August 28, 2013: Risk of Look-Alike Arterial Blood Gas Syringes and Parenteral Syringes
ISMP Canada has received a report describing a near-miss incident in which a syringe intended for withdrawal of a sample for arterial blood gas (ABG) testing was nearly used for preparation of a parenteral injection for an infant. A shipment of Smiths Medical 3 mL dry lithium heparinized ABG Luer lock syringes had recently been procured by the hospital where the incident occurred. The similarity in appearance between these ABG syringes and the standard BD 3 mL Luer-Lok and Slip-tip parenteral syringes, typically used to prepare injections, was a contributing factor leading to this near-miss incident.Read more...
