Chapter 7: Parenteral Medication Administration

7.8 IV Medications Adverse Events and Management of Adverse Reactions

Critical Thinking Exercises: Questions, Answers, and Sources / References

  1. List four complications of IV medications, and preventive measures for each one.
Possible Complications related to IV medications and Related Interventions
Complications Related Interventions
a. Speed shock: A systemic reaction caused by the rapid injection of a medication into the circulation, resulting in toxic levels of medication in the plasma. Symptoms can include cardiac arrest, flushed face, headache, irregular pulse, shock, syncope, and tightness in the chest. Use a peripheral IV site, if possible, to allow for maximum hemodilution before the medication reaches the heart/brain. Stay with the patient and observe for symptoms or changes in vital signs and level of consciousness during and after administration. Stop the injection immediately if the patient develops signs or symptoms of circulatory (drop in BP), respiratory (dyspnea), or neurological (decrease in LOC) deterioration during administration.
b. IV medication is incompatible with IV fluids or residual meds in the same IV line: Results in chemical or physical changes in their composition. Precipitates may form, colour may change (e.g., IV fluid becomes cloudy in the IV tubing), or the change may not be visible. Therapeutic effect of the medication may be reduced, obliterated, or potentiated. Toxic substances may be formed. Always follow the guidelines in the PDTM. Do not mix medications in one syringe and only give one medication at a time. Never add medications to blood, blood products, or  parenteral nutrition. To avoid mixing of medications, ensure IV tubing and injection ports are flushed adequately between medication administrations.

If precipitates are noted in the tubing, stop the infusion. Prime a new IV line and change at the cannula site. Flush IV catheter with normal saline.

Document  and notify prescriber. Report incident as per agency policy.

c. IV site shows signs of phlebitis or irritation: Injection of medication into a vein may cause inflammation or roughening of the endothelial lining (phlebitis), which can result in thrombus formation.

Septic thrombophlebitis can result from poor aseptic technique.

Dilute and administer IV meds according to PDTM. Warm compress may encourage vasodilation and provide patient comfort. Monitor for signs and symptoms of phlebitis: redness, swelling, pain, blanching, and streaking. If these signs are present, stop infusion immediately. Discontinue access device and restart in another site.  If required, provide extravasation care as per agency policy.

Sepsis may present as fever, chills, general malaise. Report symptoms to prescriber and investigate cause of symptoms.

d. Medication may also be inadvertently injected into surrounding tissue (infiltration) and cause tenderness, swelling and pain. Some agents when infused into tissue cause these symptoms plus tissue necrosis and /or nerve damage. The later is referred to as extravasation. Agents that can cause extravasation include chemotherapeutic agents Ensure IVs are patent prior to administering IV medication. Monitor for signs and symptoms of infiltration.

Sites that are infiltrating must be stopped. Check to determine if the medication is a vesicant and follow agency protocols if infiltration has occurred..

Document and notify prescriber. Report incident as per agency policy.

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 7.8  IV Medications Adverse Events and Management of Adverse Reactions.



Alberta Health Services. (2009). Direct IV medications. Specialized clinical competency program

Children’s Hospitals and Clinics of Minnesota. (2018). Infiltration and extravasation care

Lynn, P. (2011). Photo atlas of medication administration (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.


2. Name two strategies to reduce the risk of harm from high-alert medications.

Answer: the top three factors that contribute to med errors in Canada include: communication, independent check processes, and insufficient knowledge (ISMP Canada, 2014a). As such strategies include: clear communication among nursing and other health professionals involved with medication processes; knowledge and compliance with following independent double checks; current and available medication resources including internet, text and pharmacy; strive to build a culture of inquiry where people feel safe to question, to acquire knowledge and to speak up when conditions have the potential to interfere with safe medication practices.

Other general principles to follow for safer med administration include:  (note these apply to ALL medications. Principles specific to high alert meds are highlighted).

Principles for Safer Medication Administration

Principle Additional Information
Be vigilant when preparing medications. Avoid distractions. Some agencies have a no-interruption zone where healthcare providers can prepare medications without interruptions.
Perform hand hygiene before preparing meds and after administration. Reduces risk of transmitting microorganisms.
Check for allergies. Ask about type of allergy and severity. Always ask patient about allergies, types of reactions, and severity of reactions.
Prepare medications for ONE patient at a time. Reduces risk of error during preparation.
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. Confirm patient ID using two patient identifiers (i.e., name and date of birth) and check against MAR.
For all medications being administered, review purpose, normal dose, route, common side effects, onset, peak, contraindications, and nursing considerations. Knowledge is key to safer medication administration.
Label all meds prepared away from the bedside. Label should include two patient identifiers, drug, dose, time prepared, and initials of the nurse who prepared it. Labeling clearly identifies the drug, dose, patient, and person preparing the medication. Be confident that you know what you are administering.
Assessment comes before, during, and after medication administration. Complete necessary focused assessment depending on what medication is to be administered (i.e., heart rate for beta blockers and calcium channel blockers; BP for diuretics, ACE inhibitors, and calcium channel blockers; INR for warfarin; blood glucose for antidiabetic agents; etc.).

Assessment after medication administration helps to determine if the medication is having its intended effect and/or 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 healthcare. If possible, follow a standard list of steps for every patient.
Communicate with your patient before, during, and after administration. Provides opportunities for patient education and continued assessment by the nurse.
Avoid work-arounds. A work-around 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 work-arounds 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 healthcare 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 through patient safety learning systems (PSLS) allows characteristics of each near miss, error, and adverse reaction to be tracked. Analysis of this information is intended to find root causes and solutions toward safer medication administration practices.
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, insulin, 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. High-alert meds require a second person verifier (insulin, anticoagulants, chemo, etc.—check agency policy). Two clinicians independently check each high-alert medication in relation to prescribing, dispensing, and administration (i.e., insulin, anticoagulants, IV direct medications).
When possible take MARs to the bedside, open medication packages at the bedside, and label medications prepared away from the bedside. Two identifiers and having MARs and comparing these with the wrist band reduces risk of administering medications to the wrong patient. Having MARs at the bedside provides a quick reference to assist with informing the patient. It gives the nurse time to think about the rights of safe medications within each patient context and allows the patient an opportunity to ask questions.
Use a system to help you keep track of which meds you’ve prepared. Some nurses use a “dot” on the MAR; others circle the medication on the MAR. Having a method to organize and keep track of medication preparation reduces risk of omission errors.
Follow the SEVEN rights of medication preparation (right patient, medication, dose, route, time, reason, documentation). Fundamental principles of safe medication administration intended to reduce risk of error.
Complete three checks before administration of medications. Labels on the medication must be checked for name, dose, and route, and compared with the MAR at three different times:


Fundamental principles of safe medication administration intended to reduce risk of error.

1. when the medication is taken out of the drawer / dispensing system;

2. when the medication is being poured;

3. After the medication is poured and PRIOR to the medication being administered.

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 physician’s order, and, if necessary, notify the prescriber.
Provide patient education. Provide information to patient about the medication before administering it. Patients should known what medications they are receiving and what the intended purpose is, any significant side effects, and special considerations. Give the patient the opportunity to ask questions. Include family members if appropriate.
Strive to give medications on time. Consult agency guidelines for medication administration “windows”. The historic 30 minute window on either side of the medication administration time is debatable for some medications. See Table 6.2.
Sign the MAR AFTER the medication has been administered. Ensures right documentation.
Check MAR to guide you to which medications you are preparing. Follow agency policy to ensure MARs are accurate and verified appropriately. An MAR that is checked by more than one healthcare professional provides a very reliable record for administering medications. Agencies may vary in relation to MAR verification processes.

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.


Data sources:

Agency for Healthcare Research and Quality. (2014). Checklists.

Canadian Patient Safety Institute. (2012). Canadian analysis incident framework

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

Institute for Safe Medication Practices (ISMP). (2018). High-alert medications in acute care settings

National Patient Safety Agency. (2009). Safety in doses. Improving the use of medication in NHS

National Priority Partnership. (2010). Preventing medical errors: A $21 billion opportunity

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).

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.



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