Published Aug 31, 2001
I was wondering how many nurses still have to mix some of their own IV's. The small hospital I work at does not have a 24 hour pharmacy, so sometimes we end up mixing our own IV's. We even have to mix our own IV's with Potassium Chloride because admininstration says the premixed bags are too expensive. How do we convince them that having Potassium Chloride on the floors is downright dangerous and just asking for a fatal med error? I really don't mind mixing the few IV's I have to after the pharmacy is closed, but I do not like having the potassium choloride on the floor. Any ideas on how to convince people who have no concept of how dangerous this is to get us the premixed bags? Thanks!!!
canoehead, BSN, RN
We used to treat KCl as a narcotic, it had to be signed out and counted. Then after a state survey we went to premixed bags that must be signed out of the pharmacy by a supervisor.
Counting and witnessing waste etc seemed to work well as it means someone else needs to double check what you are giving.
Any ideas on how to convince people who have no concept of how dangerous this is to get us the premixed bags? Thanks!!!
This may take some time on your part, but I would go to the CINAHL data base and do a literature search for any research studies that address this problem. Find the research articles either at your hospitals library or a college library and make a written statement to your administrator addressing the issue and using the research findings to back up your stance.
Canoehead also had a good idea to have these dosages checked by 2 or more nurses prior to administration.
Either way, state your case and ask to have a protocol either written or changed to maintain patient safety. It's like you said, they have no idea how dangerous it is. Educate them about the dangers. :)
When I started in nursing we mixed all of our own IV meds, including potassium. The saying was "If you did not mix it, you do not hang it". The theory was that if you did not mix it yourself then you did not really know what was in it.
When pharmacy first started mixing the IV's it made me very nervous. More than one mistake was caught only because the fluid was the wrong color for what was supposed to be in the bag. Quite truthfully it still bothers me. Think about it--you are hanging a bag of fluid that will go directly into someones circulatory system. Do you really know what is in that bag of fluid???
Pharmacists are people, people make errors. I would hate to be responsible for hanging a fluid that was mixed wrong, but the way it is today you just have to pray that what the label says is correct.
Have you never found a wrong drug dispensed by your pharmacy?
I have and in more than one facility.
I do not want to minimize the danger of potassium BUT many other drugs are just as dangerous. I have always felt that the big push on not having potassium on the units was started by the drug suppliers--like your facility says--the pre-mixed bags are very expensive and the drug is actually very cheap. They make a great deal more money on the premixed potassium.
I, too, work in a facility that does not have 24 hour pharmacy available. My question has always been"If I am qualified to mix the drug when pharmacy is not here why am I not qualified to do it all the time? Of course, on the other hand, it is a convenience and a time saver to have someone else do part of my job for me I guess.
Oh well, did not mean to ramble. Maybe I am just one of those "old nurses" that is a little resistant to change for changes sake.
We ALWAYS mix our own gtts. The only thing we get from pharmacy is IVF's with KCL in them. When pharmacy is asked to mix a critical gtt,.....the call us and ask how it should be mixed!!!!! :eek: The exception to that is Dopamine, Dobutamine, and Lidocaine,.....these come in pre-mixed bags when we request them from pharmacy.
Ellen in Ont
The only premixed IV fluids we use are Lidocaine and Heparin. Everything else we mix ourselves. KCL is treated no differently than any other drug in our stock cupbaord and is even kept on the shelf beside the 10 and 30cc bottles of NS and sterile water. This has always made me a little nervous. Now I think I will ask about at least having it moved to a separate location.
My experience is on the other end, since I am a pharmacy tech working my way through nursing school. At most hospitals it is the tech who makes the IV's. In fact, I enter the order into the computer, figure out my drug calculations and prepare the admixture in a sterile hood. The IV's are all checked by a pharmacist after preparation. We pull the syringe back to the amount of med we injected, and place the syringe and vial next to each other, (along with the original order if we entered it) on the counter for the pharmacist to check. If the pharmacist is doing a critical calculation, and there is only one pharmacist there, I will double check their math and then make up the med. The pharmacist checks my work after that. Errors are caught in the pharmacy. I just wanted to let you know that things are double checked after they are made, but it is still very important to do your med checks on the floor. Since our orders come through by fax they are often difficult to read. We call if we can't read it but I have had experiences when it looked clear but wasn't. I hope I will always be extremely careful when it comes to giving meds to my patients.
My hospital stopped mixing drugs on the floor many years ago. This was prompted by a terrible incident in which a patient had KCL pushed straight into his HL. The nurse mistook the vial for a flush solution. He died of cardiac arrythmmias. Vials of KCL are not kept on the floor, too easy to grab the wrong bottle in a rush. The other major hospital in our area stopped allowing nurses to mix their own IVs several years ago after the same scenario happened to an infant who also died. Now the pharmacy uses the premixed bags of KCL IV fluid unless there is a special order in which case they mix the bag.
All of our other drips come in premixed bags with standardized concentrations.
My husband is a pharmacist and he just raised the question of sterility. All of the IVs that are mixed in our hospital are done so under a Laminar hood to provide a sterile field. This incudes TPN and any drugs that are mixed for OR use. Is there a hood available for mixing or is it just done in the middle of the med. room?
As for being too expensive, all it takes is one lawsuit to justify the cost. I don't recall exactly how much the parents of the infant who died settled for, but it was in the millions . And that doesn't begin to cover the emotional toll on all involved. Believe me , the adminstration at our hospital is stingy,stingy but they haven't even thought about going back to making us mix our own meds.
KRVRN, BSN, RN
One time the pharmacy sent up the ordered TPN for all the pts on my unit. The nurses double checked what the doctors ordered against the labels on the TPN bags for accuracy. The labels matched what the doctors ordered. The TPN bags were started.
Later, the pharmacy called to report that they had mixed several of the TPN bags wrong (I work NICU and many pts are on TPN). They had done something to effect of adding X amount of protein and Y amount of lipids when they should have added Y amount of protein and X amount of lipids. I guess they had hooked something up wrong with their equipment and several of the bags were wrong. They caught the mistake later when they noticed things hooked up wrong.
Now, no harm was done to any babies because it was caught early (within a few hours). The labelling on the bags DID indicate the same dosages ordered by the doctor. The nurse can double check the orders but really has no way of knowing if the pharmacy ACTUALLY put those dosages in.
Is the nurse liable for this?
P_RN, ADN, RN
I'm fairly sure the KCl advisement is NOT the drug companies' propaganda. The bags we used came from Baxter, premixed and labeled right on the bag not on a sticker .
Our hospital was one involved in such a death. It was a nurse grabbing 10cc of KCl to irrigate a hep-lok. Patient DIED! The wife grabbed the bottle and the hospital paid BIG.
The nurse lost her license, the wife lost her husband, the children lost their father.....over the difference in cost of a bag of KCl admixture vs. a bag of IVF that had to be mixed by the nurse.
Now I won't say in the past I didn't mix potassium IVs and heparin drips 'cause I did. Now days with the litigious atmosphere a hospital that considers premixed bags...not cost efficient..... is living in a dreamworld. Pennywise-pound foolish.
TPN is to be mixed according to doctor's orders. Ours was a standard formula that had certain extras added, in laminar flow hood, by the pharmacy. I couldn't imagine doing that on the unit.
The same liability would seem to be as if the nurse took a med from a blister pack and gave it......you have to rely on the system sometime. Now if you compounded that tablet, labeled and packaged it......different proposition.
I am pretty sure that our hospital went to premixed KCL drips as a result of a JCAHO recommendation. (I.e. fix this or we remove your federal funding). You Could see if JCAHO has a recommedation that you could send to your administrators.
As an aside, we still mix our own vecuronium drips.
galenight, BSN, RN
I, too, work in a small hospital. Pharmacy does try to have all needed IV mixtures available for the med/surg unit. However, in ER (and on the floor after hours), we often mix our own drugs. I can't tell you the number of times I have mixed a Cardizem drip. We do have some premixed, such as Heparin, Lidocaine, Dobutrex, and Dopamine. We mix our own antibiotics all the time.. Thankfully many come in the AdVantage set up. I've also mixed insulin drips (not real thrilled about that one). But, I feel confident doing so since I had excellent orientation on the subject. I also consult the med book frequently to ensure I am using the right solution, the right dosage, the right rate, etc. And, when in doubt, I check with the doc (who usually asks me.. or looks it up). I've also called the pharmist. There should always be one on call or at least available to you if you have questions or concers. Good luck.. Oh yeah.. and we keep our KCL in lockup.
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