Aug 23rd,2012 safety newsletter:
Avoiding inadvertent IV injection of oral liquids
...Oral doses have also been purposely administered intravenously by health professionals who were unaware of the associated dangers. 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.
To help address these problems, some hospitals use amber oral syringes for all oral liquid medications to further differentiate them by color from typical clear parenteral syringes. However, with clear liquids, pharmacy technicians and nurses often have trouble seeing and measuring the liquid in an amber syringe when preparing the medication or administering a dose. Although oral syringes are marked "Oral use only," and pharmacy labels and medication administration records (MAR) may also specify the oral route of administration, these statements are too easily missed to be relied upon to prevent misadministration. It might also help to affix an auxiliary label that uses a much larger font, such as the labels in Figure 2 marked "ORAL," which are available from Baxa.