Dear ismp, i would like to report the following safety concern with respect to tamper evident syringe caps for sterile products.Although there was recently a safety alert published in the ismp newsletter with oral syringe caps, this issue pertains to the syringes caps that are used with luer lock syringes.With the shortage of syringe caps, our organization has had to utilize different syringe caps to maintain the safety and integrity of products that are compounded or prepared within the pharmacy.Specifically, the pharmacy was using the following tamper resistant syringe caps: (sent in separate email to (b)(6)) it was identified through an internal safety event that when the red inner portion of the cap is removed, a plastic "o" will be left and can easily fall into a patient's incision or open wound.We have now started to utilize the b braun tamper resistant syringe caps that also have an issue with plastic pieces that can fall into a patient or potentially be drawn into the syringe barrel during withdrawing of irrigation fluid if the tamper resistant cap is removed over an open wound, incision, or sterile field where irrigation bowls are present.The red syringe cap is held onto the clear plastic syringe cap cover with small plastic tabs.When the clear cover is removed, the small plastic tabs can adhere to the syringe cap via static electricity or could fall or be brushed off.The pieces are small enough where they would not be noticed if they fell into an open wound and could potentially be drawn into the syringe barrel if they fell into an irrigation bowel.I understand there is a challenge with maintaining the tamper resistance with the caps and with the current shortage, i am not sure if this is a design flaw or if the manufacturer is aware.In the meantime during the current shortage, unless another product is available, everyone will need to remain hyper vigilant and aware not to open a syringe cap over a sterile filed or open wound to prevent an inadvertent foreign body exposure.Thank you in advance, and please let me know if you have additional questions.Ismp,(b)(6); access number: (b)(4).
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