Hazard Alert! The availability of certain newer needleless IV system connection ports makes it possible to inject fluid into the valve of these connectors with an oral syringe

 

From the November 27, 2002 issue MSA Acute Care Edition Newsletter

The availability of certain newer needleless IV system connection ports makes it possible for determined individuals to actuate the valve of these connectors with an oral syringe and thereby inject the fluid into an IV line. This problem was confirmed with the two major US manufacturers of oral syringes, Baxa and Becton Dickinson. According to a posting on Baxa's website (www.baxa.com) this Monday, an internal investigation showed that the following needle-free IV access valves all allow connections with an oral syringe: Porex KippMed NAC Needleless Access Connector, the B. Braun UltraSite, the FilterTek NeedleFree Connector, BD Posiflow Luer Access Valve, and Baxter ClearLink. To attach an oral syringe to the valve and inject oral liquid, it's necessary for the clinician to precisely align the tip of the oral syringe with the valve and apply forceful pressure on the plunger to open the valve. Even then, there might be some leakage around the valve. This is similar to a situation we wrote about in our May 8, 1996, issue where we noted that the injection port of B. Braun Medical's SAFSITE Reflux Valve needleless system could accommodate the tip of a Baxa oral syringe. Soon thereafter, Baxa redesigned their oral syringe to prevent all possibility of this happening. We've been in touch with Baxa during the past two weeks to discuss the current situation. Already, engineers at Baxa have developed prototype product modifications to address this new problem and they are notifying their customers. We applaud the quick action by Baxa to help solve this problem. On the other hand, we can't overlook the fact that a full failure mode and effects analysis (FMEA) on the new needleless IV system connection ports by their manufacturers, before introduction to the market, could have identified and corrected this problem up front. Until newly designed devices reach the market, we would highly recommend that you alert clinical staff to this situation if you are using any of the newer needleless IV systems. Also, oral syringes used in hospitals should always carry an auxiliary label that boldly indicates the enclosed liquid is "FOR ORAL USE ONLY."