingestion or asphyxiation by children. While we are not aware of a child (or elderly, disabled adult) who's ingested or aspirated an oral syringe tip cap, the potential exists. Nurses should be alert to this risk and consider the proper disposal of both oral and hypodermic syringe tip caps as important as syringe and sharps disposal. Remove and properly discard syringe tip caps in a secured sharps disposal container before administering any medication. Children may have access to a cap discarded in a trash can. Likewise, when dispensing oral solutions or oral syringes in the community setting, physicians, nurses and pharmacists should alert parents and other caregivers to the potential for ingestion or asphyxiation of tip caps. Since these syringes may be used for many doses, instruct parents to remove the cap before administration and to store the recapped syringe in a child-proof location. Additionally, when dispensing and administering oral liquid products, it is critical to use specially designed and labeled oral unit dose syringes which will not accept a needle or fit into parenteral injection ports. It is unsafe to use hypodermic syringes. While many small bore feeding tubes have a parenteral (Luer) fitting that attaches only to a hypodermic syringe, at least one company (Klein-Baker; 210-696-4061) distributes a small bore feeding tube that is compatible with Baxa and Becton Dickinson oral syringes.