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Promoting safer measurement and administration of liquid medicines via oral and other enteral routes

Promoting safer measurement and administration of liquid medicines via oral and other enteral routes
Reference number
0408
Central Alert System (CAS) reference
NPSA/2007/19
Issue date28 March 2007
Action date (if applicable) (date field)30 September 2007
DH Gateway reference
7735
TypeAlert

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.
Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.
Liquid medicines - Patient Safety Alert
Liquid medicines - Patient Safety Alert - 339 KB 0408 - Liquid medicines - Patient Safety Alert - 2007-03-28 - V1
Oral and enteral syringes - Poster
Oral and enteral syringes - Poster - 119 KB 0408A - Oral and enteral syringes - Poster - V1
Promoting safer measurement and administration of oral liquid medicines - Patient Briefing
Promoting safer measurement and administration of oral liquid medicines - Patient Briefing - 151 KB 0408B - Promoting safer measurement and administration of oral liquid medicines - Patient Briefing - 2007-03-28 - V1 - CY
Promoting safer measurement and administration of oral liquid medicines - Patient Briefing
Promoting safer measurement and administration of oral liquid medicines - Patient Briefing - 157 KB 0408B - Promoting safer measurement and administration of oral liquid medicines - Patient Briefing - 2007-03-28 - V1
Liquid medicines audit template
Liquid medicines audit template - 200 KB 0408C - Liquid medicines audit template - 2007-03-28 - V1