Error Number 94. Using unorthodox containers for medications

A 65-year-old man with thyroid cancer was admitted to a longterm care facility. Because the patient was having difficulty swallowing, the pharmacist dispensed the prescribed oral morphine solution in infection syringes with the needles removed.

The patient's nurses knew that morphine dispensed in this form was meant to be given orally. However, the registry nurse assigned to the patient one night was unaware of this. So when she saw the syringe containing the medication, with nothing on the label to indicate that it was an oral drug, she attached a needle and injected the morphine solution into the patient's buttock.

Later that night, the patient asked one of the staff nurses why he'd been given an injection. The nurse checked with the registry nurse and found out what had happened. She quickly alerted the pharmacist, who reassured her that the morphine would probably be absorbed systemically. But he warned that the injection could cause an abscess. (Fortunately, this didn't happen.)

As a result of this error, the staff nurses and pharmacist drew up the following guidelines, designed to prevent the use of unorthodox, improperly labeled containers for medications:

• Don't put oral drugs in syringes normally used for injection. Instead, use oral syringes, which can't accommodate a needle.
• Clearly label these syringes "For oral use only."
• Inform all temporary staff members about methods of medication administration. This information should be given during shift report and should be included on the patient's chart.