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.