Parenteral syringe oral drug error

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Intravenous news: The FDA report “A recent report by the Institute for Safe Medication Practices says that despite past warnings, serious medical errors continue to occur when parenteral syringes are used to administer oral medications. The underlying problem is that once a parenteral syringe is filled with a liquid intended for oral use, it can be accidentally connected to an intravenous line. That’s why oral syringes should always be used for oral medications because they can’t readily be connected to an IV line and can’t accommodate a needle.

ISMP describes several cases in which oral medications were prepared in a parenteral syringe and accidentally given intravenously. In one case, a week-old infant died after an intermittent feeding was prepared in a parenteral syringe and administered intravenously instead of through a nasogastric tube. In another case, a nurse prepared yogurt in a parenteral syringe, intending to give it through an enteral tube to treat diarrhea. The patient had both an enteral and PICC line, both of them unlabled, and the nurse accidentally administered the yogurt through the PICC line.”

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More information from ISMP.


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