ISMP Warns That Some Oral Medications Are Accidentally Given Intravenously

An alert issued by the Institute for Safe Medication Practices (ISMP) warns about the risk of human error playing a role in hospital medication mistakes, where oral liquid drugs were accidentally given to patients intravenously. 

The ISMP Medication Safety Alert was issued on August 13, highlighting two recent cases where nurses got confused and injected patients with the antidepressant lorazepam in one case, and chlorhexidine mouthwash in the other.

The group says the incidents highlight a need for medical providers to be more alert about the possibility of human error, the need for better drug labeling, and for hospitals to ensure all the appropriate equipment is on hand and ready for nursing staff.

In the incident involving lorazepam, sold in the U.S. under the brand name Ativan, the patient could not swallow tablets and had been prescribed a liquid oral dose. The nurse retrieved the dose from an automated dispensing cabinet with an oral syringe. However, she saw the controlled substance schedule IV (C-IV) designation on the label and thought the IV stood for “intravenous.”

When the oral syringe would not fit the IV access port, she switched the medication to another syringe that would, not realizing that it did not fit because the drug was not an IV-administered medication. The patient was observed and sent to a rehabilitation procedure after the mistake was discovered. The report does not indicate whether the patient suffered any adverse effects.

The second incident involved a patient who was prescribed chlorhexidine mouthwash due to extensive oral surgery. While it was given out by the pharmacy in prepackaged cups, the patient asked the nurse if it could be placed in a syringe so that the patient could self-administer it. The nurse was unable to find an oral syringe, so instead used a parenteral syringe, but did not label it.

Later, the nurse returned from other duties to perform a saline flush for the patient’s saline lock, failed to remember she had placed the oral mouthwash in the parenteral syringe and mistook it for the saline flush, injecting it into the patient’s peripheral arm catheter. The patient complained of a stinging sensation and the nurse realized the mistake. The patient suffered local pain overnight but no other apparent adverse effects and was discharged the next day.

“These cases reflect the impact of system vulnerabilities, at-risk behaviors, human factors, and technology limitations,” the ISMP warning indicates. “In both cases, the nurses were distracted from the immediate task at hand and lost situational awareness.”

The ISMP notes that while some technological devices have been designed to prevent these types of errors, they cannot replace human vigilance and proper preparation.

The alert recommended healthcare professionals step back and reassess the situation whenever something appears to be amiss, like an unlabeled syringe, or an IV port not fitting correctly. The ISMP also recommends that distractions and interruptions be as limited as possible, that oral syringes be stocked, easily identified and used, that labeling policies be enforced, and that pharmacy labels be designed clearly and without misleading clues.