Predrawing insulin in LTC

[ChristopherH]

I recently viewed a debate with another nurse at my workplace about whether the practice of predrawing certain insulins and tagging the syringes with a resident's name prior to a busy med pass was acceptable practice and/or legal.

On one side the argument for patient/resident safety is that if you have a lot of insulins to give during a busy med pass (this is in a LTC/nursing home) with the potential for continual distractions, etc. and you have to give certain doses of certain insulins concurrently (meaning large doses of lantus or levemir coupled with small doses of novolin r) the potential for a catastrophic med error exists if that large dose is mistakenly taken from the wrong vial during a moment of distraction or simple lack of focus. The potential that that error might not even be caught until it is too late is even greater considering that once the vials are put away the contents of both syringes will be clear and indistinguishable from another. This side argues that if the lantus/levemir and regular combinations were predrawn say a couple hours prior to administration in a less busy time period and in a more controlled environment, labeled with the appropriate resident's name and then that label double-checked at time of administration, this would be a safer practice that would greatly reduce the potential for said catastrophic error. This is in reference to a morning med pass, in which insulins are given at 6-6:30 AM (a very busy and congested time on the unit), whereas 2 hours prior the unit and environment is comparatively very calm and controlled.

The other side argues that such predrawing should NEVER happen because this 1) would be a violation of standard practice, be comparable to prepouring medications, and similarly to prepouring could be more dangerous if a nurse gets sloppy and gives it to the wrong resident (although sloppyness aside, with a clear nametag attached to a syringe I would think that potential might actually be reduced). I'm not aware if there is a specific law that definitively states this should not be done with insulins in this sort of milieu, however, particularly when large amounts of long acting insulin are given concurrently with small amounts of fast acting insulins.

2)Shouldn't be an issue to begin with if a nurse makes sure every time that what they pay attention to the rights of medication administration and makes certain that they are giving exactly what they are supposed to during the med pass. The counter-argument to this of course is that it is essentially ideological and while in theory is certainly true it also assumes that nurses are going to be perfect every time (and of course nurses are people and therefore are not perfect), regardless of extraneous circumstances and factors that may be present (multiple distractions, fatigue/burnout, feelings of being rushed/hurried or overly busy, etc).

3) Could reduce the potency of the insulin if it is predrawn ahead of time. This is something I'm unsure of, and if somebody has more info on that would be enlightening. Although I am certain that this is true if the insulin is left exposed to light, this wouldn't be the case of course as the syringes would be placed back in the med cart drawer. Similarly if it were mixed insulins I imagine the same would be the case. I don't know if that would be at all true simply by drawing unmixed insulins such as lantus/levemir and regular from their respective vials and storing them in the syringe for a couple hours, or if there have ever even been any such studies of this. My gut feeling is that any resultant potency change (if any) from being stored in a syringe for two hours versus a vial would be minute and negligible, but at the same time I don't know. However I certainly understand the concern when large doses of lantus/levemir (60, 70, 80 units for example) are given concurrently with a fast acting insulin. To put it in a greater context, in the course of the last 35 months I estimate that I've given about 8100 total insulin shots on the unit that I work. To think that just one misstep out of that many shots could potentially kill a person under my care, particularly if it were a large dose of a clear fast acting insulin mistakenly drawn from the wrong vial, is rather intimidating.

[laderalis]

I would think the surveyors would frown upon it as it IS "pre-pouring"

My other concern is if that syringe gets bumped for whatever reason (and I think it is highly unlikely), they may not be getting the full dose (50 units pulled from vile into syringe, but plunger gets pushed down and now 40 are in syringe)

Out of the 6 people I give insulin to, only 1 has a constant dose. the rest are all correctional, so I never know exactly how much they are going to need.

What I WILL do, is pull an EMPTY syringe out for each shot, to remind myself how many I need to give.

[carolmaccas66, BSN, RN]

Do not do this - ever. I showed a student RN on one of my shifts needles full of God knows what pre-drawn up & left lying in the patient's folder betwen the med chart. We would have absolutely no idea what it was without packaging to check, even then I would not give a medication left lying like that. And the potential to accidently prick yourself (ie: the cap could come off) & if yourself or a confused resident happened to get the medication, God only knows what could happen. It is SO EASY to get meds mixed up when ur very busy.

DO NOT DO THIS - EVER. It seems easy pre-doing everything, but with meds I NEVER take short cuts. It is just not worth it when u analyse the potential for disaster.

And do u really want to throw away all your hard years of study & training, for what? To save a few minutes?

I guarantee you if you do this, you WILL make a mistake 100% of the time eventually.

And people who think they won't - are fools.