Avoiding inadvertent IV injection of oral liquids - page 2

From ISMP Aug 23rd,2012 safety newsletter: Avoiding inadvertent IV injection of oral liquids... Read More

  1. 8
    Another issue with this is that the nurse administered medications that the patient refused. That's a big no no in my book. Patients have the right to refuse.
    Sadala, elkpark, nrsang97, and 5 others like this.

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  2. 2
    Yes, so much wrong with that article! Or rather, the individual who did that. I really have no words, other than to say it's a little insulting that the supreme idiocy of one person should reflect so badly on the 99% of us who KNOW that you don't do that.
    nrsang97 and psu_213 like this.
  3. 0
    Quote from Mulan
    quote." In our March 12, 1997, issue we wrote about a nurse who administered oral medications intravenously to an 86-year-old patient. The nurse crushed and mixed together PAXIL (PARoxetine), potassium chloride solution, and a multivitamin tablet, and then administered the medications intravenously, after the patient refused the oral medications. The patient died 30 minutes later. " quote
    Avoiding inadvertent IV injection of oral liquids

    I can't believe anybody would be that stupid!
    Seriously! What an idiot!
  4. 2
    This is unbelievable. I attempted to write something else about this but deleted it five times. What can you possibly say about it?
    nrsang97 and Altra like this.
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    I've been fighting this for a while at my job. We have a lot of NJ tubes. That the adapters are a luer lock connection. Which our oral syringes don't fit. To use an oral syringe, you have to have oral syringe hooked to an adapter, hooked to another adapter, which goes into NJ tube. That's right, TWO adapters. And I would say a good 2/3 of our nurses don't know that one of those adapters even exist, and those of us that know they exist have to go to an entirely different unit to get them. So often we're having to switch all the enteral meds out of the oral syringes they come in, put them in luer lock syringes, to hook them to the adapter that goes into the NJ tube.

    Even for the most sanctimonious and careful nurse, how easy would it be to walk into a room with a handful of meds (because let's face it, if there's an NJ tube, it's highly likely they've got a MAR that's a few pages long)? All those meds are in luer lock syringes, both the ones going into the IV and the the ones going into the NJ tube. Family starts asking questions. Distracts nurse. Nurse grabs just ONE syringe and sends it the wrong route.

    That's all it takes, ONE MOMENT.

    I've been trying to get the freaking adapters on our floor for more than TWO YEARS now. The email has been responded to by the head honcho of safety acknowledging that I have a good point. And still, if I get a patient with an NJ tube, I'm making the trip across the hospital for the adapters so I can at least keep my enteral meds in an oral syringe and my IV meds in a luer lock syringe. And nobody else takes the time to do so. I have a feeling we're not going to get those little tiny pieces of plastic that can't be at all expensive until we kill a patient.
    nrsang97, psu_213, *4!#6, and 2 others like this.
  6. 0
    This happens more often than it's reported, sadly. When I worked as an EI service coordinator, I saw many infants and toddlers with GI and metabolic disorders, ans most of the kids had CVL's plus some kind of enteral tube for trophic feeds, meds, sometimes for venting. Once home, patients are given plenty of luer lock syringes and pre-filled flushes, but most families receive zero to five oral syringes per month because the insurance companies do not pay for them. If a child is receiving 15 doses of enteral meds daily, even the "generous" 5-syringe allotment isn't going to cut it. Some pharmacies dispense oral syringes with enteral meds, but many don't; or worse, they dispense spoons. Most of the time, families end up re-using the flush syringes for enteral meds.

    Medically fragile/tech dependent kid
    lack of appropriate supplies necessary to safely dispense enteral meds
    parent with inadequate sleep because PDN agencies can't find enough RN's with CVL experience to cover a fraction of home nursing shifts=...
    caregiver responds to "How many times has your child received a med via wrong route" rather than "Has your child ever received..."

    ASPEN's "Be A.W.A.R.E." to practice safe enteral medication delivery LBE_AWAREASPEN's "Be A.L.E.R.T." to practice safe enteral feeding BE_ALERT
  7. 0
    I don't really think she could have been that ignorant. I think it was deliberate.
  8. 1
    I still do not understand how a nurse can inadvertently inject oral meds as IV. That reminds me of that nurse or student or whoever it was who injected a patient with COFFEE...
    redhead_NURSE98! likes this.
  9. 0
    Must be somebody thinks that somebody else will shoot oral/parenteral liquids into an IV... ever notice the sticker on the top of those bottles of Tube Feeding goo (i.e., Jevity, etc.)... the encircled abbreviation "IV" with the slash line across it?
  10. 1
    I am a neuro ICU nurse and many of my patients are prescribed Nimodopine for vasospasm. These are large,coated pills that can not be crushed. Many nurses poke holes in them with needles and either squirt the liquid into a med cup or aspirate into a 5-10mL syringe.
    This enables you to mix with other meds and administer them via a DHT, NGT/OGT, or PEG.

    One night a new graduate aspirated the medication into a syringe. She took the needle off and went over to the patient and injected it into a PIV. The patient almost died. And the new grads preceptor was right there watching her aspirate the medication with the syringe.

    Nurses need to be serious about safety at all times. The only hard stop to prevent this type of medication error (wrong route) would be to only have liquid form available in patient's that can not swallow their medications.
    nrsang97 likes this.

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