Do you mix your own IV's?

RNforLongTime · Sep 2, 2001

I work in a hospital that doesn't have a 24 hr Pharmacy--ours is open till 10pm on weekdays and only till 5pm on the weekends--not enough Pharmacists.

When I first started in Nursing 4 years ago, I mixed my own KCL IV's. Only a few years ago did the hospital that I used to work at eliminate the KCL vials from floor stock. Because an RN filled a syringe with what she thought was Hep lock flush solution--the 10cc bottles looked very similar. Pt coded, was revived, hospital sued by family. RN got 3 day suspension.

So, they took away the vials of KCL and started stocking more of the pre-mixed IV bags with KCL--we even stocked them on the floors.

As for meds like IV antibiotics? Most of those are pre-mixed by the Pharmacy. At least where I work now the pharmacy mixes all of the IVPB meds. Where I used to work, I mixed the majority of them.

Dplear · Sep 4, 2001

Just a quick response to Nlepoc....JACHO is a PRIVATE accreditation group, not affliliated with the government at all. They cannot take away anyones federal funding. In fact it is Illegal for an insurance company or medicare to even ask if a facility is JACHO certified. just trying to correct a popular misconception about JACHO.

as for admix vs mix your own I have done it both ways over the years and personally I like having already mixed for me...anything to make my job easier....and yes I have caught pharmacy mistakes and corrected the mix myself by mixing new meds...that is part of the 6 rights...

dewp_63 · Sep 15, 2001

our hospital is small also, and we have 24 hour pharmacy coverage only m-f. but - we do not keep kcl for infusion on the floors!!!!!!!!!! if we need an iv with k, we call the supervisor, who gets the bottle from pharmacy, watches us draw our dose (double check, there) and then the bottle either gets put in the sharps container or remainder squirted down the sink . . .

if i find kcl in the med room, i throw it out ... once worked with a nurse who almost gave 4 cc kcl (40 meq) instead of 4cc lasix - the bottles don't even look anything alike!!!! we need to protect our patients from the others who are not as concientious as we are (just joking - we can all make mistakes! but this one is sure to kill - might as well give the patient a paralytic without a vent!)

KellyandtheBoys · Sep 15, 2001

Where I used to work we always mixed our own IV's including bags with KCL. The potassium was origionally kept right by the NS. But, later moved to another location with the vials of heparin, dopamine, that sort of thing. I actually liked mixing my own IV's because I knew that what I was hanging was the drug ordered.

I would probably start by asking your unit manager to find a better location for potassium. This would cost the unit and hospital nothing. Then, work on changing policy about who is responsible for mixing IV solutions. Good Luck

deespoohbear · Sep 27, 2001

Great news!!! Just found out that our hospital is going to premixed bags of IV solution with potassium!! Plus, we are getting premixed dopamine, dobutamine, heparin, and NTG!! JCAHO recommendation (Type I hit). We are thrilled. Our antibiotics already come premixed or are the ADDvantage system. This should make our lives a little easier. We even got the prefilled syringes to flush saline locks with!! We used to have stock bottles of NS that we used to flush lines. I think our hospital may be moving closer to joining the 21st century. :D

debbyed · Sep 27, 2001

In the ER we mix most the antibiotics, and most of the Cardiac/Resp. drugs. The drugs we don't mix are Potassium which pharmacy has to do now and some of the more frequently used drips like NTG and Heparin.

Home Health Columnist / Guide · Sep 27, 2001

Check out the Institute for Safe Medication Practice's website, look under "Index of past articles":

http://www.ismp.org

Patient safety movement calls for reexamination of multidose vial use

From the June 14, 2000 issue

PROBLEM: The Centers for Disease Control (CDC) recently reported that a contaminated multidose vial (MDV) of saline was the likely source of transmitting hepatitis C virus (HCV) to at least three patients1. Although the vial was not available for testing, the CDC concluded that saline flushes from a 20 mL MDV were the only exposure associated with the infection. Investigators suspect that the MDV was contaminated either from reuse of a needle or syringe or improper decontamination of the rubber membrane. There were 41 patients admitted to the hospital unit during the suspected outbreak, but only one had a documented history of HCV. While 15 patients died before the investigation, death certificates did not mention HCV as an underlying cause. Five of the remaining patients tested positive for HCV and the genotype was the same. CDC identified the source patient and three confirmed cases (and one unconfirmed case) of transmission to patients with no known HCV risk factors.

In 1990, Plott et al. demonstrated that 25% of practitioners misused MDVs by reentering the vial with a needle that had already been injected into a patient2. However, actual vial contamination rates vary in the literature, from no detectable contamination identified by Christensen et al., to a 23% contamination rate noted by Bothe3-4. Yet, ongoing reports of infections transmitted through contaminated MDVs clearly suggest that their use poses a tangible risk. While common preservatives used in MDVs may be highly effective for most bacteria, they are not antiviral agents. Also, there is a vulnerable window of time (about two hours) during which contaminating organisms may remain viable in MDVs before the preservative fully exerts its effect5. Even after the preservative inactivates the organism, endotoxins may be present and cause pyretic or febrile reactions. While faulty aseptic technique is often the primary cause of vial contamination, other influential factors include the design of the vial, storage conditions, the frequency of entering the vial, the environmental air injected into the vial, and its use for patients with highly contagious diseases. The patient's underlying health also influences the risk of transmitting the infection. Further, there is little guidance regarding an appropriate expiration date after initial entry of the MDV. Practices are variable, from discarding the vial within 24 hours, to reliance on the manufacturer's expiration date and visual inspection.

SAFE PRACTICE RECOMMENDATION: The reuse of MDVs is a balancing act between cost containment and patient safety. Certainly, there are a few settings in which the cost benefit outweighs the risk because potential contamination is significantly reduced. For example, the reuse of a MDV for a single patient, such as insulin for a diabetic patient, carries little risk of patient cross contamination. In the pharmacy, the risk of contamination is minimal when MDVs are used for compounding in an aseptic environment, using proper technique, with no potential for patient-to-patient contamination. MDVs of expensive drugs also may be safely stored in the pharmacy and dispensed to units in ready-to-administer syringes. Yet on patient care units, multiple staff members use the relatively inexpensive drugs and solutions commonly found in MDVs for many different patients. In fact, many (e.g., saline and lidocaine) require multiple entries into the vial for a single patient encounter. Further, many MDVs look alike and have been confused with other drugs packaged similarly. With such ripe opportunity for contamination, single unit packages in ready to use form are preferred. At a recent CDC conference, attendees were strongly encouraged to use prefilled syringes or single dose vials for inexpensive but widely used substances (e.g., saline, bacteriostatic water, heparin, lidocaine) to reduce the risk of contamination. Don't wait until you have a nosocomial outbreak to heed this advice.

Medication error prevention "toolbox

From the June 2, 1999 issue

Selecting the best strategy to remedy medication errors is not easy. Often, the most effective action is not obvious and the best error prevention tools to use in each situation are not clear, even when system-based causes have been identified. Below, we list examples of error prevention tools in order of their effectiveness for creating lasting changes for safe medication use. Items at the top of the list, such as computerization and forcing functions, are examples of more powerful tools because they fix the system. Next are tools that attempt to fix the system, yet rely in some part on human vigilance and memory. Those at the end, such as education and information, are old, familiar tools that are intended to fix people. While many rely on these older tools, they are weak and ineffectual when used alone.

Forcing functions and constraints are the most powerful and effective error prevention tools. Their use results in designing processes so that errors are virtually impossible or difficult to make. Examples include removing potassium chloride for injection concentrate from all patient care areas; using medication cups or specially designed oral syringes (not parenteral syringes) that will not connect to IV tubing for all liquid oral medications; and eliminating nursing access to the pharmacy when it is closed by establishing a carefully selected nighttime formulary and dispensing cabinet.

Automation and computerization of medication use processes and tasks can lessen human fallibility by limiting reliance on memory. Examples include use of technologically and clinically sound computerized drug information systems; direct physician order entry, which provides drug information and warnings during order input; and use of IV infusion pumps with fail-safe design mechanisms to prevent free-flow.

Drug protocols and standard order forms guide the safe use of medications by eliminating problems with illegible handwriting and standardizing safe order communication. Yet they offer less leverage as an error prevention tool than those above since they rely on human vigilance for implementation. Nevertheless, there may be times when this is the most appropriate and only tool available to remedy a medication use problem.

Independent double check systems and other redundancies are tools that can reduce the risk of error by having one person independently check another's work. The likelihood of two individuals making the same error with the same medication for the same patient is quite small. Yet the potential for error still exists since this strategy is designed to detect human error, not prevent it.

Rules and policies: Most people prefer to intervene in a system at the level of rules and policies. Yet establishing new rules and enforcing old policies is often reactive and intended to control people, not necessarily fix the system. They often add system complexity unnecessarily. While rules and policies are useful and necessary in organizations, they should be used primarily to support more effective error prevention strategies designed to fix the system.

Education and Information: Staff education can be an important error prevention strategy when combined with other strategies that strengthen the medication use system. However, it is a weak link with little leverage to prevent errors when attempting to use only this strategy for reducing errors. The ongoing nature of effective education and its unrealistic dependence on correct human performance is often overlooked.

While each error prevention tool can play an important role in error prevention, beware of those that, on the surface, seem to provide the easiest and fastest solution. Since people cannot be expected to compensate for weak systems, select high-leverage error prevention tools that are designed to fix the system, not just people, whenever possible.

® Institute for Safe Medication Practices

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betts · Nov 10, 2001

NRSKarenRN has covered all concerns; sooooooo... 1 part vermouth, 2 ummm 3 parts vodka...

deespoohbear · Nov 12, 2001

Well, we finally got the IV bags premixed with K. Problem is now, the pharmacy refuses to give us stock bags for our med room. They say they will dispensed the appropiate amount of bags for a patient for 24 hours. We keep trying to tell them what are we suppose to do a 2 am when we have a new admit and no pharmacist or supervisor to get us the stuff? I guess after a couple of times of being called in the middle of the night to retrieve this stuff maybe the pharmacists will realize what an inconvience it is for them not to have floor stock. I just don't understand the logic behind this one. All these years they allowed us to have vials of concentrated K on the floor and never even questioned it. Now, we go to a much safer product and they are treating it like they are hoarding gold. Go figure!! :confused: :eek: