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 ().
10 mL Monoject Oral Syringe Specifications
To reduce the risk of wrong-route errors, parenteral tubing should have ports that are totally incompatible with oral syringes and enteral devices should accommodate only oral syringes and catheter tip connectors.
5 mL Oral Syringes Features & Benefits
The 35 ml Oral Syringe provides better visibility and control of smaller doses, with a 10% longer stroke for additional volume compared to other brands.
5 mL Oral Syringe Specifications
Problem: ISMP has repeatedly stressed the importance of never using parenteral syringes to prepare or administer small volumes of oral/enteral products; instead, an oral syringe should always be used. Sound familiar? Over the years, this important advice has appeared in more than 60 issues of our newsletters and in countless educational presentations. Yet, we continue to visit organizations where this simple but critical safety measure is not followed.Some may believe they have sufficiently reduced the risk of administering an oral liquid medication intravenously by having pharmacy dispense doses in either an oral syringe or a commercially available unit-dose cup. Some nurses have withdrawn a portion or all of the liquid from a unit-dose cup into a parenteral syringe in order to administer the dose. As the following errors show, all patient care units and procedure areas should be supplied with oral syringes—even if the need for using them is infrequent—and all nurses need to understand the safety features of oral syringes and the importance of using them.Using parenteral syringes (one with a Luer lock that can be attached to a needleless IV system) to administer oral/enteral liquids presents a serious danger of misadministration. After filling a parenteral syringe with an oral/enteral medication, it takes a momentary mental lapse to connect it to an intravenous line and inject it.(1) To prevent this, oral syringes have specially engineered hubs that cannot be easily or securely connected to standard IV lines and cannot accommodate a needle attachment. 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. Safe Practice Recommendations: The consistent use of oral syringes for preparation and administration of all small volume oral/enteral liquids is an effective and economical risk-reduction strategy that should be employed in all healthcare settings. Table 1 summarizes key actions to ensure widespread and consistent use of oral syringes. Patients are subjected to a substantial and unjustifiable risk of harm when oral/enteral products are prepared and administered in parenteral syringes. It’s time to make the use of oral syringes a standard of practice in every healthcare organization.