Refocusing on Medication Safety:

Best Practices for Injection Safety

Refocusing on Medication Safety:

Best Practices for Injection Safety
Christina Michalek, BS, RPh, FASHP
Medication Safety Specialist
Michelle Mandrack, MSN, RN
Director of Consulting Services

©2021 ISMP | www.ismp.org | 1

CE Activity Information & Accreditation

— This CE activity is jointly provided by ProCE, LLC and the Institute for
Safe Medication Practices (ISMP). ProCE is accredited by the
Accreditation Council for Pharmacy Education (ACPE) as a provider of
continuing pharmacy education.

— This CE activity is approved for 1.0 contact hours (0.1 CEU) in states
that recognize ACPE providers.

©2021 ISMP | www.ismp.org | 2

Disclosure
It is the policy of ISMP and ProCE, LLC to ensure balance, independence, objectivity and scientific rigor in all of its
continuing education activities. Faculty must disclose to participants the existence of any significant financial
interest or any other relationship with the manufacturer of any commercial product(s) discussed in an educational
presentation.
The speakers listed below have no relevant commercial and/or financial relationships to disclose:
Christina Michalek, BSc Pharm, RPh, FASHP
Michelle Mandrack, MSN, RN

Please note: The opinions expressed in this activity should not be construed as those of the CE provider. The
information and views are those of the faculty through clinical practice and knowledge of the professional
literature. Portions of this activity may include unlabeled indications. Use of drugs and devices outside of labeling
should be considered experimental and participants are advised to consult prescribing information and
professional literature.

©2021 ISMP | www.ismp.org 3| 3

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 Refocusing on Medication Safety:
Best Practices for Injection Safety

Online Evaluation and Statement of Completion

— www.ProCE.com

— Login with username and

password

— Deadline: January 14, 2022

Attendance Code = ??????

©2021 ISMP | www.ismp.org | 4

Learning Objectives
Following completion of this activity, participants will be able to:

1. Identify how stressors, such as the COVID-19 pandemic, challenge

medication safety efforts.

2. Considering pandemic-related disruptions, list strategies to prevent

medication errors, including the use of ready-to-administer
preparations.

3. Describe three best practices for the use of IV push medications.

4. Explain how best practices for IV push medications can provide

additional workflow benefits.

©2021 ISMP | www.ismp.org | 5

Bringing Medication Safety Back

into Focus
Christina Michalek, BS, RPh, FASHP
Medication Safety Specialist
Institute for Safe Medication Practices
[email protected]

©2021 ISMP | www.ismp.org | 6

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 Refocusing on Medication Safety:
Best Practices for Injection Safety

Early Stages
— Characterized by a lot of questions and a lot of practitioner-to-practitioner sharing

— Medication workflow related issues included limiting exposure and transmission

• Cleaning
• Automated dispensing cabinet refilling changes
• Medication delivery changes
• Pause in elective care; move toward telehealth care

— Extremes in drug shortages

— Conserving resources

— Changing responsibilities

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Settling In
— Event questions and tags
• Is this event related to COVID-19?

— Elimination or modification of workflow steps

• Don and doff of personal protective equipment

— The “new normal”

• What we stopped doing
• What we gave up doing
• What we continued to do
• Where we still had risk

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Present Challenges
— Vaccination – Positivity Rates – Surges

— The burden of COVID-19 on healthcare providers

— New job responsibilities

— Supporting healthcare practitioners

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 Refocusing on Medication Safety:
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Present Challenges
— Supply chain challenges

— Drug shortages

— Pandemic job losses

• Existing staffing shortages worsened by the pandemic
• Recent poll indicates job changes (resigned 18%; 12-19% consider leaving)

— Prioritizing safety

Morning Consult National Tracking Poll 2109015; Sept 2-8, 2021, morningconsult.com ©2021 ISMP | www.ismp.org | 10

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Pharmacy Specific Challenges

— “10 hospitals seeking pharmacy leaders” Becker’s Hospital Review

— “More than 23,000 pharmacy jobs posted in October” JobRx

• Health-systems (50%)
• Pharmacy technician (52%)

— Vaccine expansion; monoclonal antibodies

— Drug shortages; shifting priorities

— Staff shortages outside the pharmacy department

https://www.beckershospitalreview.com/pharmacy.html
Pharmacy Jobs Report (PJR) Executive Summary; https://jobrx.com/pharmacy-jobs-report-executive-summary ©2021 ISMP | www.ismp.org | 11

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Refocusing on safety:
Risks with preparation of IV push medications

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 Refocusing on Medication Safety:
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Intravenous Injections

Common component
of healthcare delivery

• Combining
Harm can result if • Admixing
sterile products are not • Diluting
properly compounded • Pooling
• Reconstituting
and/or administered • Prepackaging

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Compounding Outside the Pharmacy

— 444 practitioners — 81% acute care or specialty
hospital
— 77% nurses
• 5% ambulatory surgery center
• Including advanced practice nurses
• 3% ambulatory infusion center
— 8% anesthesia providers • 3% physician practice setting or
• Certified Registered Nurse clinic
Anesthetists • 1% long term care
• Anesthesiologists

— 15% decentralized pharmacy staff,

physicians, and supervisors

https://www.ismp.org/acute-care/medication-safety-alert-november-5-2020 ©2021 ISMP | www.ismp.org | 14

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Compounding Outside the Pharmacy

Most frequently prepared sterile injectables

— Intravenous push medications

• Mostly medications transferred from vials to syringes (e.g., opioids, antiemetics,
antibiotics, proton pump inhibitors)

— Intermittent infusions
• Mostly using vial and bag adapter systems

— Intramuscular injections
• Mostly vaccines, antipsychotic and, antibiotics

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 Refocusing on Medication Safety:
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Compounding Outside the Pharmacy

Frequency of preparation

Intravenous
Intermittent Intramuscular
push
infusions injections
medications

Always or Always or Always or

often 58% often 53% often 39%

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Compounding Risks
Risk for medication errors

— 31% aware of or personally experienced errors when preparing or

admixing injectable medications
• The practitioner preparing the medication or solution is often the one administering it

— Top errors
• Wrong drug, dose, concentration, diluent or diluent volume (82%)
• No label or labelling error (81%)

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Compounding Risks
Sterility risks

— Microbial contamination of parenteral medications: clinical versus pharmacy

environment

— Literature review
• PubMed and EMBASE search; publication dates: 2000-2018

— Significantly higher contamination rates for preparation of parenteral

medication in the clinical environment

— Clinical area prepared products: Contamination rate = 1.09 – 20.7%

— Many potential contributing factors: environment, staff, training, frequency,

aseptic technique

Larmene-Beld KHM, Frijlink HW, Taxis, K A systematic review and meta-analysis of microbial contamination of parenteral
medication prepared in a clinical versus pharmacy environment. Eur J Clin Pharmacol. 2019 May;75(5)609-617. ©2021 ISMP | www.ismp.org | 18

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Additional Risks
Workflow time study: Wasting IV push opioids

— Primary objective: quantify the waste associated with administering select

opioids IV push

— Waste included the amount of drug wasted and the time associated with the
process

— Workflow time study design, a sub-set of continuous direct observation time

motion studies was employed in inpatient care areas at two sites

— 669 distinct waste observations; combined loss of $1605.39; workforce time

waste $489.51
• Secondary measures: 86 observations included interruptions; average time removal to
disposal 2 hours

Hertig J, et al. A continuous observation workflow time study to assess intravenous push waste. Hosp Pharm 2020;56(5):584-591. ©2021 ISMP | www.ismp.org | 19

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Pharmacy’s Role
How can pharmacy minimize these risks?

— Work towards eliminating compounding outside the pharmacy

• How?
• Need to understand the what and why

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Pharmacy’s Role
Pharmacy compounding can also be associated with risk

— 634 pharmacy practitioners — 57% using some form of

• 80% pharmacists technology
• 18% technicians
• 2% student, resident, safety officer

— 87% hospital pharmacy

environment

https://www.ismp.org/acute-care/medication-safety-alert-october-22-2020 ©2021 ISMP | www.ismp.org | 21

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 Refocusing on Medication Safety:
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Compounding Risks
— Observational studies of manual compounding processes identified a
mean daily error rate of 9%

— Automation identified 7.1% error rate

— When compared to manual processes, technology-assisted

compounding provided a safety benefit detecting 14 times more errors

Flynn BA, Pearson RE, Barker KN. Observational study of accuracy in compounding i.v. admixtures at five hospitals. Am J Health
Syst Pharm 1997;54:904-12
Reece KM, Lozano MA, Roux R, Spivey SM. Implementation and evaluation of a gravimetric i.v., workflow system in an oncology
ambulatory care pharmacy. Am J Health-Syst Pharm. 2016;73(3):165-73
Eckel SF, Higgins JP, Hess E. Multicenter study to evaluate the benefits of technology-assisted workflow on iiv.. room efficiency, ©2021 ISMP | www.ismp.org | 22
costs, and safety. Am J Health-Syst Pharm. 2019; 76(12):895-901

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Compounding Risks
— 74% of all respondents were aware of at least one pharmacy
compounding error in the past 12 months
• This included those caught and corrected in the pharmacy as well as those
discovered after dispensing
• A higher percentage of pharmacists were aware of the errors (79%) compared to
technicians (67%)

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Pharmacy Challenges

Verification process

Training/Competency

Insufficient Technology

Staffing

Space

Workload

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 Refocusing on Medication Safety:
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Additional Risks
Potential for diversion in all settings

— Many of these medications are controlled substances

— 1 in 10 health professionals struggle with addiction or abusing drugs not prescribed

• 10% - 15% will inappropriately use substances over their career

— Healthcare workers pattern of drug abuse and dependency is unique to the general
population
• Tends to follow drug availability
• Job related stressors
• See the positive effects drugs have on patients
• Comfort level with use; I’m in control

— Risk exposure: routinely supplying more than needed; allowing manipulation or

products, especially when not supported, workflow required to close the loop

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Bringing safety into focus.

What can we do now to support

safety injection practices?

©2021 ISMP | www.ismp.org | 26

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Bringing Medication Safety into Focus

— Stressors

— Disruptions — What actions or decisions can

eliminate risks and improve
— Intravenous push preparation medications safety?
risks
• Infection control breeches
• Medication Errors — What can you stop or start doing
• Diversion risks to improve safety?
• Gaps in training
• Gaps in high-leverage strategies

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 Refocusing on Medication Safety:
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Bringing Medication Safety into Focus

— Eliminate the need for compounding and potential risk of hospital-
acquired infections by capitalizing on the purchase of commercially-
manufactured products

— Remove the need for compounding outside the pharmacy environment

by dispensing intravenous push medications in ready-to-administer
dosage forms

— Reduce the steps required for wasting controlled substances by

providing patient-specific doses of intravenous push controlled
substances in ready-to-administer dosage forms

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Best Practices for Injection Safety

Michelle Mandrack, MSN, RN
Director of Consulting Services
Institute for Safe Medication Practices
[email protected]

©2021 ISMP | www.ismp.org | 29

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COVID’s Toll on Clinicians

— Staffing shortages

— Crisis care

— Moral distress

— The Great Resignation

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 Refocusing on Medication Safety:
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Significant potential for error TROUBLE

AHEAD

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Consider Impact on Medication Administration

— Nurses spend 26.9% of their time on
the critical task of medication
administration
• “Most significant amount of time
spent on obtaining and verifying
medications”

— Approximately ⅔ of medication
administration time related to drug
delivery to the patient

— Other ⅓ spent preparing drugs for

administration

Keohane, CA, Bane, AD, Featherstone, E, Hayes, J, Woolf, S, Hurley, A, et.al. Quantifying Nursing Workflow in Medication
Administration. JONA. 2008;38 (1), pp 19-26.
Hendrich, A, Chow, M, Skierczynski, BA, Lu, Z. A 36-Hospital time and motion study: how do medical-surgical nurses spend
their time? The Permanente Journal. 2008;12(3), pp 25-34. ©2021 ISMP | www.ismp.org | 32

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IV Push Medication Use

— Essential component of care

— Clinically advantageous

— Many high-alert medications are

administered IV

— Errors in use have potential for

serious harm

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 Refocusing on Medication Safety:
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Factors that Increase the Risk of Errors with

IV Push Medications
— Using part of a vial or ampule, or more than one vial or
ampule for a single dose

— Manipulations needed to prepare medications (e.g., vial-to-

syringe, syringe-to-syringe transfer, dilution)

— Reconstitution of powders with specific diluents

— Dilution of some concentrated injectable drugs

ISMP. Errors with injectable medications: unlabeled syringes are surprisingly common! ISMP Medication Safety
Alert! 2007;12(23):1-2. ©2021 ISMP | www.ismp.org | 34

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Unnecessary or Improper Dilution

— ISMP survey on dilution practices (adults) N =1,773
• 83% further dilute IV push medications

• Common medications

ISMP. Part I: Survey results show unsafe practices persist with IV push medications. ISMP Medication Safety Alert! 2018;23(22):1-5. ©2021 ISMP | www.ismp.org | 35

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Unnecessary or Improper Dilution

ISMP. Part I: Survey results show unsafe practices persist with IV push medications. ISMP Medication Safety Alert! 2018;23(22):1-5. ©2021 ISMP | www.ismp.org | 36

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 Refocusing on Medication Safety:
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Unnecessary or Improper Dilution

— Volume of diluent and method to determine the volume of
diluent is variable
• Most had personal formulas
◦ 1 mL per minute of time needed to slowly administer drug
◦ Different if peripheral or central line

• No respondents described a dilution process that would result

in a specific concentration

• 43% reported policies or guidelines on dilution

ISMP. Some IV medications are diluted unnecessarily in patient care areas, creating undue risk. ISMP Medication Safety Alert! ©2021 ISMP | www.ismp.org | 37
2014;19(2):1-5.

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Use of Pre-Filled Flush Syringes for Dilution

— 81% use flush syringes for drug

dilution
• 56% reported this practice 50% of the
time

• 19% reported always

— Most often, the syringe is not

relabeled or labeled

ISMP. Part I: Survey results show unsafe practices persist with IV push medications. ISMP Medication Safety Alert! 2018;23(22):1-5. ©2021 ISMP | www.ismp.org | 38

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Misuse of Vials, Syringes, and Needles

— Survey on Carpuject™ prefilled
syringes (N=540)
• Looking at issue of overfill and
whether nurses were aware
• Many nurses not concerned about
overfill because they withdrew doses
from the cartridges using a syringe
• Using cartridges as single-/multiple-
dose vials

ISMP. ISMP survey reveals user issues with Carpuject prefilled syringes. Nurse Advise-ERR. 2012;17(16):1-3. ©2021 ISMP | www.ismp.org | 39

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Prefilled Syringe Cartridges as Single- and Multiple-Dose Vials

— Risk of: — Contributing factors:

• Contamination • Desire or need to dilute medication
before injection
• Unlabeled/mislabeled syringes
• Unavailability of syringe holders
• Dosing or measurement errors
• “This is how I was taught”
• Loss of barcode for scanning on
prefilled cartridge

• Risk of conditions that may

facilitate drug diversion of
products documented as “wasted”

ISMP. ISMP survey reveals user issues with Carpuject prefilled syringes. Nurse Advise-ERR. 2012;17(16):1-3. ©2021 ISMP | www.ismp.org | 40

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IV Administration Errors
— American Nurses Association (ANA) Medication Errors and Syringe Safety Are
Top Concerns for Nurses

• 99% believed risk to patients is serious

• Errors most likely to happen during the preparation and administration of IV

medications

— Giving IV push medications too fast is most common type of IV drug errors

• 43% to 69% (majority clinically significant)

• Wide variability in rates of administration

• Drug characteristics and fast rates associated with pain, phlebitis, other complications

Medication Errors and Syringe Safety Are Top Concerns for Nurses According to New National Study [press release].
http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2007/SyringeSafetyStudy.aspx. Silver Spring, MD: American Nurses Association; June 18, 2007. Fahimi F, Ariapanah P, Faizi M, et
al. Errors in the preparation and administration of intravenous medications in the intensive care unit of a teaching hospital: an observational study. Aust Crit Care. 2008;21(2):110-6.
Taxis K, Barber N. Incidence and severity of intravenous drug errors in a German hospital. Eur J Clin Pharmacol. 2004;59(11):815-7.
ISMP. ISMP. How fast is too fast for i.v. push medications? ISMP Medication Safety Alert! 2003;8(1):1.
Pinkney S, Fan M, Chan K, et al. Multiple intravenous infusions. Phase 2b: laboratory study. Ont Health Technol Assess Ser. 2014;14(5):1-163.
Vijayakumar A, Sharon EV, Teena S, Nobil S, Nazeer I. A clinical study on drug-related problems associated with intravenous drug administration. J Basic Clin Pharm. 2014; 5(2):49–53.

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Wrong Rate Event

— Physician prescribed 20 mg labetalol IV bolus for ED patient with
hypertensive crisis

— Nurse retrieved medication quickly but patient being moved to

radiology

— Enroute, nurse administered the drug in seconds

— Patient immediately arrested

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Rates of IV Push Medication Administration

— 2-5 minutes is a LONG time
when administering medication

— Clocks showing elapsed time

improve practice

McDowell SE, Mt-Isa S, Ashby D, Ferner RE. Where errors occur in the preparation and administration of intravenous
medicine: a systematic review and Bayesian analysis. Qual Saf Health Care. 2010;19(4):341-5.
Vijayakumar A, Sharon EV, Teena S, Nobil S, Nazeer I. A clinical study on drug-related problems associated with ©2021 ISMP | www.ismp.org | 43
intravenous drug administration. J Basic Clin Pharm. 2014; 5(2):49–53.

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Limited or Absent Labeling

— Labels on clinician-prepared
syringes more likely to be
limited or absent
• 28% reported less than 10% of the
time

• Only 50% reported always

• Significant amount of “labeling”

appears to be taping vial to syringe

Medication Errors and Syringe Safety Are Top Concerns for Nurses According to New National Study [press release].
http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2007/SyringeSafetyStudy.aspx. Silver Spring, MD: American Nurses
Association; June 18, 2007.
ISMP. Part I: Survey results show unsafe practices persist with IV push medications. ISMP Medication Safety Alert! 2018;23(22):1-5. ©2021 ISMP | www.ismp.org | 44

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Absent Labeling Event

—A syringe containing vecuronium was prepared for a trauma patient

—Medication not used, and syringe set down near saline flushes

—Vecuronium later used to flush the IV line of an alert 3-year-old girl

—Child became flaccid and respiratory efforts ceased

—Quickly intubated and ventilated, so permanent harm averted

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 Refocusing on Medication Safety:
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Labeling of Self-Prepared Syringes

Reasons syringes are not labeled when prepared

away from the bedside

Not necessary if only 1 medication is prepared 51%

Not necessary if only 1 syringe is prepared 45%
In an emergency 39%
Too time-consuming 20%
No labels are available 20%
Not an expectation 12%
Able to distinguish between multiple unlabeled 7%
syringes by visual appearance or location

ISMP. Part I: Survey results show unsafe practices persist with IV push medications. ISMP Medication Safety Alert! 2018;23(22):1-5. ©2021 ISMP | www.ismp.org | 46

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Clinician-Prepared Medications
— Clinician-prepared syringes are
common
• ANA survey: 44% of nurses administer IV
push medications more than 5 times each
shift7

— ISMP survey, 75% reported less than half

of the time IV push medications provided
in pharmacy-prepared or commercially
available ready-to-administer syringes

Medication Errors and Syringe Safety Are Top Concerns for Nurses According to New National Study [press release].
http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2007/SyringeSafetyStudy.aspx. Silver Spring, MD:
American Nurses Association; June 18, 2007.
©2021 ISMP | www.ismp.org | 47
ISMP. Part I: Survey results show unsafe practices persist with IV push medications. ISMP Medication Safety Alert! 2018;23(22):1-5.

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Safe Practice Guidelines for Adult IV Push Medications

1. Acquisition and Distribution of Adult IV
Push Medications

2. Aseptic Technique

3. Clinician Preparation

4. Labeling

5. Clinician Administration

6. Drug Information Resources

7. Competency Assessment

8. Error Reporting

https://www.ismp.org/guidelines/iv-push ©2021 ISMP | www.ismp.org | 48

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Safety Hierarchy
• Failure-mode proposed strategies
High Level • Use commercially-available, or pharmacy-prepared patient-specific doses
• Use automation and technology to assist human decision making

• Limit complexity and access

• Provide decision support or reminders at the point of order entry,
Mid-Level verification, and administration
• Consider the use of redundancies e.g., independent checks
• Provide ready to apply barcoded labels

• Create policies and expectations for practice

Low Level • Educate providers about added risk
• Validate compounding competencies

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Key Risk Reduction Strategies for Safety and Efficiency

High Leverage
— Provide IV push medications
in ready-to-administer form
• Minimize the need for
manipulation outside of the
pharmacy sterile compounding
area

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Ready-to-Administer Guidance
— ISMP Safe Practice Guidelines for Adult IV Push
Medications

— Infusion Nurses Society: Infusion Therapy Standards of

Practice

— ASHP-PPAG Guidelines for Providing Pediatric Pharmacy

Services in Hospitals

— The Joint Commission Medication Management Standards

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Key Risk Reduction Strategies for Safety and Efficiency

Medium Leverage
— Provide the rate of IV push administration on the MAR

— Provide clinical units with blank or printed, ready-to-

apply labels, including sterilized labels where needed,
to support safe labeling practices

— Appropriately label all clinician-prepared syringes of IV

push medications or solutions, unless the medication
or solution is prepared at the patient’s bedside and is
immediately administered to the patient without any
break in the process

— Do NOT withdraw IV push medications from

commercially-available, cartridge-type syringes into
another syringe for administration

— Do NOT dilute or reconstitute IV push medications by

drawing up the contents into a commercially available,
prefilled flush syringe of 0.9% sodium chloride

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Key Risk Reduction Strategies for Safety and Efficiency

Lower Leverage
— Provide instructions and access to the
proper diluent when reconstitution or
dilution is necessary outside of the
pharmacy sterile compounding area

— Provide standardized, facility-approved

IV push medication resources at the
point of care to guide the safe practice
of IV push medication administration

— Only dilute IV push medications when

recommended by the manufacturer,
supported by evidence in peer-reviewed
biomedical literature, or in accordance
with approved institutional guidelines

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Questions?

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 Refocusing on Medication Safety:
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Online Evaluation and Statement of Completion

— www.ProCE.com

— Login with username and

password

— Deadline: January 14, 2022

Attendance Code = 64VE9K

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