When it comes to safe medication administration, the stakes are definitely high. And they are even higher when we look at IV medication administration. Not only do medications given by this route take effect quickly, but they also come with a set of risks all their own, and once you infuse it, there’s no going back.

In this article, we’ll be talking about key IV medication safety factors that come into play with IV medication administration. Keep in mind that these things are ON TOP of everything else you are doing to ensure safe medication administration. Ready? Let’s do this.

Trace Your Lines

As part of your head-to-toe assessment and room safety check,  you want to always trace your lines. What does this mean? This means looking at each and every IV bag that is hanging and tracing the IV tubing all the way to your patient. You would be surprised to find IVs that are mislabeled, running at the wrong rate, or aren’t even actually connected to the patient. Your basic tracing follows the BPP framework: bag, pump, patient.

  • Start with the bag to see what solution or medication is infusing. Check it against the medication order. For example, I see a bag of normal saline with 20 mEq of potassium is hanging. I check the MAR and see that I do indeed have normal saline with 20 of K ordered.
  • Next, trace the IV tubing from the bag to the pump and confirm that the pump is programmed with that particular medication at the prescribed rate. For example, my order is to run this NS with 20 of K at 75ml per hour. I confirm that the pump is programmed correctly with the proper fluid and at the proper rate.
  • And then, trace the line from the pump to the patient to ensure proper connection. On doing so, I see the IV tubing is connected to the patient’s IV catheter in her right forearm. Perfect! Sometimes IV tubing will be connected to another IV tubing. We’ll talk more about Y-site Compatibility in a moment. For now, your basic tracing is complete. Good job!

IV Medication Safety: Label Your Lines

All IV lines should be labeled with the medication or fluid that is running through them. It is best practice to do this at the port or Y-site closest to the patient. Not sure what a Y-site is? This image shows where the Y-site is located, it is the location of ports where you can attach another IV line or a syringe for IV push medications. Most IV tubing will have one Y-site before the tubing enters the pump and another one closer to the patient. You will label your line at the one that is closest to your patient.

Check Y-site Compatibility

Now that you understand what a Y-site is, many times your patient will have multiple medications running through the same IV catheter. We do this by connecting them at the Y-site. Any time a medication runs in with another medication, you must determine the compatibility of those medications. So, let’s look at our Davis Drug Guide as an example. If you have yours handy, you can follow along.

Let’s say you trace your lines and notice the vancomycin is connected at the Y-site with amiodarone. Do not assume the other nurse checked compatibility. If you are going to continue running these medications together, you must check their compatibility. So, you can pull out your Davis Drug guide or use an online tool provided by your hospital. Looking in the Davis Drug Guide, search for vancomycin and click on IV administration. You will see the words Y-site Compatibility followed by a long list of medications that can be run with vancomycin. Scrolling down the list you see that one is amiodarone. So, unless your facility has a policy against running medications together in this way, you are generally ok to connect these medications at the Y-site. Again, always defer to your facility policy.

In the critical care setting, patients will often have three or four or more medications all Y-sited together. When we have more than two or three, we generally use something called a “manifold” but you will probably hear it referred to more commonly as a “bridge.” The same compatibility rules apply whether you are using a bridge device or simply connecting them at the Y-site.

When you are looking at the compatibility of multiple solutions, it can be a bit of a puzzle. In that case, we use an online IV compatibility checker like this one.

Y-Site compatibility is not just for those medications that you connect at that distal site. It also applies to medications you are running as IVPB. Never assume that what you are hanging as an IVPB is compatible with the patient’s IV fluids. Some medications will interact negatively with lactated ringers, which is a common IV fluid, and others can only be administered with D5W. Amphotericin B, for example, is incompatible with saline solutions. So, never make assumptions and always check.

Another reason to check Y-site compatibility is with IV-push medications. If you are pushing into the Y-site of an existing line, those solutions have to be compatible. And when you are pushing straight into the IV catheter, you have to be sure that whatever you are flushing the line with is compatible with that medication. Again, it’s not always going to be normal saline…it usually is, but when you are new, assume nothing. If it’s medication new to you, assume nothing. If it’s a medication you haven’t used in a while… assume nothing.

What happens to medications that are incompatible?

There are three types of medication incompatibility:

  • Chemical incompatibility means that mixing the medications together changes their potency. When a medication loses more than 10% of its potency when mixed with another medication, it is considered incompatible. Your patient is at risk for not getting the therapeutic benefit of the medication.
  • Physical incompatibility can include cloudiness, gas formation, haziness, and the formation of a precipitate. For example, lactated ringers (which contain calcium) cause a precipitate to form when mixed with many medications. If you ever see anything abnormal in your IV tubing, immediately stop the infusion and disconnect from the patient.
    • Medications that go through physical changes can physically harm your patient. For example, infusing a medication that has formed a precipitate can do more than just make the medication ineffective. It can cause relatively small problems like an occluded catheter but can also become an embolus that can travel through the patient’s body leading to thrombophlebitis, organ failure, and even death.
  • Note that another form of incompatibility occurs therapeutically when medications that are not compatible or antagonize one another are administered at the same time. Note we are not talking about the medications being infused through the same line…but simply at the same time or close to it. This is called therapeutic incompatibility. For example, the medication chloramphenicol should be given at least one hour after penicillin for this reason.

IV Medication Safety: The right rate

While your IV infusions will be programmed on your pump or by drops per minute, your IV push medications are given at the rate you push them. Many medications will have a dose limit per minute such as phenytoin which is typically not to exceed 25mg/minute. Other medications will simply be given as “slow IV push” while others may specify a time frame such as 2-3 minutes. Always check the medication administration record (MAR) and your drug guide before giving IV medications you are not very familiar with.

The right equipment

IV medication safety means making sure you are using the proper equipment.

  • Specialized tubing – Some medications should not have anything Y-sited into them. For this reason, we use specialized tubing with no y-site connectors. A perfect example of this is PCA tubing for patient-controlled analgesia. Another example is nitroglycerin which is absorbed into standard IV tubing, so most facilities will use what we call “nitro tubing” which is a special non-PVC infusion set. Note that some nitro tubing does not have a Y-site. And one more example is the tubing used for blood transfusions. It contains two spikes (one for the blood product and one for the flush of 0.9% sodium chloride) as well as a filter.
  • In-line filter – Some medications need to be run through a filter before infusing into the patient. There are different types of filters based on the size of the particles, so be sure to check the medication administration information in your MAR or drug guide. Amiodarone is an example of a common medication infused with a 0.2 or 0.22-micron filter. Sometimes the filters are attached and look like little discs or spaceships and other times they may be part of your specialized IV tubing and look more like a flat rectangle. If you see anything “extra” within your IV tubing or attached to it, ask what it is… there’s a good chance it’s a filter.
  • Filter needle – When drawing up certain medications, you will use a filter needle to ensure no particles enter the syringe. A common example of this is digoxin which comes in a glass ampule. You’ll use the filter needle to draw up the medication. Any glass particles will get filtered by your needle so they don’t enter the syringe. You then discard the filter needle and cap your syringe.

Functional equipment

It’s important to understand that while IV pumps do allow us to deliver precise doses of fluids and medications, they are not infallible. There have been instances of IV pumps delivering medication at the wrong rate (basically just allowing the medication to flow freely or much too quickly into the patient) resulting in patient harm and death.

Whenever you hang a medication-infused through an IV pump, do a quick safety check:

  • Make sure all components of the pump are working correctly
  • Ensure the tubing is sitting correctly within the pump mechanism
  • Ensure the channel door shuts properly
  • Ensure the channel is securely attached to the “brain” of the pump.

Once you start your medication, watch the infusion and look to see that the rate correlates with the rate programmed into the pump. If you see medication freely flowing or dripping rapidly and your pump is set at 25 ml/hour, then you know something is wrong. Clamp the tubing immediately and start over with a new pump setup.

I hope these tips help you feel more confident when giving IV medications at the bedside. For more tips on medication, download my free guide Bulletproof Medication Administration

References:

Institute For Safe Medication Practices. (2017, April 6). Two unsafe practices: Administration of a product with a precipitate and reuse of a saline flush syringe. Institute For Safe Medication Practices. https://www.ismp.org/resources/two-unsafe-practices-administration-product-precipitate-and-reuse-saline-flush-syringe

Marsilio, N. R., Silva, D. d., & Bueno, D. (2016). Drug incompatibilities in the adult intensive care unit of a university hospital. Incompatibilidades medicamentosas em centro de tratamento intensivo adulto de um hospital universitário. Revista Brasileira de terapia intensiva, 28(2), 147–153. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943052/#:~:text=Drug%20incompatibilities%20can%20lead%20to,involved%20drugs%2C%20and%20organoleptic%20changes.https://journals.lww.com/nursing/Fulltext/2008/03000/What_you_should_know_about_drug_compatibility.13.aspx

Young, J. B., Pratt, C. M., Farmer, J. A., Luck, J. C., Fennell, W. H., & Roberts, R. (1984). Specialized delivery systems for intravenous nitroglycerin. Are they necessary?. The American journal of medicine, 76(6A), 27–37. https://pubmed.ncbi.nlm.nih.gov/6430075/