Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition.

In a February 2007 Pharmacy Times article, we shared a report of a 9-month-old child who nearly died after a cap on a parenteral syringe became lodged in her throat. In the article, a pharmacist had given the mother a parenteral syringe (without the needle) to accurately measure and administer an oral rehydration solution for her child. The pharmacist, however, was unaware that the manufacturer used a small translucent cap on the syringe tip as a protective cover.

The solution was drawn up with the cap in place and, upon administration, the cap ejected into the child?s throat. Unfortunately, similar reports have previously been received by the Institute for Safe Medication Practices. To prevent similar tragedies, we provided several recommendations. For example, never use parenteral syringes for oral liquids, and practice sites should stock several sizes of oral syringes for distribution or purchase. (For more recommendations, see this article in the March issue.) Recently, we received 2 more reports that further support our recommendations.

In one case, a radiologist prescribed oral acetylcysteine (Mucomyst) for a 69-year-old man to help prevent worsening of his renal impairment due to radiographic contrast media that was to be administered during a diagnostic procedure. A community pharmacist prepared each of the 4 prescribed doses in separate parenteral syringes. Each was correctly labeled with the dose, route, and frequency of administration; however, the syringes were dispensed with needles attached.

Unfortunately, neither the physician nor pharmacist explained how the medication was to be taken orally after appropriate dilution. As a result, the patient self-administered one of the doses subcutaneously. The patient was unharmed, and the additional doses were administered correctly because his daughter read the labels and noticed a sticker on the syringes that said, "Not for injection."

In another report, a mother shared an experience she had after picking up an antibiotic liquid at her pharmacy for her 2-year-old child. After speaking with the pharmacist about the medication, the mother looked around the pharmacy for a measuring device to accurately measure the 5-mL dose. Unable to find one, she asked a pharmacy technician if they had something. A pharmacist located a 1-mL and a 20-mL syringe and gave her the 20-mL syringe that was marked in 1-mL increments.

When the mother later tried to administer the medication, she discovered that the barrel of the syringe was too large to fit into the antibiotic bottle. She considered several options: (1) using a dose cup provided with another product; (2) delaying the start of the antibiotic until the next day when she could get a new device; and (3) using a kitchen teaspoon. Fortunately, the mother was able to figure out a way to accurately measure each dose, but not all patients or caregivers could do so.

In each of these cases, practitioners intended to assist their patients by premeasuring the dose or providing a measuring device. They incorrectly assumed that patients or caregivers, however, would know how to properly use the devices. Therefore, in addition to providing patients with appropriate devices for measuring doses, practitioners must ensure that the patient or caregiver understands how to properly use the device with the medication. This is best accomplished with education and a demonstration performed by the practitioner followed by a return demonstration by the user. If this had been done in each of these cases, the problems or hazards encountered by the users would likely have been discovered and corrected before leaving the pharmacy.