Ingestion or Aspiration of Foreign Objects or Toxic Substances is Not Just a Safety Concern With Children

ISMP Medication Safety Alert 

In This Article

Safe Practice Recommendations

ll staff who directly interact with patients or enter patient care areas, including housekeeping and maintenance staff, need to keep the patient's room and/or immediate care area free of hazards that could result in accidental ingestion or inhalation of unintended products—even when patients are fully alert and oriented. Proper removal and disposal of syringe caps before drug administration is essential to prevent accidental ingestion or asphyxiation. Practitioners should be alert to this risk and consider the proper disposal of syringe caps (if present) as important as syringe and sharps disposal. If feasible, remove and properly discard syringe caps in a secured sharps disposal container before administering medications or flushing lines.

Never leave fixatives, developer solutions, hazardous chemicals (e.g., cleaning agents), topical antiseptics, or other topical liquid products at the bedside or in other areas where they can be misidentified as oral products. "External Use Only" or "Hazard" labels can warn staff and patients about hazardous and topical products, but they are not always enough to prevent ingestion.

As a final safety check, staff who directly interact with patients or enter patient care areas, particularly the patient's room or outpatient bay area, should continuously scan the patient's environment for safety hazards and correct any existing hazards before leaving the patient's bedside. Scanning the environment for hazards should also be incorporated into patient rounding procedures. Simulations where practitioners identify various hazards can be used to facilitate training. Also, encourage patients and family members to tell you if they see or find any loose objects, bottles, or solutions near the patient.

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