Oral syringes: making better use of a crucial and economical risk-reduction strategy.

PROBLEM: The Institute for Safe Medication Practices (ISMP) has repeatedly emphasized that parenteral syringes should never be used to prepare or administer oral or enteral products; instead, an oral syringe should always be used. Over the years, this advice has appeared in numerous ISMP newsletters and educational presentations. However, many organizations have still not followed this simple but critical safety measure. Using parenteral syringes—which have a Luer lock that can be attached to a needle-less intravenous (IV) system— to give oral and enteral liquids presents a serious danger of misadministration. After fi lling a parenteral syringe with an oral or an enteral medication, it takes only a momentary mental lapse to connect the syringe to an IV line and inject it.1 To prevent this misstep, oral syringes have specially engineered hubs that cannot be easily or securely connected to standard IV lines and that cannot accommodate a needle attachment. Although some health care practitioners are confi dent that they might never make this type of error, most events occur when knowledgeable staff members, intending to administer the product orally or enterally, inadvertently administer it by the wrong route or access port or when they mistake the contents of a syringe—often unlabeled—as a parenteral product. Such errors continue to occur far too often. Here are a few cases that were reported to the ISMP.