IV med admin: terrified of making error!

Altra, BSN, RN · Sep 5, 2007

Hi Mallo, as an RN of 2 years I remember well the feeling of unease you're describing. Probably 80% of the meds we give in the ER are IV, and they are often big doses to correct an acute problem. Some things to think about:

1. Your facility/department policies. Ultimately, I don't care what practices you see in your co-workers ... the med administration policies that are in writing must be followed.

2. Use your resources. Ask your preceptor and/or nurse educator what printed materials are available for you to make a copy, study, etc. re: what concentration of common drugs your ER has on hand, and what are the policies on min/max dosages. This is especially invaluable in an ER where, to give an example, you may commonly get a verbal order to "start him on a nitro drip and let's titrate it until he's pain free." Learn what the policies and practices are re: starting dose and increments to titrate up or down.

3. Flushing? Always, unless there are fluids running. If you're giving a bunch of meds (i.e. SOB patient who will get NTG, Mag Sulfate & SoluMedrol in quick succession) it's often easier to just hang a bag of fluids - even just a little 50 or 100mL bag if you're concerned about fluid overload.

4. Always look up meds you don't know or haven't given before.

HTH.

Soneshine · Sep 5, 2007

With IV pushes, I always flush before and after with at least 5 cc of NS for peripheral IV's. If it concerns a piggyback, I will set primary fluid (if they have it) to a TKO rate and flush 10 or so cc's.

With central lines, I always follow the proper recommendations using a 10 cc or greater syringe (SASH) Saline, administer, saline, heparin.

Always look up meds in book to know how to give properly- and know your workplace policies.

I always dilute IV meds that can be irritating or viscous such as phenergan and ativan, ect ect.

Hope that helped some

NPinWCH · Sep 5, 2007

Well I find it difficult to answer your question since there are so many variables involved in giving any drug. The amount of morphine I feel comfortable giving relatively healthy 30 year olds non diluted is different from the amount I feel comfortable giving a frail 80 year old non diluted.

Aside from reading your policy manual, which is a very good place to start, you also have to consider things like: IV site, needle guage, age and relative health of your pt, including any underlying problems not related to their current ER admission, reason for the med, is this a running IV or a saline lock, are you giving other drugs after this one or is this the only one, and sometimes even how badly do I need to keep THIS IV viable.

For years I've given phenergen IVP diluted in 3-5 ml over 3-5 min. Now hospital policy states I am to dilute it in no less than 10 ml and push it over at least 10 min. OK, so I don't have time to do it this way some days so I take a 50ml bag of saline, remove 40ml, add my phenergen and run it IVPB at 60ml/hr. Of course if every nurse assessed the IV site prior to pushing the drug this wouldn't be an issue, but obviously it is...

My advice is when in doubt check the policy, most drugs can be diluted and most drugs can be pushed slowly...it's never wrong to flush, even with an IV running and always flush with a lock, in fact flush before and after. Always assess your site prior to giving any med, even if you assessed it just before you left the room the last time, it only takes a few seconds and it could save you a bunch of trouble.

alkaleidi · Sep 5, 2007

The responses present pretty much cover my "2 cents" -- with a couple additions:

When retrieving meds you are going to administer, where are you getting them from? If you have a med station like a Pyxis/McKesson, look at the screen. Ours pops up with a little message with certain meds with administration instructions (i.e. dilute with 5ml NS, push slowly over no less than 5 minutes, etc) -- follow those directions if you have that luxury!

WHEN IN DOUBT, and without a quick resource handy (resource being a drug book or another nurse who can give you a concrete answer), call pharmacy! I have a piece of clear plastic tape on the back of one of my badges (one that is blank on the back) that I've written a few extensions I use frequently, and pharmacy is one of them. There are phones at the nurse's station and usually in all of the rooms... if I ever wonder, I just pick up the phone and ask. Every time I've called, the pharmacist rattles off the directions quickly -- they're a wealth of knowledge!

Good luck!

Medic/Nurse, BSN, RN · Sep 5, 2007

First of all - relax a bit!

Terrified is not the best start of anything.

I think it is important to be deliberate.

(When in trouble, when in doubt - run in circles, scream and shout! -- KIDDING!!)

Really, just relax. Take a deep breath.

And NOW what can you do that is gonna help?

First, there is only 1 drug that I am aware of that is given in the ED that must be delivered undiluted and with meaning! That is ADENOSINE. No debate there.

Everything else you get a little time.

My rules:

I dilute most EVERYTHING. And I mean EVERYTHING whenever possible. (except Adenosine) (I will also exclude premixed syringe medications, paralytics, other RSI drugs)

Check your policies for any SPECIFICS - but, most issues of administration are left to accepted safe practice.

For a system. Start with this -

Most all hospitals have a drug formulary. These are the medications that are approved for use at your facility. Even more specific than this - most ED's that I have worked in have a (with rare exception) certain "set" of drugs that they use. Some are standing orders and others are specific to certain doc's.

Make yourself a "cheat sheet" if it helps you - but, never get too comfortable with it/dependent on it - always remember the 5 rights and remember you are a registered, professional nurse - you got the right stuff - now, just use it! :)

EMERGENCY DRUG REFERENCE

*** I'm going off the top of my head - so I may forget something - I'll add 'em if they come to me. ***

These are the ones that are given in truly CRITICAL or RESUSCITATION situations:

Prefilled syringes that contain:

Lidocaine

Epinephrine

Atropine

Narcan

D50

Sodium Bicarb

Adenosine

Amiodarone

These are also critical, but usually require them to be reconstituted or drawn from a vial. These should not be diluted (other than recommended by mfg)

*** ALSO THESE SHOULD BE LABELED IN THE SYRINGE *** HIGH RISK MEDS! ***

Etomidate

Anectine/Succinylcholine (or ANY PARALYTIC)

Norcuron/Vecuronium (or ANY PARALYTIC)

Additionally, these medications when given in doses for intubation/sedation following intubation and may be higher than what you give for other indications - in this case I label the syringe AND administer with a flowing IV fluid.

Fentanyl (doses as high as 1 MILLIGRAM have been given)

Ketamine

Versed

Ativan

Morphine

After you get past the meds listed above - you get into the "everyday" IV meds that your doc's give on a regular basis.

I have found, as a rule:

Morphine

Demerol (not as often now vs. 5 years ago - thankfully :))

Dilaudid

Toradol

Phenergan

Zofran

Kytril

Benadryl

Solumedrol

Solucortef

Decadron

Digoxin

Regular Insulin

Pepcid

Lasix

Protinix

Valium

Ativan

Beta Blocker du Jour

Cardizem

Labetalol

Heparin

Your "list" may vary. Learn your more common drugs that you use. This knowledge alone will be so valuable.

I always draw the ordered medication into the most accurate syringe for the ordered dose. I then draw another syringe of 10 or even 20 ml of NS. Take the NS syringe and then discard the amount (that equals the ordered drug dose) of NS that I will replace with the ordered drug dose from the other syringe - I then add my drug ordered to the NS syringe - I label and then administer via IV.

It may sound complicated, but it is really easy with a little planning/practice. And since I always do this - I just keep supplies at hand and stay prepared. For instance giving 40 mg of Lasix in 4 ml. I pull 16 ml of NS in a 20 ml syringe, add my 4 ml Lasix from the other syringe and then I administer.

I NEVER draw saline and then try to draw out a desired dose from a vial - too much of a chance of error if the vial contains more drug than you are ordered to give. The best way to reduce a chance for error is to do the same thing, the same way - each and every time.

This practice helps to insure that my patients will have their veins for another day. This practice can also work well on medication that must be given over time, it is easier to give 20 ml over 2 minutes than to try and give 2 ml over 2 minutes. I can also put the syringe on the pump (if your facility has that option) if needed.

But, check your facility guidelines - they may have specific ways that you must do it. This is just my way. And I have never had an error or infiltration incident from this method.

Just remember to always look up meds that you are not familiar with - also, any dose that seems "odd" should alert you to look up the med and confirm it with the MD.

Remember, once you push a drug - you can't pull it back. So be certain. Be deliberate. Be prepared.

Feel free to email me with any questions. I'd be glad to help if I can.

Relax, breathe. You and the patient will be fine.

Everyone starts at the beginning - and you want to do a great job! And that alone is a big part of successful nursing practice!

Practice SAFE!