Injectable Medicines

Injectable Medicines
Pharmacy Department

Housekeeping
• Welcome & Registration
• Fire
• Facilities
• Plan for today

Content
• Risk of Injectable Medicines
• NPSA 20
• Advantages and disadvantages
• Different types of administration
– Their advantages and disadvantages
• Extravasation
• Preparing medication for iv use
• Stability
• General Information

Risks To Patient Safety From
Injectable Medicines
• The NPSA receives 800
incident reports a month
concerning injectable
medicines.
• 24% of all medication
incident reports.
• 58% of incident reports
leading to death and
severe harm

• Undertake a risk assessment of
injectable procedures and
products in clinical areas to
identify high risks and develop
an action plan to minimise them.
• Ensure there are up to date
protocols and procedures for
prescribing, preparing and
administering.
• Ensure there is up to date
technical information in clinical
areas
• Implement purchasing for safety
strategies
• Provide training and supervision
• Audit – and annual report

Examples of other NPSA alerts
relating to injectable medicines
• Potassium
• Epidurals
• Insulin
• Loading doses
• Anticoagulants

Risks In Preparing And Administering
Injectable Medicines
• Incomplete, Incorrect and ambiguous prescriptions
• Transcription errors
• Calculation errors (2 nd check vital)
• Administration to the wrong patient.
• Administration by the wrong route.
• Administration at the wrong rate.
• Unsafe handling or aseptic (non-touch) technique.

Risks In Preparing And Administering
Injectable Medicines
• Selection of the wrong drug or diluent
• Use of a drug or diluent or infusion after its expiry
time and date
• Incompatibility problems
• Complex procedures/process before they can be
used.
• Failure to follow procedures e.g 2 nd check.
• Failure to monitor infusions appropriately

Risks In Preparing And Administering
Injectable Medicines
• Absence of multidisciplinary procedures
• Lack of essential technical information
• Health and safety risks to the operator or
environment.
• Variable levels of knowledge, training & competence
amongst health care practitioners

Examples Of Incidents
With Injectable Medicines

• Insulin – misread prescription/transcription error
• Vincristine – wrong route
• Potassium – wrong drug/incomplete mixing (No 2 nd check)
• Morphine – SCBU multiple dilution/incorrect prescription
• Heparin Infusion – wrong rate
• Acetylcysteine – 800mg infusion prescribed instead of 8g
• TPN – Nuffield report – Contaminated-post op sepsis
• Gentamicin/Clindamicin Wrong drug – No 2 nd Check
• Lack of monitoring – TPN infused over 4 hours- prescribed
over 24hrs.
• Vancomycin – Infused too rapidly – anaphylactic reaction

Why the Injectable Route?
• Maintain Fluid balance in pts NBM/shock
• Achieves high and predicable drug levels in acute
situations
• Pts who’s gut has to be rested
• Pts intolerable oral medications
• Drug unavailable orally

Advantages of IV route
• Drug reaches circulation – minimum delay.
• Maintain fluid balance or administer medication to
patients unable to swallow e.g. unconscious or
requiring gut rest.
• Medication that is broken down in, or not absorbed
from the gastro-intestinal tract.
• To achieve high and predictable drug levels in acute
situations
• If injection required but injecting into skin would
cause pain or trauma.

Disadvantages of IV route
• Once injected no recall
• Too rapid an injection can cause adverse effects on
circulation or respiration
• Anaphylactic reactions may be more severe in a
sensitised individual
• Danger of embolism
• Increased risk of infection if aseptic technique poor
• Haemolysis, agglutination, thrombophlebitis may be
caused by hyper or hypotonic solutions

Methods of I.V administration
• Continuous Infusion
• Intermittent Infusion
• Injection

Continuous Intravenous Infusion
• IV administration of a volume of fluid with/out
medication over a number of hours.
• Large or small volume of fluids possible
• Infusion bag
• Syringe driver
• Infusions prepared in clinical areas can only be
infused for a max of 24 hours, these infusions must
be changed after this time.

Advantages and Disadvantages to
Continuous Infusion
• Easy to maintain a constant therapeutic
concentration
• Good for medication with a short half life in the body
BUT
• Large volumes may lead to fluid overload
• Incompatibility with diluent
• Incomplete mixing may lead to layering

Intermittent Intravenous Infusion
• IV administration over a set time period
• Usually a small volume of fluid
Useful for:
• Achieving a high level of medication quickly but
without the potential adverse effects of a bolus
injection

Potential Problems with Infusions
• Inappropriate dilution
• Incompatibility issues
• Incomplete mixing
• Miscalculation of administration rate
• Increased risk microbial/particulate contamination.
• Flushing line
• Risk of phlebitis/extravasation
• Appropriate monitoring – essential this is done.

Intravenous Injection
• A small volume of medication introduced directly into
a cannula or the injection site of a giving set.
• Bolus or push
• Slow I.V injection 3 to 5 minutes

Advantages and Disadvantages of
IV bolus Injections
• Achieves immediate and high levels of medication
BUT
• If given too fast can result in adverse effects.
• If too concentrated can damage veins
• Patient has received entire dose if ADR becomes
apparent

Extravasation
Symptoms
• Burning, stinging, discomfort at injection site
• Resistance felt on plunger of syringe for bolus
• Absence of free flow of fluid of infusion
Actions
• Stop infusion
• Aspirate as much residual medication as possible
• Elevate limb and apply warm pack
• Refer to extravasation policy

Preparation of IV Products
• Prepare products immediately before administration
• Never prepare in advance and store in clinical areas.
• Avoid working near a sink
• Do not prepare if you are unwell – cold/skin lesion

Preparation of IV Products
• I.V Infusions - Always use yellow I.V additive label
• I.V injections use an I.V additive label if the product
leaves the hands of the operator.
• Always ensure the diluent/ infusion fluid is compatible
with the drug.
• If more than one drug in a bag/syringe - check
• Ensure thorough mixing of product
• Check for particulate contamination
• Swab additive ports and allow to dry.

Stability Issues
• A proportion of the drug will always be lost
between preparation and administration if any
of the following occur;
– Medicines undergoes degradation
– Interaction with diluent
– Interaction with giving set

Factors affecting stability
• pH
• Light
• Temperature
• Time
• Diluent
• Oxidation

Compatibility
• All drugs have potential to react with each other or
their diluent
• Check diluent/infusion fluid to be used
• If more than one drug addition check compatibility
• Precipitation, may be immediate or slow to form.
• pH - main factor
• Remember drugs may meet in the line
• If unsure of compatibility – check

Incident Reporting
• Any adverse incidents should always be
reported via the trust incident reporting
system.
– Patient adverse reaction
– Error in medication used
– Fault with equipment
– And anything else that concerns you!
• Forms available via Intranet.

Checklist
• Ensure injectable medicines prescribed appropriately
• Use Commercially prepared infusions/injections.
• Dose/infusion volume/infusion fluid/ rate/ timescale
are present
• 2 nd Check – Vital (Calculations,drug, volumes & dose
etc)
• Ensure well mixed
• Aseptic technique at all times

Checklist
• Incompatibilities/precipitation
• I.V additive labels
• Flushing
• If unsure – check with
– Prescriber
– Pharmacy
– Medicines guide
– Injectable medicines guide (MEDUSA)
– Royal Marsden procedures.

General information
• Injectable medicines policy for the Trust
• Medicines guide – via intranet
• Has monographs and infusion charts for good
range of drugs
• I.V guide (MEDUSA) - via intranet
• Provides information on how to prepare
injectable medicines
• Royal Marsden procedures/ Paediatric procedures
available via the intranet.

Medicines Storage
Why is this so important?We must ensure that
these headlines never appear from our Trust.
Stepping Hill hospital in Stockport
where 4 people have died of
possible insulin poisoning. Police are
still trying to establish who has
tampered with medicines
£100,000 fine over
hospital
death
A patient was administered epidural anaesthetic
bupivacaine instead of saline solution.
The two drugs had “almost identical packaging” and her
life could have been saved if the bags were kept in
separate cupboards.
The trust had pleaded guilty to an offence under the
Health and Safety at Work Act. An inquest at Trowbridge,
Wiltshire, two years ago ruled that this patient was
unlawfully killed, also citing the “chaotic” drug storage

Responsibilities
• It is the responsibility of the ward manager to ensure the
overall safe custody and storage of medicinal products at
ward level. However, it is the responsibility of all nursing
staff to ensure that all the points on the following slides are
adhered to.
• Matron spot checks are now carried out monthly & each
ward will be classed as Red, Amber or Green status. This
information will be displayed on a Trust dashboard and any
recurring problems will be escalated to senior
management.
•Make sure that your ward area scores Green!!

Keys must be held by a registered
practitioner
Fridges must be kept locked ,
temperature maintained between 2
and 8 0 C and monitored daily
Air tube cupboard to be kept locked.
Registered practitioner to empty
cupboard when the red light shows

CD order books must be locked away and CD
cupboards must not be identified to
highlight contents
Deliveries of medicines from Pharmacy must be
signed for by a registered practitioner. The
person signing for the bag must put the
medicines in the locked medicines
room/cupboards promptly
Bedside medicines lockers must be kept
locked. All patient’s own drugs must be
stored in here

Medicine room must be locked and all
medicines put away in locked
cupboards.
The medicines returns box must be kept in a
locked cupboard
IV fluids must be kept:
- In a locked room
- On shelves
- In original containers and not mixed

• Any Questions?