LPN IV Series: Administration Methods

Nurses have a significant and unique role in medication administration. There are legal responsibilities involved in the preparation and administration of medication. Accountability and responsibility are a part of the legal requirements of medication administration that LPNs must adhere to. Medication administration through an intravenous (IV) line is a popular form of administration because of its ease of use and ability to help patients quickly. Though IV medication administration is commonly used, there are still many errors involved with its use.

Many risks increase the potential for errors in IV medication administration. The Institute for Safe Medication Practices (ISMP) has outlined the risks involved with medication administration errors; they include the following:

• A lack of patient information poses a risk to the safe prescribing of medication and the preparation, administration, and monitoring of medications administered via IV.
• There is a lack of direction on the medication order. For example, the order may not indicate if there is a specific rate for administration, or it uses unclear terminology such as IV bolus, "slow," or "fast" IV push, which leads to personal interpretation and error.
• There is a lack of direction on the medication order on whether a medication can or must be diluted before IV push administration.
• There is a lack of awareness that an adjustment in the dose or administration frequency of the IV medication may be needed depending on the patient's clinical status or the bioavailability of the medication.
• There is a lack of administrative policies and protocols that guide IV injections, leaving the expectation for safe practices undefined and left solely to each LPN's preferences.
• Terminology such as "IV push," "IV bolus," or "slow IV push" is undefined.
• There is an inability to distinguish between orders for IV medications such as IV injection (push) or IV infusions, leaving the decision open to interpretation by the LPN administering the medication.
• The prescriber not providing a rate of administration with orders for IV medications leaves the rate open to interpretation.
• Medication administration records (MARs) that do not provide easy-to-read or readily accessible instructions on administration or the dilution, reconstitution, or rate of administration of IV push medications increase the risk of errors.
• IV medications prepared in empty sterile syringes and left unlabeled increase the risk of administration error.
• IV push medications diluted and reconstituted in commercially available syringes of 0.9% sodium chloride flush solution may be mislabeled as containing only 0.9% sodium chloride, increasing the risk of adverse effects if administered.
• Pre-labeling empty syringes before use increases the risk of error, especially if the syringes are labeled wrong, used for the wrong patient, or filled with a different medication or solution.
• Misleading or confusing labeling or packaging from the pharmacy or manufacturer increases the risk of a medication error.
• There is often variability in practice with IV syringe pump devices to administer an IV push medication; specific department or regulation guidelines should be followed.
• Occasionally, vendor design flaws in medication delivery pumps, administration sets, tubing, or syringes lead to misinformation or misuse. Error during preparation and administration may occur if there is a design flaw.
• There is an increased risk of error when there is insufficient staff education and training on IV insertions, maintenance, and medication administration (ISMP, 2015).

Nurses have the most significant role in medication safety. However, studies show that nurses are responsible for 26-38% of medication administration errors. Adherence to medication administration guidelines was low in these scenarios, and at least one in four medication rights were regularly violated (Wondmieneh et al., 2020). Most of these errors are preventable, and according to the Institute of Medicine (2011), nurses are pivotal in reducing medication errors. Nurses should be diligent when administering medications and use the rights of administration with every patient. The rights in the list below are only one version; some guidelines or departments include different rights or a more comprehensive list.

Right Patient: Use two identifiers. The room number is not an identifier. Ask the patient to identify themself and check the name on the order and the patient ID band. If available, use technology such as barcode scanning. For patients not wearing ID bands or those that are not able to identify themselves, extra caution is required. A system should be in place to identify patients without name bands or who are unable to identify themselves.

Right Medication: Every medication administered must have an order from the provider. Compare the order with the MAR for accuracy. Compare the label on the medication to the information on the MAR three times: 1) before removing the container from the drawer, 2) as the medication is removed from the container, and 3) at the bedside before administering it to the patient. Do not prepare unmarked medication containers or illegible containers. Verify medications at the patient's bedside with the MAR and two identifiers.

Right Dose: Have a second nurse check any calculations that need to be done, including pediatric doses and high-risk medications such as heparin and insulin. Use standard measuring devices such as syringes, graduated cups, and scaled droppers. Inquire if the pharmacy can split any required pills for safety. If medications need to be crushed, clean the devices before and after use. Nurses should have access to information on therapeutic doses, therapeutic serum levels if applicable, and laboratory results when needed. If there is any doubt about the dosage on the order in the MAR, or if there is a question on the medication, stop and verify all information before administering.

Right Route: Medication errors involving the wrong route of medication administration are common. Giving medications via the wrong route can cause serious harm to patients. When using a syringe or other device, label the appropriate route. Be sure to verify if there is any question as to the medication route.

Right Time: Nurses need to understand why medications are given at certain times. Although some medications require clinical judgment on when to administer, such as a PRN sleeping medication, other medications are considered time-critical. Studies show that giving medications at the incorrect time results in 30-40% of all medication errors. Giving medication at the incorrect time can impact the bioavailability and efficacy of the medication. Likewise, medications should not be prepared or mixed in advance for the same reason (Hanson & Haddad, 2022).

Right Documentation: LPNs should perform complete and accurate documentation, including medication administration parameters.

Right Action: It is essential to understand the rationale for the medications prescribed. If the medication ordered is incongruent with the patient's diagnosis and the rationale for its use is not apparent, it is appropriate to gather more information before administration.

Right Response: Document the effectiveness of the medication and the patient's response. For example, it is pertinent to note if the patient had an allergic reaction or if the medication had its intended effect.

Right Form: Administration of the medication in the appropriate form is essential; for example, a liquid medication versus a tablet (Tsegaye et al., 2020).

The elderly, children, and pregnant women have physiologic differences that must be considered when administering medication.

Due to physiological changes associated with aging, particularly in hepatic metabolism and renal elimination, dosing in the elderly population can be challenging. There is a decrease in blood flow to the stomach, sometimes limiting the absorption of medications. As we age, kidney size decreases, limiting the excretion of medications. The elderly may also experience increased side effects or toxicity more easily. As most elderly patients are on more than one medication, care should be taken when combining medications (Drenth-van Maanen et al., 2020).

Pediatric doses are very different from adult doses. Differences in dosing are not merely due to body weight but must include physiological differences. Rates of renal clearance can be different in each age group. The liver and kidneys impact the pharmacokinetics of a child dose versus an adult dose. The rate of absorption in an infant varies significantly from a school-age child. The metabolism of medications is dependent upon hepatic blood flow, which is reduced in infants. Body weight, which most medications are based on, does not give an indication of how organs are functioning. Therefore, developmental growth must also be considered when administering medications to this population (Rodieux et al., 2015).

Pregnant women represent another population where careful consideration must be taken when administering medications. The effect of the medication on the fetus may be detrimental as side effects are harder to detect in the fetus until it is too late. An understanding of how the fetus develops during pregnancy must be considered. The risks of not treating a disorder must also be contemplated (Dathe & Schaefer, 2019).

Each facility has a policy defining what medications can be given IV. The policy should define administration by area of practice and administration methods. It is essential to follow those policies to help reduce medication errors.

Policies should also note information on aseptic techniques. An aseptic technique is required for all IV injections and mixing medications or fluids. An aseptic technique includes (ISMP, 2015):

• Hand hygiene before and after preparation and administration of the medication or solution
• Disinfection of the medication access diaphragm on a vial or the neck of an ampule before accessing the medication or solution
• Disinfection of the IV access port, needleless connector, or other vascular access devices (VAD) before administration of the medication or solution
• The use of personal protective equipment (PPE) if contact and exposure to blood or bodily fluids are possible when administering the medication or solution

Policies should also note guidelines for various administration methods. A needleless system of infusing medications is the best practice. Do not use a needleless system if infusing a large volume of blood. Instead, attach the tubing directly to the hub.

When infusing or pushing multiple medications, flush 10cc of normal saline (NS) through the IV before and after each medication; it will clear the IV line.

An IV piggyback is a solution or medication attached to a primary infusion line or intermittent VAD to deliver medication over a specified period of time (Lee et al., 2021). IV piggybacks usually run over 1 hour. More modern or current pumps have the exact infusion time and rate pre-programmed by medication. Remember to hang the piggyback higher than the main infusion bag if you use a gravity drip.

IV push, or bolus, is the administration of medication from a syringe directly into an IV. The IV push can be injected into the tubing or a saline lock. The indications for use are (Nettina, 2019):

• When a rapid concentration of medication in the bloodstream is needed, such as in CPR
• When a quicker response to the medication is necessary, such as with furosemide or digoxin
• To administer a loading dose for a planned continuous infusion, as with heparin or pain medication
• For patient comfort and to avoid intramuscular injections
• To avoid incompatibility issues when several medications are mixed in one bag
• When the patient is unable to take the medication orally or via the IM route
• It is cost-effective when you do not need a continuous infusion

Consult the pharmacy, institutional policy, or manufacturer's insert if you do not know how quickly a medication push should be given. Most medication is given slowly. Pushes are usually between 30 seconds and a minute but may be as long as 5 minutes. A push that is too rapid can cause serious adverse effects.

The best practice recommended by the ISMP include the following:

• Use an IV push medication or flush in a ready-to-administer form rather than drawing up medication in a syringe.
• When administering IV push medications through an existing IV infusion line, use a needleless connector that is proximal (closest) to the patient unless contraindicated in current evidence-based literature or if the proximal site is inaccessible for use, such as during a sterile procedure.
• Never use IV solutions in containers intended for infusion, including mini bags, as common source containers (multiple-dose products) to prepare IV flush syringes or to dilute or reconstitute medications for one or more patients in clinical care areas.
• Have the pharmacy prepare more than one medication in a single syringe for IV push using their sterile compounding center. If the clinician needs to prepare and administer more than one syringe of medicine or solution to a single patient at the bedside (ISMP, 2015):
  • Prepare each medication or solution separately and immediately administer it before preparing the next syringe or
  • If preparing several IV push medications at a time for sequential IV push administration, label each syringe as it is being prepared before preparing any subsequent syringes.
• If preparing one or more medications or solutions away from the patient's bedside, immediately label each syringe, one at a time, before preparing the next medication or solution.
• Never pre-label empty syringes in anticipation of use.
• Immediately discard any unattended, unlabeled syringes containing any solution.
• Bring only one patient's labeled syringe(s) to the bedside for administration.
• Only dilute IV push medications when recommended by the manufacturer, supported by evidence in peer-reviewed biomedical literature, or following approved institutional guidelines.
• Unless its use would result in a clinically significant delay and potential patient harm, use barcode scanning or similar technology immediately before administering IV push medications to confirm patient identification and the correct medication.
• Assess central line patency using, at a minimum, a 10 mL diameter-sized syringe filled with preservative-free 0.9% sodium chloride. Once patency has been confirmed, IV push administration of the medication can be given in a syringe appropriately sized to measure and administer the required dose (ISMP, 2015).

Do not administer IV fluids and medications that have particulate matter or discoloration. Some medications may come as a colored fluid. If in doubt, double-check. Some drugs come in a dark bag because the medication is light-sensitive, limiting its ability to be double-checked.

Some medications require dilution, particularly medications that are irritating to the vein. If you withdraw the medication from a glass ampule, use a filter needle or straw unless contraindicated.

Eliminate air from the tubing set and injecting device to avoid air emboli. Before injecting anything into an IV, check the patency. Flush the IV tubing or saline lock with NS before and after a push. Check medication compatibility if you insert the push into an ongoing IV infusion or push more than one medication.

Monitor the patient's reaction during and after the push. Major adverse effects include (Nettina, 2019):

• Anaphylaxis
• Respiratory distress
• Tachycardia
• Bradycardia
• Seizures

Minor adverse effects include (Nettina, 2019):

• Nausea
• Flushing
• Rash

If there is an adverse effect, stop the medication and notify the provider. Take emergency action if needed. Document in detail and generate an adverse event report.

Monitor the IV site for infiltration or extravasation.

Provide patient education regarding the medication or fluid to be infused and for the patient to report any burning, pain at the IV site, and symptoms of adverse effects.

Blood and fluid warmers are ordered to avoid hypothermia and require strict adherence to institutional guidelines of administration (Nettina, 2019).

Power injectors are used in radiology to deliver a specific amount of contrast media at a specific time. Contrast material is to be considered a vesicant solution. Check your patient after return from contrast injection for infiltration and extravasation (Nettina, 2019).

Never infuse medications or solutions through a continuous IV that is infusing:

• Blood
• Blood products
• Heparin
• Insulin
• Cytotoxic medications
• Parenteral nutrition
• Vasoactive medications (Doyle & McCutcheon, 2015)

In most situations, medications will be delivered pre-mixed. Ask the pharmacist or check your drug resource if you have doubts about compatibility with IV solutions and medications.

NS is compatible with most medications. However, check with your pharmacist if administering warfarin, imipenem-cilastatin, meropenem, or nitroglycerin (Grissinger, 2016).

D5W is also compatible with most medications. However, check with your pharmacist if you are administering pentobarbital sodium, heparin, meropenem, or nitroglycerin. It is the preferred solution to administer insulin, lidocaine, norepinephrine, propranolol, and zidovudine (Brown et al., 2018).

Many medications have not been researched for IV administration compatibility. The best and safest practice is never to mix IV medications unless you are certain.

Dana is an LPN working on the medical surgical floor and caring for an 89-year-old female, Linda, who was diagnosed with cancer complications. An IV has been inserted in the right antecubital area, and patency has been maintained. Linda has a 25-year-old roommate, John, who was hospitalized after he broke several bones in a car accident. John has a PRN order of 1mg of morphine given IV push for pain. Both Linda and John have been complaining of pain. Dana is managing multiple patients and is in a hurry to clock out on time. Dana draws up the morphine to be given to John. Amid the busy day, Dana does not check any identifiers and administers the 1mg of Morphine IV push to Linda instead of John.

Almost immediately, Dana realizes the mistake she has made. Linda experiences decreased respirations, nausea, dizziness, and sleepiness. Luckily, the side effects wore off over a couple of hours, and no further consequences resulted. John received his pain medication. Dana felt extremely guilty and discussed with the charge nurse the consequences of her actions. Dana was counseled on safe medication administration, including using two identifiers.

IV medication administration is a common practice. There are rules and guidelines that serve as the standard for legal accountability and responsibility in medication administration. For example, the right patient, the right drug, the right dose, and the right route are rights that LPNs can follow to reduce medication errors. The ISMP (2015) has implemented best practice recommendations, including hand hygiene and an aseptic technique. Other guidelines include careful medication administration for specific populations, such as the very young, the elderly, and pregnant women. Each of these populations is at an increased risk of errors and side effects if proper care is not taken.

There are various routes of IV administration, including IV piggybacks and IV pushes. Each way of administration includes a set of recommendations to prevent errors and adverse effects, including using barcode scanning and discarding unlabeled syringes. Care should also be taken to ensure that lines infusing products such as blood are not mixed with medications.

There are advantages and disadvantages of IV medication administration. It is a quick option for delivering medications which is essential in an emergent situation. However, disadvantages that could result in patient harm, such as immediate adverse effects, exist. LPNs should take care and precautions when administering medications via IV, including following administration guidelines.

• Brown, R. M., Stollings, J. L., & Semler, M. W. (2018). Making the Medicine Go Down: Salt or Sugar? Critical care medicine, 46(8), 1370–1371. Visit Source.
• Dathe, K., & Schaefer, C. (2019). The Use of Medication in Pregnancy. Deutsches Arzteblatt international, 116(46), 783–790. Visit Source.
• Doyle, G. R., & McCutcheon, J. A. (2015). Clinical Procedures for Safer Patient Care. Victoria, BC: BCcampus. Visit Source.
• Drenth-van Maanen, A. C., Wilting, I., & Jansen, P. A. F. (2020). Prescribing medicines to older people-How to consider the impact of ageing on human organ and body functions. British journal of clinical pharmacology, 86(10), 1921–1930. Visit Source.
• Grissinger, M. (2016). Understanding and Managing Intravenous Container Overfill. P & T: a peer-reviewed journal for formulary management, 41(3), 140–172.
• Hanson A., & Haddad L.M. (2022) Nursing Rights of Medication Administration. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Visit Source.
• Institute for Safe Medication Practices (ISMP). (2015). ISMP Safe Practice Guidelines for Adult IV Push Medications. Institute for Safe Medication Practices. Visit Source.
• Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. (2011). The Future of Nursing: Leading Change, Advancing Health. National Academies Press (US).
• Lee, R., Tran, T., Tan, S., & Chun, P. (2021). 602. Intravenous Push Versus Intravenous Piggyback Administration of Cephalosporin Antibiotics: Impact on Safety, Workflow, and Cost. Open Forum Infectious Diseases, 8(Suppl 1), S403–S404. Visit Source.
• Nettina, S. M. (2019). Lippincott manual of nursing practice (11th ed.). Wolters Kluwer.
• Rodieux, F., Wilbaux, M., van den Anker, J. N., & Pfister, M. (2015). Effect of Kidney Function on Drug Kinetics and Dosing in Neonates, Infants, and Children. Clinical pharmacokinetics, 54(12), 1183–1204. Visit Source.
• Tsegaye, D., Alem, G., Tessema, Z., & Alebachew, W. (2020). Medication Administration Errors and Associated Factors Among Nurses. International journal of general medicine, 13, 1621–1632. Visit Source.
• Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC nursing, 19, 4. Visit Source.