100% of participants will use the correct technique administering IV fluids and medications.
After completing the course, the learner will be able to:
Nurses have the largest role in medication safety. However, studies show that nurses handle 26-38% of medication administration errors. Medication administration guidelines adherence was low. Their results showed that at least one in four of the five medication rights were regularly violated. The majority of these errors is preventable and according to the Institute of Medicine Report, The Future of Nursing, nurses as pivotal in reducing medication errors. Although some have suggested that the five rights of medication administration need to be expanded upon to include documentation, response, and any actions were taken, nurses should be diligent when administering medications and use the five rights with every patient.
Right Patient: Use two identifiers. The room number is not an identifier. Ask the patient to identify himself or herself, check the name on the order and the patient. If available use technology such as barcoding. For patients not wearing ID bands or those that are not able to identify themselves, extra caution is a need. A system should be in place to identify patients without name bands or who are incompetent.
Right Medication: Every medication administered must have an order from the provider. Compare the order with the medication administration record (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 to the patient. Do not prepare unmarked medication containers or illegible containers. Be sure to verify medications at the patients’ bedside with the MAR and two identifiers.
Right Dose: Have a second nurse check any calculations that need to be done, pediatric doses, and high-risk medication (i.e., heparin, insulin). Use standard measuring devices such as syringes, graduated cups, scaled droppers. See if the pharmacists can split any required pills for safety. If medications need to be crushed, be sure to clean the devices used before and after. Nurses should have access to information on therapeutic doses, therapeutic serum levels if applicable, and laboratory results when needed. If there is any doubt as to the dosed on the order on 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. Be sure to verify if there is any question as to the medication route. The nurse handles knowing the appropriate route for the medication. Giving medications via the wrong route can cause serious harm to patients. If possible when using a syringe or other device, label the appropriate route.
Right Time: Nurses need to understand why medications are given at certain times. Although some medication requires clinical judgments as to when to administer, such as a PRN sleeping medication, other medications are labeled as time-critical in some hospitals. 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 bioavailability and efficacy of the medication. Likewise, medications should not be prepared or mixed in advance for the same reason.
The elderly, children, and pregnant women have physiologic differences that need to be considered when administering medication.
Due to physiological changes, particularly in hepatic metabolism and renal elimination, dosing in the elderly population can be challenging. The elderly may experience an increase in side effects or toxicity more easily. This is particularly important as the majority of elderly patients are on more than one medication. Care should be taken when combining medications.
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. 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.
Pregnant women present another population where careful consideration must be taken when administering medications. The effect of the medication on the fetus may be detrimental. An understanding of how the fetus develops during pregnancy must be considered. The risks of not treating a disorder must be contemplated as well.
Each facility has a policy defining what medication can be given IV. This policy should define administration by area of practice and administration methods. Follow that policy.
Aseptic technique is required for all IV injections and mixing of medications or fluids.
Aseptic technique includes1:
A needleless system of infuse medications is the best practice. If infusing a large volume of blood, do not use a needeless system. Instead, attach the tubing directly to the hub.
When infusing or pushing multiple medications, be sure to flush 10cc of NS through the IV before and after each medication. This practice will clear the IV line.
IV piggybacks usually run over 1 hour. More 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 are using a gravity drip.
IV Push, or bolus, is the administration of medication from a syringe directly into an IV. This can be injected into the tubing or into a saline lock. The indications for use are2:
Consult the pharmacy, policy, or manufacturer’s insert if you do not know how quickly a medication push should be given. Most medication is given slowly. Push is rarely in less than 1 minute and may be as long as 30 minutes. A push that is too rapid can cause serious adverse effects.
The best practice recommended by the Institute of Safe Medication Practices include1:
Do not administer IV fluids and medications that have particulate matter or discoloration. Some medications will be colored fluid. If in doubt, double check. This cannot be checked for the few drugs that come in a dark bag because of the medication is light sensitivity.
Some medications required dilution, particularly medications that are irritating to the vein. If you are withdrawing the medication from a glass ampule, use a filter needle or straw unless contraindicated.
Alert: 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 pushing more than one medicine.
Monitor the patient’s reaction during and after the push. Major adverse effects include2:
Minor adverse effects include2:
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.
Patient education includes 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. This most commonly occurs with the replacement of large blood volume, the patient is known to have cold agglutinins, and during cardiopulmonary bypass.2
Power injectors are used in radiology to deliver a specific amount of contrast media in a specific time. Contrast material is to be considered a vesicant solution. Check your patient after return from contrast injection for infiltration and extravasation.2
Never infuse medication or solution through a continuous IV that is infusing:
In most situations, medications will be delivered pre-mixed. If you have any doubts about compatibility with IV solutions and medications, ask the pharmacist or check your drug resource.
NS is compatible with most medications. However, check with your pharmacist if administering warfarin, Imipenem-cilastatin, meropenem, or nitroglycerin.3
D5W is also compatible with most medications. However, check with your pharmacist if administering pentobarbital Na, heparin, meropenem, or nitroglycerin. It is the preferred solution to administer insulin, lidocaine, norepinephrine, propranolol, and Zidovudine.3
Most medications are not compatible when given IV. Many medications have not been researched for IV administration compatibility. The safety practice is to never mix IV medications unless you are certain.