This Patient Safety Alert advises healthcare organisations on how the design of medical devices and the methods used to measure and administer oral liquid medicines can improve patient safety.
If intravenous syringes are used to measure and administer oral liquid medicines, this increases the risk of wrong route errors by connecting to intravenous or other parenteral lines.
A review of data from the Reporting and Learning System (RLS) showed 33 patient safety incidents involving intravenous administration of oral liquid medicines between 1 January 2005 and 31 May 2006.
Incorrect intravenous administration of oral liquid medicines resulted in three reported deaths between 2001 and 2004, and four reported incidents of harm or near misses between 1997 and 2004. This risk has been recognised in the Department of Health report ‘Building a safer NHS for patients: Improving medication safety’ and in other publications worldwide.
Healthcare organisations are advised to:
- review the design and supply of the oral/enteral syringes and enteral feeding systems being used, as well as the way in which they are used;
- review and make changes to organisational procedures, training and audit where necessary.