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Similar to FOI 4498- Pharmaceutical Calculation Methods - Intravenous Medications pharmacy for FOI.ppt
FOI 4498- Pharmaceutical Calculation Methods - Intravenous Medications pharmacy for FOI.ppt
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- 2. Contents • NPSA Alert •General Principles of Administration • Sources of Information • Commonly Reported incidents • Common Sources of Error • The Worst Offenders • Flushing • Quiz Time! • Questions
- 3. Injectable medicines aredefined as: “Medicines intended for administration by bolus injection, perfusion or infusion by any of the following routes: intravenous, intramuscular, intrathecal, intra-arterial, subcutaneous, intradermal, intraventricular, epidural, intravesicular, intravitreal, intrapleural and intraocular.” (NPSA 2007)
- 4. NPSA Alert • NRLSreceived 800 reports a month on medication safety incidents involving injectable medicines between Jan 2005- June 2006 • This accounted for 24% of all medication safety incidents (NPSA, 2007) • In an analysis of medication safety data reported to the NRLS between January and December 2007, injectable medication errors accounted for 62% of incidents resulting in severe patient harm and death(NPSA, 2009).
- 5. Patient Safety Alert20: Promoting the Safer Use of Injectable Medicines (NPSA, 2007) Recommendations – Undertake a risk assessment of injectable medicine procedures and products in all 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 injectable medicines in all clinical areas. Ensure essential technical information on injectable medicines is available and accessible to healthcare staff in clinical areas at the point of use. Provide training for, and supervision of, all healthcare staff involved in prescribing, administering and monitoring injectable medicines.
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- 7. General Principles Administration • Initiateimmediately after preparation, not put aside for later use • Twenty-four hour expiry unless advised otherwise. • Pharmacy CIVAS products state expiry • No addition if compatibility unknown • Only one drug per bag unless confirmed by pharmacist • No further addition once infusion has started • Ampoules or vials should not be used to prepare more than one injection
- 8. Sources of Information MedusaInjectable Medicines Guide Medicines Policy Trust Guidelines for Flushing IV Lines Pack insert / SPC BNF Appendix 6 Ward or Medicines Information Pharmacist
- 11. Distribution of ErrorsInvolving IV Medications Reported to NRLS (Jan 2005 – Nov 2010)
- 12. Common Sources ofError 1. Prescribing 2. Preparation 3. Administration 4. Drug incompatibility 5. Monitoring
- 13. 1. Prescribing Decimal points •Avoidwhere possible •For example .5mg could be read as 5mg instead of 500micrograms •Can lead to overdoses of potent drugs e.g. morphine, insulin Abbreviations •Writing U for units can be mistaken for 0 •IU for international units can be mistaken for IV or 10 •Mcg/µg can be mistaken for mg
- 14. 2. Preparation • Wrongmedication – caution with sound-alike drugs e.g. cefuroxime and cefotaxime • Wrong formulation e.g. amphoteracin Fungizone vs Ambisome • Incorrect diluent - a drug in the wrong pH will precipitate or degrade • Water pH 7 • Sodium Chloride 0.9% pH 7 • Glucose 5% pH 4 – 5 • For comparison, blood pH 7.35 – 7.45
- 15. 2. Preparation 1. Readthe prescription carefully 2. Clean, uncluttered and quiet preparation area 3. Assemble everything you need: • Sharps bin for waste disposal • Medicine vial(s) and ampoule(s) of diluent • Syringe, needle, alcohol wipe, disposable protective gloves, and clean reusable plastic tray. 4. Use an aseptic non-touch technique
- 16. 3. Administration • Bolusinstead of infusion oVancomycin - exaggerated hypotension, including shock, and, rarely, cardiac arrest oClarithromycin – vein damage oPhenytoin – Bradycardia, hypotenion, CNS depression Vancomycin ‘Red man syndrome’
- 17. 3. Administration 1. Safetytriangle- drug/prescription/ patient 2. Check the route 3. Check the rate – infusion vs injection Infusion Injection Continuous vs Intermittent Slow IV Injection vs IV push Preferable where- Preferable where - Direct injection would cause toxic levels of drug Optimum blood levels required rapidly Venous irritation Incompatible or unstable in infusion fluids Short acting drugs Narrow therapeutic index drugs
- 18. 4. Incompatibility DOH Guidancestipulates that the mixing of medicines should: •Only be undertaken in the best interests of the patient •Be avoided where possible •Only be done by a person who is competent and willing to do so •Take place in a pharmacy (where possible)
- 19. Physicochemical reactions • Physicochemicalreactions can cause precipitation, separation, gas formation and changes in colour or turbidity • Can lead to catheter occlusion or emboli formation, causing organ failure and death • Detectable through visual check • E.g. Changes in pH – phenytoin, morphine
- 20. 1) Propofol andlidocaine incompatibility, resulting in layering and coalescence of propofol’s vehicle 2) Phenytoin precipitation caused by mixing with a solution that lowers its pH (e.g. glucose 5%)
- 21. Chemical Instability • Chemicalinstability between drugs can lead to reduced effectiveness of active ingredients • Therapeutic failure or the production of toxic compounds • Often not visible • E.g. Erythromycin
- 22. Physical Incompatibility • Light •Protect during administration e.g. nitroprusside • Temperature • Maintain potency • Prevent microbial contamination • Giving set – PVC • Drugs may stick to plastic leading to loss of potency • GTN, nimodipine
- 23. ‘NO ADDITION’ The followingshould never be used as a diluent or allowed to mix with drugs •Blood (or blood products ) plasma, nutrition solutions •Sodium bicarbonate •Mannitol •Lipid emulsions •Colloids
- 24. 5. Monitoring • Checkinfusion site – leakage, infection, inflammation • Monitor…… • Patient • Contents of infusion container • Rate of infusion • Clinical parameters • Document
- 25. Allergic Reactions Medicines Policy •“Any information relating to drug hypersensitivity ….. should be recorded by the prescriber during the admission process • Nurses, Pharmacists and Pharmacy Technicians are also authorised to complete • ‘Drug allergy status undetermined’ only valid for 24 hours
- 26. Allergic Reactions Immediate vsDelayed Outcomes: • Rash • Angioedema • Upper airways compromise • Anaphylactic shock • Can be fatal
- 27. Reducing the Risk oCheckfor potential cross-reaction with other medicines oe.g. penicillins & cephalosporins ocheck with pharmacist if unsure oBe aware of all penicillin containing antibiotics: oTazocin oAugmentin (co-amoxiclav)
- 28. The Worst Offenders! •Paracetamol • Furosemide • Vancomycin • Phenytoin • Pabrinex • Potassium
- 29. IV Paracetamol • Licensedonly for short term treatment of moderate pain/ fever • Summary of product characteristics recently amended to emphasis the need to adjust dose in selected patient groups • Patient weight must be recorded on EPMA / kardex • Do not prescribe as IV / oral • Switch to oral asap
- 30. IV Paracetamol • IVparacetamol dose will need to be reduced in high risk patients: • Low body weight • Renal impairment • Hepatic impairment • Post large liver resection (for 2-3 months)
- 31. IV Paracetamol Dosing •Adult > 50kg = 1g qds • Adult < 50kg = 15mg/kg/dose ( max 3g / 24 hrs) • E.g Patient weighing 40kg = 600mg qds • Maximum daily dose of IV paracetamol must NOT exceed 3g in patients with: • hepatocellular insufficiency • chronic alcoholism • chronic malnutrition (low reserves of hepatic glutathione) • dehydration
- 32. Furosemide • Alkaline pH •Precipitates in glucose 5% • Must dilute in Sodium Chloride 0.9% • Do not mix with other drugs • Dedicated line in Critical Care • Max rate 4mg/min • too fast = tinnitus, transient deafness
- 33. Vancomycin • Reconstitute thendilute further before administration • Dilute each 500mg with at least 100mL to give a concentration of not more than 5mg in 1mL • E.g. 1gram in 200ml diluent • Slow IV infusion • The rate must not exceed 10mg per minute • E.g. 1 gram over 2 hours • Check levels before the 4th dose
- 34. Vancomycin Rapid infusion •Hypotension (includingshock and cardiac arrest), •Wheezing, dyspnoea, urticaria, pruritus •‘Red man syndrome’ •Pain and muscle spasm of back and chest •Thrombophlebitis –peripheral admin
- 35. Phenytoin • Poor solubility,so formulated in sodium hydroxide (alkaline pH), & solvents • Incompatibility problems • may precipitate & block lines & filters • Dedicated line preferable • Do not use if hazy or has precipitated
- 36. Phenytoin • DO NOTDILUTE • Maximum rate 50mg/min • Slow iv or syringe pump • ECG monitoring recommended • Inject into a large vein using a large-gauge needle or intravenous catheter • Flush before & after each injection with Sodium Chloride 0.9%, through the same needle or intravenous catheter
- 37. Phenytoin • Local • Irritant,whether or not it extravasates • Cases of necrosis, sloughing, amputation • Systemic • CNS depression • Cardiovascular collapse • Monitor • ECG, BP, Resp Function, Injection site
- 38.
- 39. Vitamins B andC, I/V High Potency Injection (Pabrinex ) • Ampoule 1 - thiamine hydrochloride riboflavin and pyridoxine hydrochloride • Ampoule 2 - ascorbic acid, nicotinamide and anhydrous glucose • May cause serious allergic reactions including anaphylactic shock • Warning signs are sneezing or mild asthma • Facilities for treating anaphylactic reactions should be available
- 40. Potassium Chloride: Concentrated Solutions •40mmolPotassium chloride in 100ml sodium chloride 0.9% •Potassium chloride 15% injection (CVVHF) •Potassium acid phosphate injection 13.6% (10mmol in 10ml)
- 41. Potassium Chloride: Concentrated Solutions •These can be FATAL if given inappropriately • Ampoules look similar to those of Sodium Chloride 0.9% or Water for Injections • This has led to fatal overdoses • Use of IV potassium is covered by: • Intravenous (IV) Potassium Administration Policy, 3rd Ed, June 2007
- 42. Potassium Chloride: Concentrated Solutions AdverseEffects • Bolus = cardiac arrest; brain damage; death • Very irritant oPain & thrombophlebitis, oExtravasation damage • necrosis, grafts, chronic disability
- 43. Administering IV Potassium Infusions •All prescriptions must state: Number of mmol Volume of diluent Infusion rate • Max peripheral concentration is 40mmol in 500ml • Use suitable infusion pump to control rate & volume • Measure potassium daily • Review and change to oral where ever possible
- 44. Flushing o Before andafter each drug o Sodium chloride 0.9% o Glucose 5% if saline incompatible o Hepsal (heparinised saline) only used for PICC /central lines etc – not venflons oAdults: 5ml peripheral line, 10ml central line oAll flushes must be labelled if they leave the hand of the person preparing them (NPSA)
- 45. Pre-plan BEFORE drawingup dose Be aware of local protocols 2nd registered nurse must check prep/admin (CD) Calculations - independent 2nd check CHECK MEDUSA
- 46. TRUE OR FALSE?! 1.Most drug incidents involving IV medications result from prescribing errors FALSE 2. MCG is an acceptable abbreviation of micrograms FALSE 3. Two medications can be treated as compatible for IV administration if there is no information to say they are incompatible FALSE 4. Nurses are authorised to record drug allergy information in EPMA/ drug kardex TRUE
- 47. TRUE OR FALSE?! 6.Phenytoin should be administered undiluted by slow IV infusion TRUE 7. A patient weighing 45kg can receive IV paracetamol 1g qds FALSE 8. The maximum concentration IV potassium that can be administered peripherally is 40mmol in 500ml saline 0.9% TRUE
- 48.
Editor's Notes
- #3 Injectable medicines are often potent medicines that must be prepared and administered carefully and patients must be monitored closely. Consequently the NPSA has indetified injectable medicines as high risk of medication errors.
- #4 NRLS - UK National Reporting and Learning System National Patient Safety Agency published Patient Safety Alert 20: Promoting the Safer Use of Injectable Medicines (NPSA, 2007)
- #5 6 Recommendations in total
- #6 Medicines Policy is available on the Intranet under the pharmacy pages
- #13 Dosing errors account for nearly one third of all reports Can lead to overdosing and toxicity or underdosing and lack of therapeutic benefit for the patient Decimal points can result in serious prescription errors -
- #14 Two cancer patients died after receiving the more toxic non-lipid formulation of intravenous amphotericin (Fungizone) instead of the prescribed lipid formulation (AmBisome) in error.
- #18 When two or more medicines and their diluents are mixed together in the same syringe or infusion bag, or when two or more infusion lines meet at a Y-site junction, there is a risk that they may be incompatible with one another. The type of infusion vehicle used for administration of the drug can also affect the stability of the drug.
- #19 Changes in pH can cause drugs to precipitate out of solution e.g. phenytoin is a weak acid, but is formulated to IV administration as a strong base pH 12. Any solution that lowers its pH can cause phenytoin to precipitate out of solution, for example when mixed with glucose 5% it starts to precipitate almost immediately. Changes in concentration can affect the comptability of some drug combinations – especially important for syringe drivers
- #21 A clear, colourless fluid free of precipitation is not definitive proof of compatibility between two or more substances Erythromycin – when reconstituted is degraded by hydrolysis so will lose potency after 8 hours
- #26 A drug allergy is an adverse drug reaction that is caused by an immunologic reaction elicited by a drug. Immediate reactions - occur within one hour of the first administered dose Delayed reactions - occur after one hour, but usually more than six hours and occasionally weeks to months after the start of administration Immediate reactions are usually IgE-mediated and carry the risk of immediate life-threatening anaphylaxis if the drug is readministered. These reactions most commonly appear within minutes after exposure. Delayed reactions - not IgE mediated and can be caused by a variety of factors. Some of these reactions can also be life threatening, and as a group, delayed reactions probably account for more deaths than anaphylaxis.
- #27 Value quoted in literature in that up to 10% of patients allergic to penicillin will also be allergic to cephalosporins, this is taken from studies conducted in the 70s where manufactured cephalosporins were contaminated with trace amounts of penicillin.
- #29 Doses of intravenous paracetamol higher than recommended may increase the risk of very serious liver damage. This could lead to hepatic failure and death.