Patient Safety and IV Complications IV & Infusion Basics

Medication Errors Statistics 1.3 million people in the United States are injured by medical treatments each year Cost of medication errors range from $20-75 billion annually National Institute of Health estimates that 98,000 Americans die annually as a result of preventable medical errors To Err Is Human: Building a Safer Health System (2000). Institute of Medicine (IOM)

Be aware that IV Medications Are given directly into the blood stream Cannot be retrieved if there is an error Requires an antidote or dialysis to reverse or remove the medication Can cause tissue damage and necrosis if IV infiltrates Requires critical thinking and accountability by those who administer them Intravenous Medications Be aware that IV Medications

SAFETY- Infiltration vs. Extravasation The Infusion Nurses Society's national standards of practice require that a nurse who administers IV medication or fluid know its adverse effects and appropriate interventions to take before starting the infusion. A serious complication is the inadvertent administration of a solution or medication into the tissue surrounding the IV catheter--when it is a nonvesicant solution or medication, it is called infiltration; when it is a vesicant medication, it is called extravasation. Both infiltration and extravasation can have serious consequences: the patient may need surgical intervention resulting in large scars, experience limitation of function, or even require amputation. Nursing interventions include early recognition, prevention, and treatment (including the controversial use of antidotes, and heat and cold therapy). Hadaway, L. (2007). Infiltration and extravasation. American Journal of Nursing. Aug 107(8):64-72. SAFETY- Infiltration vs. Extravasation .

SAFETY- Incompatibility Interaction - Result of 2 meds that don’t mix well in an infusion line Physical and/or Chemical incompatibilities can cause: Additive or Synergistic Effect to the one of the medications Inactivation Effect of one of the medications Always separate incompatible or unknown compatibility drugs with a saline flush (SAS) Physical precipitation of Midazolam as a result of an unfavorable pH medium

IV Administration The Basics

“SAS” Method: for incompatible meds . “SAS” = Saline, agent, saline Technique used to give incompatible IV meds (saline block) SASASASASAS is the method used to give multiple meds at same scheduled time Initial saline = confirms patency Saline in between meds = creates saline block Final saline = Flushes meds in and prevents catheter from occluding SAS for IV Push (IVP) or IV Piggy Back (IVPB)

Back Priming The process of back priming or flushing requires a primary (or flush) bag and a secondary bag. Here’s the steps to success: Ensure roller clamp on secondary tubing is open Lower empty IVPB bag below primary bag and “back prime” primary IV solution into IVPB bag until line is cleared of mediation from previous infusion. Keep bag upright during the clearing process. Clamp secondary tubing Remove old IVPB bag and hang ordered IVPB medication Video on back priming is found later in tutorial

Dilution of Medications for IVP Some medications must be diluted Decreases phlebitis to the vessel, required for caustic medications! Some nurses dilute all medications Easier calculation and administration over allotted time The Institute of Safe Medicine Practices reports that the use of prefilled syringes for medication dilution increases the risk of medication errors. Dilution from a single use vial is always encouraged. Infusion Nursing Standards of Practice. (2011). Infusion Nurses Society. .

Process of Dilution for IVP If using a 10 mL prefilled syringe for dilution, empty out the quantity of saline that will be replaced by the medication. Use the smallest syringe possible to accurately draw up the medication from the multidose vial. Remove the needleless cap from the 10 mL syringe and inject the medication into the larger syringe. Replace the needleless cap. Gently mix the 2 solutions. ACCURATELY LABEL THE SYRINGE BEFORE SETTING IT DOWN TO PREVENT MEDICATION ERRORS. Single dose vial: If using a 10 mL prefilled syringe for dilution, empty out the quantity of saline that will be replaced by the medication. Aspirate the entire dose of medication from a single dose vial. Gently mix the 2 solutions. ACCURATELY LABEL THE SYRINGE BEFORE SETTING IT DOWN TO PREVENT MEDICATION ERRORS

Determining Rate of Administration: ROA IVPB via pump runs in mL/hour IVPB to Gravity runs in gtts/min IVP is delivered evenly over the prescribed time Pump infusion: mL of solution over time in hours Gravity flow: mL of solution x gtt factor over time in minutes IV push rate: administration rate based on medication instruction

Syringe Size Guidelines Peripheral lines 3-5mL syringe size The smaller the syringe size the greater the PSI pressure Central lines ALWAYS use 10mL syringe size (or larger) The larger the syringe the lower the PSI pressure Less risk of catheter rupture * Remember *: Always label all syringes!!

The Procedure IV Meds

IV Administration Start with the Order & Look the Medication up! Reliable sources for looking it up Micromedex Online resources Pharmacist IV med book Not so reliable A fellow student or nurse Drug insert

Ask yourself… Let’s work this through using the order from previous page- Lasix) Is it a safe dose for my patient? Why is my patient getting this med? Any precautions or side effects? What do I monitor before or after the med is given? Is it IVP or IVPB, how much solution is it diluted in? What IV site does the patient have? What’s running through it? Compatible or not? ROA? mL or gtts/min?

Is it safe? Why is my patient getting this med? Looking it Up! Is it safe? Why is my patient getting this med? Open your Gahart book and look up Furosemide. Follow along which what to find that is important.

How do I dilute it safely? Do I need to give this IVP or IVPB? How do I dilute it safely?

What is the rate at which I deliver this? Any precautions? What should I monitor?

What side effects might Is this medication compatible? What side effects might the patient have?

Answers… Is it a safe dose for my patient YES Why is my patient getting this med? CHF Any precautions or side effects? ↑ UO, ↓K+, ↓BP What do I monitor before or after the med is given? UO, K+ and BP Is it IVP or IVPB, how much solution is it diluted in? IVP, undiluted What IV site does the patient have? What’s running through it? Peripheral IV D5NS Compatible or not? Compatible ROA? mL or gtts/min? Dose over 1-2 minutes

Most Common IV Meds pantoprazole (Protonix) hydromorphone (Dilaudid) morphine ondansetron (Zofran) promethaine (Phenergan) ketorolac (Toradol) metoprolol (Lopressor) vancomycin ceftriaxone (Rocephin) levofloxacin (Levaquin) metronidazole (Flagyl) piperacillin (Zosyn) ampicillin (Unasyn) cefaolin (Ancef) clindamycin (Cleocin)

Steps to IV Administration

Medications via a Capped Line- IVP Gather Supplies: Prepared/ labeled syringe with ordered medication, 2 NS flushes, Alcohol swab Aseptically, aspirate/flush IV catheter to verify patency Aseptically administer IV push medication at prescribed ROA Flush IV catheter at same ROA as medication to fully clear line of all medication When line is cleared, complete flush at steady rate http://www.youtube.com/watch?v=xRTTUVNFlgs&feature=c4-overview&list=UUG7a6tFPh1wvF0QDMZ3DarQ

Meds via a Compatible IV Line- IVP Verify IVP medication is compatible with the primary solution Gather Supplies: prepared / labeled syringe with ordered medication, Alcohol swab Using port closest to patient, aseptically administer IVP medication at prescribed ROA Video link med on IV push (IVP) through a compatible line http://www.youtube.com/watch?v=qoG9aasJzcQ

Medications via a Capped Line- IVPB Gather Supplies: IVPB with ordered medication, NS flush, Alcohol swab, Normal Saline flush bag, long, primary tubing and short, secondary tubing if a new set up  Ensure roller clamp on secondary tubing is open Lower empty IVPB bag below primary bag and “back prime” primary IV solution into IVPB bag until line is cleared of mediation from previous infusion Clamp secondary tubing Remove old IVPB and hang ordered IVPB medication Aseptically, aspirate/flush IV catheter to verify patency Aseptically connect primary IV tubing to catheter site Fully open roller clamp on secondary tubing Regulate IVPB infusion using roller clamp on primary tubing. Determine and run at calculated ROA. After IVPB has completely infused, allow primary solution (NS flush bag) to infuse until line is fully cleared of all medication (primary bag will automatically begin infusing after IVPB has emptied) Close roller clamp on primary tubing Disconnect patient from IV set-up

Meds via a Compatible IV Line- IVPB Verify IVPB medication is compatible with primary solution Gather Supplies: IVPB with ordered medication Ensure roller clamp on secondary tubing is open Lower empty IVPB bag below primary bag and “back prime” primary IV solution into IVPB bag until line is cleared of mediation from previous infusion Clamp secondary tubing Remove old IVPB bag and hang ordered IVPB medication Fully open roller clamp on secondary tubing Regulate IVPB infusion using roller clamp on primary tubing. Determine and run at calculated ROA. *Primary solution will automatically begin infusing after IVPB bag has emptied, be sure to return to confirm primary solution is running at prescribed rate. Video link on back priming and setting pump for IVPB below… http://www.youtube.com/watch?v=99LA20UNYgk

Meds via an Incompatible IV line IVP IVPB Verify IVP medication is incompatible with primary solution Gather Supplies: Prepared / labeled syringe with ordered medication, 2 NS flushes, Alcohol swab Stop / pause primary infusion Using port closest to patient, aseptically flush IV line to fully clear tubing of incompatible primary IV solution Using port closest to patient, aseptically administer IVP medication at prescribed ROA Flush IV catheter at same ROA as medication to fully clear line of all medication When line is cleared of medication, complete flush at steady rate Open roller clamp to re-start infusion of primary solution DO NOT INFUSE AN IVPB THRU AN INCOMPATIBLE MAINLINE INFUSION If no other immediate IV access is available, follow the steps below: Disconnect incompatible mainline infusion Using a primary/secondary flush bag set-up, administer IVPB Following IVPB infusion/flush, disconnect from patient and re-connect mainline infusion

Practice Scenarios

IV site: peripheral capped line Order: ondansetron (Zofran) 4 mg IVP now On hand: ondansetron (Zofran) 2mg/mL (2 mL vial) Ask…. Safe dose? Why is my pt. getting this? Side effects? What do I need to monitor for? Dilute? IV solutions? Compatible? ROA? CATS PRRRL

If diluted If undiluted Dosage: Deliver ondansetron (Zofran) 4mg = 2mL Supplies needed: SAS, alcohol swabs If diluted If undiluted Purge 2mL NS from a 10mL prefilled syringe Dilute ondansetron with 8mL of NS for a total volume of 10 mL Label syringe Administer 1st saline using steady push-pause motion Deliver medication at 5 mL/min (10mL / 2min,) Deliver 1st mL of 2nd saline at same ROA as Zofran Draw up 2 mL ondansetron in 3 mL syringe Label syringe Administer 1st saline using steady push-pause motion Deliver medication at 1 mL/min (2mL / 2 min.) Deliver 1st mL of 2nd saline at same ROA as Zofran

New Set-Up Existing Set-Up Dosage: Deliver famotidine (Pepcid) 20 mg in 100 mL NS Supplies needed: SAS, primary and secondary flush bag set-up, alcohol swabs New Set-Up Existing Set-Up Prime primary flush bag set-up with long tubing. Spike medicated bag with secondary tubing and back prime to clear air in the line. Pug in to port closest to the bag of the primary line Confirm IV patency with saline flush Connect and run at 200 mL/hr (100 mL/30 min.). Program pump to infuse ~ 30 mL post flush Back prime secondary tubing into old IVPB bag. Spike IVAB to secondary line Confirm IV patency with saline flush Connect and run at 200 mL/hr (100 mL/30 min). Program pump to infuse ~30 mL post flush

Why is my pt. getting this? Side effects? IV site: Continuous Infusion D5.45 NS @ 100 mL/hr Order: ondansetron (Zofran) 4 mg IVP now On hand: ondansetron (Zofran) 2mg/mL (2 mL vial) Ask…. Safe dose? Why is my pt. getting this? Side effects? What do I need to monitor for? Dilute? IV solutions? Compatible? ROA? CATS PRRRL

If undiluted If diluted Dosage: Deliver ondansetron (Zofran) 4mg = 2mL Supplies needed: alcohol swabs If undiluted If diluted Purge 2mL NS from a 10mL prefilled syringe Dilute ondansetron with 8mL of NS for a total volume of 10 mL Label syringe Deliver medication at 5 mL/min (10mL / 2min,) Draw up 2 mL ondansetron in 3 mL syringe Label syringe Deliver medication at 1 mL/min (2mL / 2 min.)

Why is my pt. getting this? Side effects? IV site: Continuous IV D5 .45NS @ 100mL/hour Order: famotidine (Pepcid) 20 mg IVPB every 12 hours On hand: famotidine (Pepcid) 20mg/100mL NS prepared and labeled by pharmacy Ask…. Safe dose? Why is my pt. getting this? Side effects? What do I need to monitor for? Dilute? IV solutions? Compatible? ROA? CATS PRRRL

New Set-Up Existing Set-Up Dosage: Deliver famotidine (Pepcid) 20 mg in 100 mL NS Supplies needed: Secondary tubing, alcohol swabs New Set-Up Existing Set-Up Spike medicated bag with secondary tubing and back prime to clear air in the line. Pug in to port closest to the bag of the primary line Connect and run at 200 mL/hr for secondary piggyback (100 mL/30 min.). Back prime secondary tubing into old IVPB bag. Spike IVAB to secondary line Connect and run at 200 mL/hr (100 mL/30 min) for secondary piggyback.

IV site: Continuous Infusion D5 IV site: Continuous Infusion D5.45 NS with 20 mEq KCl@100 mL/hr Order: methylprednisolone (Solu-Medrol) 125 mg IVP now On hand: methylprednisolone (Solu-Medrol) 125 mg/2 mL (2 mL vial) Ask…. Safe dose? Why is my pt. getting this? Side effects? What do I need to monitor for? Dilute? IV solutions? Compatible? ROA? CATS PRRRL

If diluted If undiluted Dosage: Deliver methylprednisolone (Solu-Medrol) 125 mg IVP Supplies needed: SAS, alcohol swabs If diluted If undiluted Purge 2mL NS from a 10mL prefilled syringe Dilute methylprenisolone with 8mL of NS for a total volume of 10 mL Label syringe Stop/pause primary infusion, crimp tubing, Use the port closest to the patient, flush tubing with first saline syringe Administer medication at prescribed ROA: 5 mL/min (10ml/2 min total solution) Flush at same ROA as medication to clear line of all medication, then flush remaining solution Re-start infusion of primary solution Draw up 2 mL methylprednisolone in 3 mL syringe Label syringe Stop/pause primary infusion, crimp tubing, Use the port closest to the patient, flush tubing with first saline syringe Administer medication at prescribed ROA: 1 mL/minute (2mL/2 min) Flush at same ROA as medication to clear line of all medication, then flush remaining solution Re-start infusion of primary solution

IV site: Continuous Infusion Heparin 1000 u/hr Order: famotidine (Pepcid) 20 mg IVPB every 12 hours On hand: famotidine (Pepcid) 20mg/100mL NS prepared and labeled by pharmacy Ask…. Safe dose? Why is my pt. getting this? Side effects? What do I need to monitor for? Dilute? IV solutions? Compatible? ROA? CATS PRRRL

First Option Second Option Dosage: Deliver famotidine (Pepcid) 20 mg in 100 mL NS Supplies needed: Depends…. First Option Second Option Start a 2nd IV site Disconnect incompatible infusion for the length of the administration and set up as a capped line; IVPB infusion using a flush bag.

Documentation Sign MAR with initials, date, time, signature and any other required data Intake / Output: Record IVPB medication and flush solution once IV medication is completed. IVP medication is not recorded on I/O Narrative note – only needed if an unexpected event occurred (reaction, infiltration, etc.)

FAQ How much fluid is needed for the flush before or after a medication? Pre-flush to confirm patency = 3 to 10 mL NS Post IVP or IVPB: “The minimum volume of flush recommended is twice the internal volume of the catheter” (Standard 60). Most times your will see 3-10 mL for IVP and 20-30 mL for IVPB. Infusion Nursing Standards of Practice. (2011). Infusion Nurses Society.

FAQ Am I able to use the same syringe for both the pre and post flush when using SAS? “Consider a syringe or needle/catheter contaminated once it has been used to enter or connect to a patient, a patient's solution container, or administration set.” Infusion Nursing Standards of Practice. (2011). Infusion Nurses Society.

FAQ Do I need to wear gloves when administering an IV medication? “Standard Precautions are based on the assumption that every person is potentially infected or colonized with an organism that could be transmitted, and that all blood/body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible agents.” If you are going to be in contact with body secretions and/or your patient is infected, gloves should be used Infusion Nursing Standards of Practice. (2011). Infusion Nurses Society.

FAQ Is it safe to transfer medications from one syringe to another? Prefilled saline syringes should not be used for dilution of medications. Due to risk of serious medication errors, syringe to syringe drug transfer is not recommended Drawing up medications in an appropriately sized syringe which is then diluted into a 10mL syringe of PFSC. Syringe is labeled before the syringe leaves your hand. Infusion Nursing Standards of Practice. (2011). Infusion Nurses Society.

FAQ How long do I need to scrub an IV port with an alcohol wipe before accessing it? Most hospital policies say 15-30 seconds CDC does not offer specific guidelines, follow the institution’s policy Infusion Nursing Standards of Practice enforce the single use of each alcohol wipe Infusion Nursing Standards of Practice. (2011). Infusion Nurses Society.

If not….it’s OK…consider it differences in technique FAQ What do I do when I have EBP information that is different than what I see the nurses doing in practice? Ask 3 questions….. Is patient safety being compromised? Is aseptic technique being compromised? Is a hospital policy and procedure being compromised? If not….it’s OK…consider it differences in technique