Best Practice #4 FAQ

Best Practice #4: Ensure that all oral liquids that are not commercially available as unit dose products are dispensed by the pharmacy in an oral syringe.

1. Question: Is the emphasis of this best practice on preparing oral doses in oral syringes in the pharmacy, or preparing oral doses in an oral syringe in unit dose amounts versus a bulk bottle?

Answer:  The goal of this best practice is avoid requiring nurses to draw oral solutions into a syringe on the patient care unit – especially a parenteral syringe. The emphasis is on providing nurses with a patient-specific-dose in an oral or enteral syringe, not on replacing bulk medications with unit doses. To that end:

• Bulk oral solutions should not be stocked in patient care units (e.g., in an automated dispensing cabinet [ADC]), dispensed by pharmacy). Nurses should not be required to measure the medication dose using a cup or syringe.

• Oral solutions in commercially available unit dose containers (either cup or oral syringe) can be stocked in the ADC, or dispensed from the pharmacy for specific patients.

• If an oral solution is available only in a bulk size, or the patient-specific dose is less than the unit dose amount (e.g., dose is 3 mL when the unit dose product in the ADC is 5 mL), the pharmacy should prepare the patient-specific dose in an oral or enteral syringe (or cup) and dispense it to the unit. The nurse should not be required to prepare that patient’s dose from a unit dose cup that holds more than the patient-specific dose.

• If an oral solution is available in a patient-specific dosing cup, and the patient cannot drink the solution from the cup, the safest practice is to dispense the dose from the pharmacy in an oral or enteral syringe so a nurse is not required to draw the dose into a syringe for administration.

We want to emphasize that oral liquid medications should be dispensed in patient-specific doses in oral or enteral syringes (or dose cups, if the patient can drink the medication from the cup). Although not part of this best practice, ISMP also recommends replacing dosing cups with oral and enteral syringes on patient care units, and educating nurses about the purpose and use of oral syringes. Studies have also shown that oral syringes are more accurate in terms of drawing up the dose.1
Finally, as stated in the goal, make sure that all oral and enteral syringes used in your hospital do not connect to IV tubing used in your hospital.

_{Reference: 1. Sobhani P, Christopherson J, Ambose P, et al. Accuracy of oral liquid measuring devices: comparison of dosing cup and oral dosing syringe. Ann Pharmacother. 2008:42(1):46-52.}
^{Rev. 3/26/2014}

2. Question: For oral syringes, is there is a recommendation to use clear vs. amber syringes? The clear syringes allow the contents to be seen more easily, but the amber ones visually look different than clear parenteral syringes.

Answer: ISMP does not specify whether clear or amber oral (or enteral) syringes should be used.
^{Rev. 3/26/2014}