Chapter 7: Parenteral Medication Administration
7.2 Preparing Medications from Ampules and Vials
Critical Thinking Exercises: Questions, Answers, and Sources / References
- Describe three strategies the nurse might do to reduce distractions while preparing medication. Answer:
a. Implement changes to medication practices with staff involvement and staff champions
b. medication preparation areas and include signage that identifies distraction free zones
c. Staff to wear signage to educate patients, facilities / visitors in an effort to educate and involve them in safe medication practices
d. Encourage a culture where staff, patients and families / visitors recognize the importance of not interrupting the nurse during medication preparation.
Source: Connor, J., et al. (2016). Implementing a distraction free practice with the red zone medication safety initiative. Dimensions of Critical Care Nursing Vol. 35 / No. 3 Wolters Kluwer Health, Inc. DOI: 10.1097/DCC.0000000000000179
2. Identify three strategies the nurse should do to prevent infection associated with parenteral medication administration.
| Principle / strategy | Additional Information |
| Perform hand hygiene. | Always perform hand hygiene before administration and after removing gloves. |
| Prevent needle/syringe contamination. | Keep sterile parts of the needle and syringe sterile. Avoid letting the needle touch unsterile surfaces such as the outer edges of the ampule or vial, surface of the needle cap, or counter. Always keep the needle covered with a cap when not in use, and use the scoop-cap method to avoid needle-stick injuries. Avoid touching the length of the plunger. Keep the tip of the syringe sterile by covering with a cap or needle. |
| Prepare patient’s skin. | Wash the patient’s skin with soap and water if it is soiled with dirt, drainage, or fecal matter/urine. Follow agency policy for skin preparation. When using an alcohol swab, use a circular motion to rub the area for 15 seconds, and then let the area dry for 30 seconds. If cleaning a site, move from the centre of the site outward in a 5 cm (2 in) radius using friction. |
| Prevent contamination of solution. | Use single-dose vials/ampules whenever possible. Do not keep multi-dose vials in patient treatment area. Discard if sterility is compromised or questionable. Do not combine and administer medications from single-dose vials or ampules for later use. Ampules should not sit open and should be used immediately, then discarded appropriately. |
| Use new, sterile equipment with each injection. | Single use syringe and needle must be used with each patient. Always inspect packaging for intactness; inspect for dryness, rips, torn corners, and expiry date. If single use equipment is not available, use syringes and needles designed for steam sterilization. |
Copied from
Anderson, R. (2018). Clinical Procedures for Safer Patient Care – Thompson Rivers University Edition. Adapted from Clinical Procedures for Safer Patient Care by G. R. Doyle and J. A. McCutcheon. Chapter 7. 2 Preparing Medications from Ampules and Vials. https://pressbooks.bccampus.ca/clinicalproceduresforsaferpatientcaretrubscn/
Sources:
Centers for Disease Control (CDC). (2015). Injection safety. http://www.cdc.gov/injectionsafety/.
Children’s Hospitals and Clinics of Minnesota. (2018). Infiltration and extravasation care. https://www.childrensmn.org/educationmaterials/childrensmn/article/16565/infiltration-and-extravasation-care/.
Hutin, Y., Hauri, A., Chiarello, L., Caitlin, M., Stillwell, B., Ghebrehiwet, T., Garner, J., & Members of the Safe Injection Practices Development Group (2003). Best infection control practices for intradermal, subcutaneous, and intramuscular injections. http://www.who.int/bulletin/volumes/81/7/Hutin0703.pdf.
Perry, A., Potter, P., & Ostendorf, W. (2017). Clinical skills and nursing techniques (9th ed.). St. Louis, MO: Elsevier-Mosby.
Provincial Infectious Disease Advisory Committee. (2014). Best practices for hand hygiene in all health care settings (4th ed.). http://www.publichealthontario.ca/en/eRepository/2010-12%20BP%20Hand%20Hygiene.pdf.
Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2007). Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf.
3. Identify five principles of safe medication administration.
| Principle | Additional Information |
| Be vigilant when preparing medications. | Avoid distractions. Some agencies have a no-interruption zone (NIZ), where health care providers can prepare medications without interruptions. |
| Check for allergies. | Always ask patient about allergies, types of reactions, and severity of reactions. |
| Use two patient identifiers at all times. Always follow agency policy for patient identification. | Use at least two patient identifiers before administration AND compare against the medication administration record (MAR). Whenever possible, MARs and eMARs should be taken to the bedside. |
| Label all meds prepared away from the bedside. | Label should include 2 patient identifiers, drug, dose, time prepared, initials of the nurse who prepared it. Be confident that you know what you are administering. |
| Assessment comes before and after medication administration. | All medications require an assessment (review of lab values, pain, respiratory or cardiac assessment, etc.) prior to medication administration to ensure the patient is receiving the correct medication for the correct reason.
Assessment after medication administration helps to determine if the medication is having its intended effect and to determine possible adverse reactions |
| Be diligent in all medication calculations. | Errors in medication calculations have contributed to dosage errors, especially when adjusting or titrating dosages. If in doubt, ask a colleague for an independent double check. |
| Avoid reliance on memory; use checklists and memory aids. | Slips in memory are caused by lack of attention, fatigue, and distractions. Mistakes are often referred to as attentional behaviours, and they account for most errors in health care. If possible, follow a standard list of steps for every patient. |
| Communicate with your patient before, during, and after administration. | Provide information to patient about the medication before administering it. Answer questions regarding usage, dose, and special considerations. Give the patient the opportunity to ask questions. Include family members if appropriate. |
| Avoid workarounds. | A workaround is a process that bypasses a procedure, policy, or problem in a system. For example, nurses may “borrow” a medication from another patient while waiting for an order to be filled by the pharmacy. These workarounds fail to follow agency policies that ensure safe medication practices. |
| Ensure medication has not expired. | Medication may be inactive if expired. |
| Always clarify an order or procedure that is unclear. | Always ask for help whenever you are uncertain or unclear about an order. Consult with the pharmacist, charge nurse, or other health care providers and be sure to resolve all questions before proceeding with medication administration. |
| Use available technology to administer medications. | Technology has the potential to help decrease errors. Use technology that is available to you when administering medications, but be aware of technology-induced errors. |
| Report all near misses, errors, and adverse reactions. | Reporting allows for analysis and identification of potential errors, which can lead to improvements and sharing of information for safer patient care. |
| Be alert to error-prone situations and high-alert medications. | High-alert medications are those that are most likely to cause significant harm, even when used as intended. The most common high-alert medications are anticoagulants, narcotics and opiates, insulins, and sedatives. The types of harm most commonly associated with these medications include hypotension, respiratory depression, delirium, bleeding, hypoglycemia, bradycardia, and lethargy. High alert situations include: frequent dosing to the same patient (i.e., q4h insulin sliding scale; q1h morphine IV) , multiple meds (i.e., having to administer meds to multiple patients and each have multiple medications), high stress environments, noisy environments, and multiple distractions during medication preparation. |
| Independent double checks. | Two clinicians independently check each high-alert medication in relation to prescribing, dispensing, and administration (i.e., insulin, anticoagulants, IV direct medications).
Note: know your agency policy / guidelines about independent double check medications |
| Open medications at the bedside | Doing so gives you time to think about the rights of safe medications within each patient context and allows the patient an opportunity to ask questions. |
| If a patient questions or expresses concern regarding a medication, stop and do not administer it. | If a patient questions a medication, stop and explore the patient’s concerns, review the prescriber’s order, and, if necessary, notify the practitioner in charge of the patient. |
Copied from:
Anderson, R. (2018). Clinical Procedures for Safer Patient Care – Thompson Rivers University Edition. Adapted from Clinical Procedures for Safer Patient Care by G. R. Doyle and J. A. McCutcheon. Chapter 6.2 Safe Medication Administration. https://pressbooks.bccampus.ca/clinicalproceduresforsaferpatientcaretrubscn/
Sources:
Agency for Healthcare Research and Quality. (2014). Checklists. http://psnet.ahrq.gov/primer.aspx?primerID=14.
Canadian Patient Safety Institute. (2012). Canadian analysis incident framework. http://www.patientsafetyinstitute.ca/english/toolsresources/incidentanalysis/documents/canadian%20incident%20analysis%20framework.pdf.
Debono, D. S., Greenfield, D., Travaglia, J. F., Long, J. C., Black, D., Johnson, J., & Braithwaite, J. (2013). Nurses’ workarounds in acute healthcare settings: A scoping review. BMC Health Services Research, 13(175). doi: 10.1186/1472-6963-13-175.
Institute for Healthcare Improvement. (2015). High-alert medication safety. http://www.ihi.org/topics/highalertmedicationsafety/pages/default.aspx.
Institute for Safe Medication Practices (ISMP). (2018). High-alert medications in acute care settings. https://www.ismp.org/recommendations/high-alert-medications-acute-list.
National Patient Safety Agency. (2009). Safety in doses. Improving the use of medication in NHS. http://www.nrls.npsa.nhs.uk/resources/?entryid45=61625.
National Priority Partnership. (2010). Preventing medical errors: A $21 billion opportunity. http://psnet.ahrq.gov/resource.aspx?resourceID=20529.
Prakash, V., Koczmara, C., Savage, P., Trip, K., Stewart, J., McCurdie, T., . . . Trbovich, P. (2014). Mitigating errors caused by interruptions during medication verification and administration: Interventions in a simulated ambulatory chemotherapy setting. BMJ Quality and Safety, 23(11). https://doi.org/10.1136/bmjqs-2013-002484.
Shah, K., Lo, C., Babich, M., Tsao, N., & Bansback, N. (2016). Bar code medication administration technology: A systematic review of impact on patient safety when used with computerized prescriber order entry and automated dispensing devices [PMID: 27826157]. Canadian Journal of Hospital Pharmacy, 69(5), 394-402. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5085324/.
4. Describe two strategies to prevent needle-stick injuries.
| Principle / strategy | Additional Information |
| Avoid recapping needles. | Recapping needles has led to the transmission of infection. If possible, always use devices with safety features (i.e., safety shield) and engage the needle’s safety system. If absolutely necessary, use the scoop method of recapping. |
| Dispose of the needle immediately after injection. | Immediately dispose of used needles in a sharps disposal container (puncture-proof and leak-proof) to avoid unsafe disposal of a sharp. |
| Reduce or eliminate all hazards related to needles. | Avoid using needles if possible. Use a needle only when performing an SC, ID, or IM injection (i.e., blunt fill and blunt fill filters). Use a needleless system and engineered safety devices for prevention of needle-stick injuries. |
| Plan disposal of sharps before injection. | Plan the safe handling and disposal of needles before beginning a procedure that requires a sharp needle. Bring sharps container close to the bedside prior to injection. Sharps containers should be at eye level and within arm’s reach. |
| Participate in required training and education. | Attend training on injury-prevention strategies related to needles and safety devices as per agency policy. Participate in and evaluate the selection of safety devices, and report known needle-stick hazards to managers. |
Copied from: Anderson, R. (2018). Clinical Procedures for Safer Patient Care – Thompson Rivers University Edition. Adapted from Clinical Procedures for Safer Patient Care by G. R. Doyle and J. A. McCutcheon. Chapter 7.2 Preparing medications from ampules and vials. https://pressbooks.bccampus.ca/clinicalproceduresforsaferpatientcaretrubscn/chapter/safe-injection-administration-and-preparing-medication-from-ampules-and-vials/
Data sources:
American Nurses Association. (2002). Needlestick prevention guide. http://www.who.int/occupational_health/activities/2needguid.pdf.
Centers for Disease Control (CDC). (2012). NOISH fast facts (home healthcare workers). How to prevent needlestick and sharps injuries. http://www.cdc.gov/niosh/docs/2012-123/pdfs/2012-123.pdf.
National Patient Safety Agency. (2009). Safety in doses. Improving the use of medication in NHS. http://www.nrls.npsa.nhs.uk/resources/?entryid45=61625.
Perry, A., Potter, P., & Ostendorf, W. (2018). Clinical skills and nursing techniques (9th ed.). St. Louis, MO: Elsevier-Mosby.
Pratt, J. R., Pellowe, C. M., Wilson, J. A., Loveday, H. P., Harper, P. J., Jones, S. R., … Wilcox, M. J. (2007). Epic2: National evidence based guidelines for preventing health care associated infections in NHS hospitals in England. Journal of Hospital Infection, 65(1), S1-64. https://doi.org/10.1016/S0195-6701(07)60002-4.
Wilburn, S. Q. (2004). Needlestick and sharps injury prevention. The Online Journal of Issues in Nursing, 9(3). http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No3Sept04/InjuryPrevention.html.
Wilburn, S. Q., & Eijkemans, G. (2004). Preventing needlestick injuries among healthcare workers: A WHO-ICN collaboration. International Journal of Occupational and Environmental Health, 10(4), 451-456. https://doi.org/10.1179/oeh.2004.10.4.451.
- Describe 2 strategies to prevent needle stick injuries.
Answer: minimize use of needles when preparing medications by using blunt fill and blunt fill filters; scoop cap if necessary; prepare medications away from distractions
Sources: noted above in question #4.
2. Identify 5 guidelines for safe medication practices.
Answer:
-
- use 2 patient identifiers to correctly identify the patient
- Check for allergies
- Communicate with the patient before, during and after medication administration
- Clarify unclear orders before administration
- Assess before and after medication administration
- Report near misses
- Use technology to administer meds (ie. pyxis, bar codes, access to current literature)
- Be alert to high risk meds and error prone situations
Source: noted above in question #3.
3. Name two strategies to reduce the risk of harm from high-alert medications.
Answer: independent double check where another nurse performs a check of the medication separate from the person administering it; be vigilant when preparing meds, have another nurse verify calculations; be alert to high alert meds and high risk situations (multiple IV meds / frequent insulin administration)
Sources:
Institute for Healthcare Improvement. (2015). High-alert medication safety. http://www.ihi.org/topics/highalertmedicationsafety/pages/default.aspx.
Institute for Safe Medication Practices (ISMP). (2018). High-alert medications in acute care settings. https://www.ismp.org/recommendations/high-alert-medications-acute-list.