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Reporting a Medication Error

Replace bottle stopper with childproof cap after using liquid medication

Liquid medicines, especially those required for small children and pets, are often measured using oral syringes. Sometimes, there is a device that comes with the syringe called an adapter. This allows the oral syringe to directly attach to the bottle, eliminating the step of pouring the liquid into a cup for withdrawal by an oral syringe.Using a syringe adapter is a convenient way to accurately measure and administer liquids. However, depending on the actual product, parents should be aware they are not always childproof.

Recently, we received a medication error report alerting us to the dangers of not removing the syringe adapter after use. In the report, a little boy was taking a chronic antiarrhythmic medication called Tambocor for a serious condition that makes his heart beat too fast. The drug works by slowing down electrical impulses between the upper and lower chambers of the heart, allowing it to beat normally. A pharmacy compounded a liquid suspension and properly dispensed it in a prescription bottle with a childproof cap.

The pharmacy gave the family an oral syringe and syringe adapter. After using the stopper with the syringe, the family did not remove it from the medicine bottle to replace it with the childproof cap. One evening the family saw their child coming up the stairs with a nearly empty bottle of the medicine in hand. Somehow, when the child went into the refrigerator to get a juice bottle, he instead picked up the medicine bottle and was able to get at the medicine and drink most of it. The child was taken to a local hospital for treatment of a severe overdose and then later transferred to a children's hospital for further care.

The syringe adapter used by the family did not contain a safety mechanism to stop the liquid from coming out of the bottle and it also could easily be removed by a small child. Therefore, the child was able to use the bottle to drink the contents.

If you are using a syringe adapter and oral syringe, never store the bottle with it still in place. Be sure to remove it after every use and immediately replace the container with a childproof lid. And, as always, keep all medicines far out of reach of children.

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