Injectable Medicines

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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?

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