Description of Event or Problem · 1
IN 2018, ACUTE CARE ISMP MEDICATION SAFETY ALERT EDITION, THERE WAS A SAFETY BRIEF REGARDING THE CHOKING HAZARD ASSOCIATED WITH THE RESIDUAL PLASTIC RING AFTER BREAKING THE SEAL ON TAMPER EVIDENT CAPS. WE IDENTIFIED AN ADDITIONAL SAFETY RISK AT OUR INSTITUTION RELATED TO THE PLASTIC RINGS FOR THE CONVERSE SCENARIO WHEREBY THE RING MAY EASILY SLIDE OFF WITHOUT FORCE AND BY GRAVITY ALONE. THE TAMPER EVIDENT CAPS HAVE HISTORICALLY BEEN USED FOR PHARMACY PREPARED SYRINGES AS SUPPLIED TO OUR CATH LAB TO FACILITATE CATHETER IN INSERTION AND REMOVAL VIA THE RADIAL ARTERY. WHEN THEY WERE READY TO BE USED, THE TAMPER EVIDENT CAPS WERE TAKEN OFF BY A CATH LAB NURSE. IN THE CASE OF THE INTERNATIONAL MEDICAL INDUSTRIES REF (B)(4) TAMPER EVIDENT CAP, THE PLASTIC RING VERY EASILY SLIDES OFF THE BARREL OF THE SYRINGE TIP. THERE IS POTENTIAL FOR THE RING PIECE TO FALL INTO AN UNINTENDED LOCATION OR EVEN INTO THE STERILE FIELD. WE HAVE DISCONTINUED THE USE OF THESE CAPS IN AS MUCH AS POSSIBLE THROUGHOUT OUR INSTITUTION INCLUDING THE CATH LAB AND WOULD ADVISE INCREASED CAUTION WITH THIS DELIVERY DEVICE. SEVERITY: CIRCUMSTANCES OR EVENTS HAVE CAPACITY TO CAUSE ERROR. (B)(6), ACCESS NUMBER: (B)(4).