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.

i

• 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 prescriptionsp

• Transcription errors

• Calculation errors (2 nd check vital)

• Administration i i 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 ty 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 i a constant t therapeutic

ti

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 i may lead to layering


Intermittent t 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 p 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, g, 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 g 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 it • 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 i charts for good

range of drugs

• I.V guide (MEDUSA) -via intranet

t

• Provides information on how to prepare

injectable medicines

i

• Royal Marsden procedures/ Paediatric procedures

available via the intranet.


• Any Questions?

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