The inadvertent intravenous administration of oral suspension which is rarely reported has contributed to potential patient harm. We received an incident report in which a patient had received an oral liquid formulation intravenously. This has been happening when an oral liquid is prepared or dispensed in a parenteral syringe. Due to the break-in mental concentration, the medicine had been administered intravenously. Some health professionals did not accept the fact that the Luer connection on an intravenous syringe facilitates mis-administration. This is why we constantly repeat recommendations to dispense and administer unit doses of oral liquids in particular oral syringes. We strongly support that, the dispensing and administering of commercially available and compounded medicine in a particular cup and oral syringes or any other suitable containers. In order to avoid such medication administration error ensure the availability of oral syringes in the hospital and patient areas where liquid doses are administered orally. Oral syringes are not available in Pakistan and nurses routinely use injection syringes for oral liquid administration, as it helps in preventing spill of dose especially in young/non-cooperative children or patients. Availability of oral syringes in the hospital may reduce the inadvertent administration of medicine.