Part I: Survey results show unsafe practicespersist with IV push medications

In July and August 2018, we invited practitioners who administer intravenous (IV)push medications to adults to participate in a survey.1The survey was conducted inresponse to three prior ISMP surveys that revealed numerous risky practices associ-

ated with the administration of IV push medications. These included the withdrawal ofmedications from prefilled syringes or cartridges, unnecessary dilution of IV push med-ications, and nurse preparation or manipulation of IV push medications at the bedside.Although the 2018 survey demonstrates a reduction in some of these unsafe practices,a surprising number of practitioners still report using prefilled syringes or cartridges asvials, diluting IV push medications despite their availability in a ready-to-administerform, unsafe labeling practices, and preparing IV medications at the bedside. Some ofthese unsafe practices appear to be associated with ongoing drug shortages, systemvulnerabilities, and/or teaching strategies that perpetuate these practices.

Prior ISMP Surveys and GuidelinesIn 2010, we conducted a survey on the impact of the economic crisis on medicationsafety, which uncovered long delays in dispensing pharmacy-prepared IV solutions andan increase in nurses preparing or manipulating parenteral medications on the clinicalunit.2 In 2012, we conducted a survey to learn about practices when using CARPUJECTprefilled medication syringes, which exposed the widespread practice of using the car-tridge as a vial to withdraw the medication into another syringe prior to administration.3

In 2014, we conducted a survey on IV push medications, which revealed unnecessarydilution associated with medications that were dispensed in ready-to-administer forms.The survey also uncovered the inappropriate use of prefilled normal saline flush syringesto dilute IV push medications, which results in mislabeled syringes.4

To address these safety concerns and others, ISMP held a national summit of expertstakeholders in 2014, which resulted in publication of the ISMP Safe Practice Guide-lines for Adult IV Push Medications in 2015.5 Now, 3 years later, we have surveyedpractitioners to understand current practices associated with IV push medications andto determine if ongoing drug shortages and teaching strategies around this critical skillhave impacted current practices. In Part I, we present the findings from the latestsurvey. In Part II, which will appear in our next issue, we will provide recommendationsfor safe preparation and administration of adult IV push medications based on thesurvey results. We will also provide you with access to a new gap analysis tool as ameans to evaluate your organization’s adherence to ISMP’s best practice guidelines.

Respondent ProfileISMP thanks the 977 practitioners who participated in our 2018 survey. Participantsincluded nurses (93%), advance practice nurses (4%), and nurse anesthetists, anesthesi-ologists, and physicians (almost 3%). Most of the survey participants work in inpatientsettings, including medical-surgical units (31%), critical care units (24%), surgical areas(13%), emergency departments (12%), labor and delivery units (7%), oncology units (3%),and a variety of other inpatient units (4%). Only 6% of the participants work in outpatientlocations such as infusion centers, physician office practices, or diagnostic areas.

November 2018 Volume 16 Issue 11

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Entire bottle of nitroglycerin given,again! No, this is not a case from our oldfiles, but a new case of administering anentire bottle (25 tablets) of sublingual nitro-glycerin (Figure 1). During orientation, aninexperienced nurse administered the en-

tire bottle to a patient,which was witnessedby another nurse whoimmediately removedthe tablets from underthe patient’s tongue.Fortunately, the patientwas not harmed.

This event was likelyan unintended conse-quence of the 50-year-old “unit dose” safetyinitiative. The errorusually occurs be-cause most nurses

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Supported by educational grants from Novartis and Fresenius Kabi

ISMP welcomes two new 2018-2019 FDA/ISMP Safe Medication Management Fel-lows: Avani Bhalodia, PharmD, and MonaHammam, PharmD, MS. Avani and Monawill spend 6 months at ISMP and 6 monthsat the US Food and Drug Administration(FDA). Prior to the Fellowship, Avani wasworking as a hospital pharmacist at UnionHospital of Cecil County (Elkton, MD) aftercompleting a PGY1 Pharmacy Residency atJefferson Health (NJ). She received herPharmD from MCPHS University (Boston,MA) in 2014. Mona received her PharmD in2012 and her MS in Drug Regulatory Affairsin 2018 from Long Island University (Brook-lyn, NY). She was working as an emergencydepartment pharmacist at New York Pres-byterian Hospital, Weill Cornell Campus(New York, NY), prior to the Fellowship.

New FDA/ISMP Fellows

Figure 1. Entirebottle of 25 nitro-glycerin tablets wasgiven to a patient.

November 2018 Volume 16 Issue 11 Page 2

Ready-to-Administer SyringesOnly one-quarter (25%) of participants receive more than half of adult IV push medicationsin pharmacy-prepared or commercially available ready-to-administer syringes (Chart 1).Just 6% always receive ready-to-administer syringes. Most participants (75%) receive half

or fewer IV pushmedications inready-to-adminis-ter syringes. Eightpercent said theynever receiveready-to-admin-ister syringes—95% of these par-ticipants work ininpatient settings,

mostly medical-surgical units. The medications most frequently NOT provided in ready-to-administer syringes include:

Antiemetics (e.g., ondansetron, prochlorperazine, promethazine) Antipsychotics (e.g., haloperidol) Benzodiazepines (e.g., LORazepam, diazePAM) Antibiotics with short stabilityOpioids (e.g., fentaNYL, HYDROmorphone, morphine)PantoprazoleMetoprololFurosemide

While some of these medications are marketed in a prefilled syringe, the syringesare, or have been, in short supply, making availability problematic.

Withdrawing Medications from a Prefilled Syringe and Transferring to AnotherTwo-thirds (66%) of participants reported withdrawing medications from a prefilled syringe(or cartridge) and transferring into another syringe to administer some or all of an IV pushmedication dose—16% do this more than half of the time they encounter a prefilledsyringe. This may represent an increase from our 2012 survey, when 12% of respondentsreported concern about this unsafe practice in the comments section of the survey. Themost common reasons for withdrawing medication from a prefilled syringe are listed in

Table 1, with dilution leading the way.Based on survey comments, other rea-sons for withdrawing medications fromprefilled syringes are linked to drugshortages (e.g., to administer partialdoses to promote opioid conservation),the need to filter some medications incracked or particulate-containing pre-filled syringes (www.ismp.org/ext/122),and the erroneous belief that a 10 mLsyringe must be used to administermedications via an implanted port orperipherally inserted central catheter

(PICC). (According to the Infusion Nurses Society, clinicians should use a syringe appro-priately sized for the medication once patency has been confirmed using a 10 mL syringe.6)

DilutionOverall, 84% of participants reported that they have further diluted certain adult IV push

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consistently receive medications in unitdose packages; typically holding a singledose for patient administration. Unexpect-edly, a very small vial or bottle of medica-tion is dispensed that contains more thanone dose, and an assumption is made thatit also must contain a single patient dose.We often caution practitioners, manufac-turers, and compounders against placingmultiple doses in one container, but insome cases that is not possible. Nitro-glycerin tablets are one example.

Because of stability issues, nitroglycerintablets must be dispensed in their original25-count amber glass bottle and cannotbe unit dosed. For charging purposes,order entry systems require a dispensequantity of 25 tablets even though the doseis just one tablet at a time. So, scanningthe label will not cause an alert that thequantity in the bottle does not match theamount to be administered. In fact, whenthe nurse was asked why she adminis-tered 25 tablets, she stated that no alertwas issued when scanning the bottle, soshe thought the amount in the containerwas the correct dose.

To help avoid this error, ensure the med-ication administration record (MAR) andautomated dispensing cabinet (ADC)screens include instructions to adminis-ter just 1 tablet sublingually (with addi-tional doses as prescribed), and considerplacing a flag label on the glass bottlewith this same information. Packagingthe nitroglycerin vial in a plastic bag orplastic amber vial, and affixing a labellisting the per tablet strength and notationto administer just 1 tablet per dose, is alsoan option. Remind all practitioners whenpreparing or administering any medica-tion, “If you need more than 3 (pills, vials,or other dosage form), call the pharmacy.”

Suppository mix-up. Hospitals havebeen reporting dispensing errors withlook-alike packages of G&W Laboratoriesfoil-wrapped suppositories. In one case,prochlorperazine and promethazine sup-positories were mixed up. In another case,a nurse found bisacodyl and promethazinemixed with acetaminophen suppositoriesin an automated dispensing cabinet (ADC)

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© 2018 ISMP. Reproduction of the newsletter or its content for use outside your facility, including republication of articles/excerpts or posting on a public-access website, is prohibited without written permission from ISMP.

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Reason Percent of Respondents

Dilution 64No designated syringe (cartridge)holder 22

Taught to do this 15

Hard to read syringe dose increments 14Syringe without a needlelessconnector or removable needle(e.g., opioids, insulin, heparin)

14

Other 22

Table 1. Reasons practitioners withdraw medications fromprefilled syringes

6%

8%

19%34%

33%

Never

Rarely (1-10% of the time)

Sometimes (11-50%)

Often (51-95%)

Always (>95%)

Chart 1. Frequency of receiving ready-to-administer syringes

November 2018 Volume 16 Issue 11 Page 3

medications prior to administration. These findings are similar to our 2014 survey inwhich 83% of respondents further diluted certain IV push medications. However, the fre-quency of dilution has decreased since 2014 (Table 2). Pertaining to the containers inwhich IV medications are provided, medications available in single-dose vials weremost often diluted in both the 2014 and 2018 surveys. Yet, as many as 1 in every 5 partic-ipants still reported in 2018 that they sometimes, often, or always dilute medicationsprovided in multiple-dose vials (21%) or manufacturer’s prefilled syringes (16%). Dilutionwas least frequent with pharmacy-dispensed syringes that contain patient-specific doses(6%). While the frequency of dilution has decreased, the practice continues.

In our 2018 survey, opioids, anxiolytics/antipsychotics, and antiemetics were the mostfrequently diluted medications, regardless of the container in which the medication wasprovided. In fact, approximately three-quarters of participants reported further dilutionof opioids provided in both commercially available (78%) and pharmacy-dispensed(69%) prefilled syringes. Anticonvulsants, naloxone, insulin, and heparin were the leastfrequently diluted medications in the survey. Medications that were not included in thesurvey but frequently mentioned as being diluted included famotidine and pantoprazole.

Among participants who dilute adult IV push medications prior to administration,81% confirmed that they have used a prefilled 0.9% sodium chloride (saline) flushsyringe (commercially or pharmacy-prepared) for this purpose. Approximately 56%said they use a flush syringe to dilute medications at least half of the time, and 19%said they always do. When describing this practice, most participants did not includerelabeling of the flush syringe. This unsafe practice has increased in frequency sinceour 2014 survey, at which time 54% of practitioners said they had diluted medicationsusing a saline flush syringe. One possible reason for the increase may be the shortageof vials of 0.9% sodium chloride at the time of the survey, which many practitionersnoted in the comments section.

The primary factors that influenced a decision to further dilute adult IV push med-ications were associated with the desire to administer the drug slowly (94%), avoidpatient discomfort (70%), reduce the risk of extravasation (33%), and measure small-volume doses accurately (25%). Other reasons (13%) included drug-specific require-ments (e.g., LORazepam), facility policies, recommendations in drug references,and prior education.

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pocket (Figure 1). Nurses identified the errors(one visually, one via barcode scanning) inboth cases before patients received thewrong drug. If possible, pharmacies shouldpurchase these suppositories from differentmanufacturers to reduce labeling similarities.

We have contacted G&W Laboratoriesabout the need for improved labeling. In themeantime, nurses should scan the medica-tion prior to administration and contact thepharmacy if you find products mixed withinthe ADC pocket.

A drug shortage-related event. In anemergency department (ED), a woman withsevere abdominal pain was given 3 dosesof morphine 4 mg intravenous (IV) pushabout an hour apart. An additional dose wasgiven 2 hours later due to inadequate painrelief. A decision was made to admit thepatient, and because she was still in pain,the ED physician consulted with the admit-ting physician for admission orders. Dueto a shortage of HYDROmorphone, theadmitting physician ordered fentaNYL250 mcg IV push for one dose, not realizingthis was a very high dose given his unfamil-iarity with fentaNYL dosing. This high dosewas listed on the order entry screen, as thedrug is available in a 250 mcg/5 mL vial. Apharmacist verified the order and an EDnurse administered it. The patient’s husband,who was at the bedside, called for helpwhen his wife became unresponsive. Thepatient was found apneic but with a pulse.Assisted ventilation was started and nalox-one 2 mg IV was administered. The patientregained respiratory function with a blood

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Newsletter also partially supported by an educational grant from

Container Type

Percent of Respondents Most FrequentMedications Diluted

(2018 Survey Only)Year Never

0%Rarely1-10%

Sometimes11-50%

Often51-95%

Always>95%

Manufacturer’sprefilled syringe

2014 42 15 18 15 10Opioids, anxiolytics/anti-psychotics, antiemetics,diphenhydrAMINE,cardiovascular agents,ketorolac2018 70 14 11 4 1

Pharmacy syringewith patient-specific dose

2014 63 17 8 7 5Opioids, anxiolytics/anti-psychotics, antiemetics,cardiovascular agents,antibiotics, cortico-steroids 2018 86 8 4 1 1

Single-dose vial2014 9 14 35 28 14

Opioids, antiemetics,anxiolytics/antipsychotics,antibiotics, diphenhydr-AMINE, ketorolac2018 16 25 37 18 4

Multiple-dosevial

2014 36 15 23 15 11Opioids, antiemetics,anxiolytics/antipsychotics,cardiovascular agents,diphenhydrAMINE,antibiotics2018 65 14 14 5 2

Table 2. Frequency of further dilution of adult IV push medications and the most frequent medications diluted

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Figure 1. G&W bisacodyl, promethazine, andacetaminophen suppositories look nearly identical.Expired promethazine was among the three drugsmixed together in the same ADC pocket.

November 2018 Volume 16 Issue 11 Page 4

LabelingOnly half (50%) of the participants told us they always label IV push medications that areself-prepared away from the patient’s bedside. Comments suggest that labeling wassometimes accomplished by taping the vial to the syringe. More than a quarter (28%) ofparticipants said they rarelyor never label these syringes. Participants who said they did

not always label syringes preparedaway from the patient’s bedside told usthat labeling was not necessary if theyprepared just one medication (51%) orone syringe (45%) (Table 3). Surpris-ingly, 7% of participants said they couldeven distinguish between multiple sy-ringes without a label by visual appear-ance or location of the syringe. Amongthese participants, the most frequentways of distinguishing between two ormore unlabeled syringes was by thedifferent volumes of medication in eachsyringe (76%); the size of the syringes(40%); differences in needles, caps, or

medication colors (36%); orientation on a tray or sterile field (16%); or by carryingsyringes in different hands (12%) or pockets (12%).

Impact of Drug Shortages Given the continuing drug shortage crisis, approximately one-third of participantsagreed or strongly agreed with these statements:

I am giving more medications via IV push that were previously given as infu-sions (particularly antibiotics, antiemetics, proton pump inhibitors) (38%) I am required to prepare more IV push medications at the bedside (or waitlonger for pharmacy preparation and dispensing) (34%)IV push drugs are being provided in unfamiliar concentrations and packages(or in volumes greater than needed for each dose) (31%)I get less prefilled, ready-to-administer syringes than previously (particularlyin the correct concentrations or volumes) (31%)

Comments suggest that drug shortages also result in adverse outcomes such as delays intherapy due to pharmacy preparation of products in short supply, and drug waste. Evenwhen medications are provided in prefilled syringes, the amount of drug in the syringe isoften more than the patient’s dose, leading to product waste along with using additionalstaff time to document the wasting of drugs such as opioids. Numerous participants saidit seemed like they waste more medications than ever during drug shortages.

Learning to Administer and Dilute IV Push MedicationsMost participants learned how to administer IV push medications during their profes-sional training (79%), during orientation with their first professional position (56%)and/or current position (32%), from drug references (43%), and from on-the-job expe-riences (35%).

Approximately half of participants were taught to dilute adult IV push medicationsduring their professional training (53%) or during orientation to their first professionalposition (47%). About a quarter of participants were taught this practice during orien-tation to their current position (29%), and more than one-third learned it from on-the-job experiences (39%) or drug references (38%). Only 9% reported receiving no formalinstructions on diluting adult IV push medications.

> IV push medications—continued from page 3

Reason Percent of Respondents

Not necessary if I prepare only onemedication 51

Not necessary if I prepare only onesyringe 45

Emergency 39

Too time consuming 20

No labels available 20

Not an expectation 12Not necessary because I can distin-guish syringes by visual appearanceor location

7

Table 3. Reasons why syringes prepared away from thebedside are not labeled

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oxygen saturation of 100%. The patient didnot have any long-term consequencesfrom this dosing error.

It is not difficult to see how similar eventscould happen elsewhere. During order entry,the computer software defaulted to an orderentry string that allowed the prescriber toselect fentaNYL250 mcg IV without a warn-ing that this is a very high dose for mostpatients. The pharmacist overlooked the highdose because he was unfamiliar with fenta-NYL and extremely busy, with many med-ication orders awaiting approval in thequeue. The nurse was also unfamiliar withan appropriate dose range for fentaNYL inthis situation. The automated dispensingcabinet (ADC) in the ED was stocked withfentaNYL250 mcg vials and provided no high-dose warning when the drug was removed.

After this event, the hospital developed anopioid conversion chart to guide physiciansregarding equivalent opioid doses. The hos-pital also removed fentaNYL 250 mcg as aroutine option in the computer order entrysystem. FentaNYL 250 mcg may now onlybe ordered through a procedural sedationorder set. A high-dose alert, “Recommendmax dose of 50 mcg,” now appears whenprescribers choose fentaNYL100 mcg, anda high-dose alert must be acknowledgedwhen nurses remove fentaNYL vials con-taining 100 mcg or more from an ADC.

Nebulizer solution mix-up.A close callrecently occurred at a children’s hospital inwhich racepinephrine (ASTHMANEFRIN)inhalation solution was mistaken for ipratro-

pium bromide in-halation solutiondue to look-alikepackaging. Theunit-dose vials ofboth products,manufactured byNephron Phar-m a c e u t i c a l sCorporat ion,come in similarbarcoded over-wraps with awhite back-ground andgreen panels

continued from page 3

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Figure 1a. Ipratropiuminhalation solution (left) andolder Asthmanefrin (racepi-nephrine) inhalation solution(right) overwraps look alike.

November 2018 Volume 16 Issue 11 Page 5

ISMP Nurse AdviseERR(ISSN 1550-6304) © 2018 In-stitute for Safe MedicationPractices (ISMP). Subscribersare granted permission to re-

distribute the newsletter or reproduce its contents withintheir practice site or facility only. Other reproduction, in-cluding posting on a public-access website, is prohibitedwithout written permission from ISMP. This is a peer re-viewed publication.

Report medication and vaccine errors to ISMP:Call 1-800-FAIL-SAF(E), or visit www.ismp.org/MERP orwww.ismp.org/VERP. ISMP guarantees the confidentialityof information received and respects the reporters’wishes regarding the level of detail included in publica-tions.

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Editors: Ann Shastay, MSN, RN, AOCN; Judy Smetzer,BSN, RN, FISMP; Michael Cohen, RPh, MS, ScD (hon),DPS (hon); Russell Jenkins, MD; Ronald S. Litman, DO.ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044.Email: ismpinfo@ismp.org; Tel: 215-947-7797; Fax: 215-914-1492.

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Determining and Controlling the Rate of Administration Only about two-thirds (63%) of participants indicated that the rate of administrationof an IV push medication is provided on the patient’s medication administrationrecord or electronic health record. Many participants said they need to look up therate of administration in drug references (41%), in facility-specific guidelines (40%),or remember the rate from previous administrations (41%). Eighteen percent of par-ticipants reported that they administer all IV push medications over 2 to 5 minutes,so they don’t need to look up or know the specific rate of administration for eachdrug. A few reported they administer all IV push medications in less than 2 minutes.To control how fast they are administering IV push medications, 82% use a clock,watch, phone, or other timing device. To administer the dose over the desired time-frame, 38% stated that they give small incremental doses frequently, whereas 30%said they just apply constant pressure on the plunger.

ConclusionsMost participants in the recent survey do not receive IV push medications in ready-to-administer syringes and must prepare these medications prior to administration,which has only become more common during the ongoing drug shortage crisis.Various unsafe practices associated with preparing and administering IV push med-ications have been reported in our 2018 survey, including the withdrawal of medica-tions from one syringe (or cartridge) and transferring to another syringe, a practicethat has increased in frequency compared to our 2012 survey. Dilution is the mostcommon reason for withdrawing a medication from the prefilled syringe. Althoughthe frequency of diluting IV push medications has decreased since 2014, the practicecontinues.

When dilution occurs, most practitioners have used a saline flush syringe for thispurpose, an unsafe practice that has also increased since our 2014 survey. Althoughfurther dilution is often not necessary, the decision to dilute is often guided by adesire to administer the dose slowly to avoid adverse effects, reduce patient dis-comfort at the administration site, prevent extravasation, and measure small dosesaccurately. Unfortunately, saline flush syringes that contain a medication are rarelyrelabeled. Finally, more than a quarter of survey participants reported that theyrarely or never label IV push medications that have been prepared away from thebedside.

While these unsafe practices associated with IV push medication administrationhave been widespread for years, the drug shortage crisis has likely contributed totheir ongoing occurrence. Also, from our survey it seems that some of these unsafepractices are taught during training, orientation, or on-the-job experiences, perpetu-ating their occurrence.

In Part II, we will provide recommendations to improve the safety of adult IV pushmedication administration, based on the vulnerabilities identified in the 2018 survey.We will also provide access to a valuable tool to evaluate current practice.

References

ISMP. ISMP survey on IV push medication practices. ISMP Medication Safety Alert! Nurse AdviseERR.1)2018;16(7):4-5.ISMP. Survey shows recession has weakened patient safety net. ISMP Medication Safety Alert!2)2010;15(1):1-4.ISMP. ISMP survey reveals user issues with Carpuject prefilled syringes. ISMP Medication Safety3)Alert! 2012;17(16):1-3.ISMP. Some IV medications are diluted unnecessarily in patient care areas, creating undue risk.4)ISMP Medication Safety Alert! 2014;19(12):1-5.ISMP. ISMP safe practice guidelines for adult IV push medications. 2015. www.ismp.org/node/975)INS (Infusion Nurses Society). Infusion therapy standards of practice (standard 40, flushing and6)locking, practice criteria D3). J Infus Nurs. 2016;39(1S):S1-S159.

> IV push medications—continued from page 4

Practitioner in Residence opportunityHealthcare professionals can spend theweek of April 1-5, 2019 at ISMP’s office insuburban Philadelphia, PA, learning aboutmedication safety from experts. Participantswill learn to use ISMP’s unique model foridentifying and controlling areas of risk tosupport safety efforts in their organization.To learn more or to enroll, call 215-947-7797or visit: www.ismp.org/node/872.

that display the nonproprietary names in asmall, white font (Figure 1a, page 4). The dis-pensing mix-up was noticed before any

patients receivedthe wrong drug.While both prod-ucts are bron-chodilators, theirpharmacologydiffers; ipratro-pium is an anti-c h o l i n e r g i cwhereas racepi-nephrine acts onboth alpha andbeta receptors.

The company re-cently revised the racepinephrine label(Figure 1b) to help differentiate the products.Scanning the barcode on the overwrap canalso help verify that the correct product isbeing dispensed and administered.

continued from page 4

Figure 1b. Revised Asthma-nefrin (racepinephrine) labelwill help differentiate it fromthe ipratropium label.