Replace bottle stopper with childproof cap after using liquid medication

In an earlier blog I pointed out that using a household spoon to give liquid medication can provide an inaccurate dose. Household spoons (teaspoons, tablespoons, dessert spoons) are not standardized. Depending on their size, typical household teaspoons can hold between 3 and 7 milliliters (mL). That’s far too wide a range for accurate liquid medication dosing.

To get around this problem, I’ve recommended that doctors prescribe liquid amounts in terms of mL in order to take advantage of special oral syringes. These allow more accurate measurement since they’re calibrated in mL. They also make it easier to give liquids to children who can’t take medications from a spoon and they help when measuring very small amounts for infants and even pets.


Oral syringes sometimes accompany OTC and prescription liquids or can be purchased in pharmacies. Dosing directions that state “teaspoonfuls” alone should not be used. I’m certainly not alone in making this recommendation. For good reason, many others in the medical field have as well.

One thing I’ve learned over the years though is that nearly every time that I think safety advocates have been able to tackle an important medication safety issue, the law of unintended consequences seems to kick in. Applied to patient safety efforts, the law states that actions taken to improve safety sometimes have effects that are unanticipated or unintended and they can be good or bad. Such is the case with the growing use of special oral syringes for accurate and convenient dosing of liquid medications, especially in children. Unfortunately, last week I heard of a negative consequence.  

A little boy was taking a chronic antiarrhythmic medication called Tambocor for a serious condition that makes his heart beat too fast. The drug works by slowing down electrical impulses between the upper and lower chambers of the heart, allowing it to beat normally. A pharmacy compounded a liquid suspension and properly dispensed it in a prescription bottle with a childproof cap.  The pharmacy gave the family an oral syringe and bottle stopper that fits the syringe to facilitate removal and measurement of the suspension.

After using the stopper with the syringe, the family did not remove it from the medicine bottle to replace it with the child proof cap. One evening the family saw their child coming up the stairs with a nearly empty bottle of the medicine in his hand. Somehow, when the child went into the refrigerator to get a juice bottle, he instead picked up the medicine bottle and was able to get at the suspension and drink most of it. The child was taken to a local hospital for treatment of the severe overdose and later transferred to a children’s hospital. I hope to learn soon about his condition. Right now my thoughts are with the family.

I must admit that although similar overdoses may well have happened previously, I’ve never really heard about a problem like this before. Still, it’s clear this horrible incident should serve as a warning to consumers and the entire health care industry. In the home, stoppers must be removed and replaced with the safety cap after each dose is prepared. Otherwise a hazardous condition will be created for children. Labeling on some of these products does not warn about this potential problem, nor does it say anything about removing the cork and recapping for storage of the medicine.

Oral syringes and accompanying stoppers are sold widely in pharmacies and elsewhere. They’re also used in hospital pharmacies to prepare unit doses from bulk liquid supplies. There are various types of stoppers sold. Some are screwed onto the prescription liquid container while others are inserted into the neck of the container, like a cork. Each has a hole in the middle to allow the bottle to be turned upside down to facilitate syringe filling. Here’s a link to proper instructions for use of oral syringes and stoppers.

On a positive note, it appears that the new OTC acetaminophen infants’ products I wrote about last week are sold with an embedded stopper, designed to make it nearly impossible to remove fluid without the syringe. Also, some pharmacies may dispense liquids in containers with stoppers that would be very difficult for a child to remove.  For example, Target dispenses liquids in what they refer to as a “blunder proof” container. In view of this incident, it’s clear that safer products are needed, so I am calling on drug manufacturers and pharmacies to make sure the design of their stoppers also serves as a childproof container in case they are left on bottles.

This is also a good time for me to remind parents, grandparents, family friends, etc. of their responsibility to keep any medication container far out of the reach of children. It’s amazing how easy it is for kids to get into things they shouldn’t. Finally, the episode above also presents an opportunity for me to reach community pharmacists to further stress the importance of educating parents about removing the stopper immediately after each use and replacing it with the child proof lid.


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