View Entire Collection
By Clinical Topic
Diabetes – Summer 2012
Future of Nursing Initiative
Heart Failure - Fall 2011
Influenza - Winter 2011
Nursing Ethics - Fall 2011
Trauma - Fall 2010
Traumatic Brain Injury - Fall 2010
Fluids & Electrolytes
An ED nurse went to the automated dispensing cabinet (ADC) to get a dose of the antiemetic drug ondansetron, 4 mg for I.V. infusion. She accidentally removed a syringe containing ondansetron oral, 4 mg/5 mL, which was intended for pediatric patients. The ADC screen listed both products as follows:
* ondansetron, 4 mg/2 mL injection
* ondansetron, 4 mg/5 mL solution (the entry didn't specify "oral").
The syringe containing oral ondansetron was labeled "for oral use," but because the solution was clear like I.V. ondansetron, the nurse thought it was intended for injection. When she couldn't fit a needle on the end of the oral syringe, she used a parenteral syringe and needle to withdraw the medication, then added it to an I.V. piggyback solution and administered it.
The nurse repeated this process for another patient. She realized her errors when she went to remove a third syringe from the ADC, and she immediately notified the ED physician. Fortunately, the patients who received the oral medication I.V. weren't harmed. The hospital where these errors occurred has removed ondansetron oral solution from the ADC and has pharmacy dispense it as needed.
Oral syringes are purposely designed so you can't connect them to I.V. ports or parenteral needles. If you think a unit dose must be moved from one syringe to another before use, investigate further and have another practitioner verify that you have the correct drug for the correct route.
Find in-depth content on major issues provided by leading companies in partnership with NursingCenter.com
BD Safety Beyond Needlestick Prevention Learning Center
Sponsored by BD Medical
Sign up for our free enewsletters to stay up-to-date in your area of practice - or take a look at an archive of prior issues
Join our CESaver program to earn up to 100 contact hours for only $34.95
Explore a world of online resources
Back to Top