Infusion Medication and Solution Administration

Purpose and Scope

This clinical standard establishes evidence-based requirements for the safe administration of infusion medications and solutions across all care settings. It applies to all clinicians involved in preparing, verifying, and administering parenteral therapies, and serves as a reference for institutional policy development, quality improvement initiatives, and clinical education.

Core Verification Requirements

Medication and Solution Identification

Prior to administration, clinicians must identify and verify all medications and infusion solutions by examining the label for the following elements:

• Brand and generic name
• Dosage and concentration
• Total volume
• Beyond-use date and expiration date
• Route of administration
• Frequency and rate of administration
• Any special instructions

When an infusion control device is in use, the programmed settings must be compared against the medication order to confirm accuracy.

Clinical Appropriateness Review

Before administering any prescribed medication or solution, the clinician must review the appropriateness of the therapy. This review encompasses the indication for use, dosing parameters, diluent selection, acceptable infusion routes and rates, compatibility data with concurrent infusions, and potential adverse effects or side effects. Any concerns regarding order appropriateness must be escalated to the pharmacist, prescribing provider, supervisor, or risk management personnel according to organizational policy.

System Integrity Inspection

The complete infusion system must be inspected prior to initiating therapy. This inspection includes confirming the clarity of the solution (absence of particulate matter, discoloration, or precipitation), verifying the integrity of all system components (checking for leakage and ensuring secure connections), validating the accuracy of the programmed flow rate, and confirming both the expiration date and beyond-use date of the infusate and administration set.

Clinical Practice Standards

Medication Reconciliation

Medication reconciliation must be performed at every care transition and whenever a new medication is ordered. This includes admission, transfer between levels of care, and discharge to a new healthcare setting. The reconciliation process must include verification of discontinued medications to reduce the risk of medication errors such as omissions, duplications, dosing errors, and drug interactions (Almanasreh et al., 2016; Cheema et al., 2018; Redmond et al., 2018).

Special Population Considerations

Clinicians must recognize physiologic characteristics that affect drug dosage and volume limitations in special patient populations. These considerations include pharmacologic actions, potential interactions, side effects and toxicities, monitoring parameters, and anticipated response to infusion therapy. Pediatric, geriatric, pregnant, immunocompromised, and critically ill patients require particular attention to these factors.

Structured Clinical Reasoning

A structured clinical reasoning approach supports safe medication administration. While traditional frameworks focus on the “rights” of medication administration, comprehensive assessment extends beyond these basic checkpoints to include appropriateness of drug selection, dose verification, route confirmation, compatibility assessment for multiple concurrent medications, review of monitoring test results, and validation of flow-control device settings (Martyn et al., 2019; Blazeck et al., 2020).

The WARRIORS framework provides a comprehensive clinical guide for medication administration assessment:

Why — What is the clinical indication for this patient receiving this medication?

Allergies — Does the patient have documented allergies? If so, should this medication be administered or held?

Right laboratory values and vital signs — What laboratory values or vital signs are trending outside normal range for this patient, and how will they be affected if this medication is administered or withheld?

Range — Is this dose within the correct therapeutic range?

Implications or interactions — What are the clinical implications and potential interactions of this medication for this specific patient?

Only — Am I the only clinician administering this medication to this patient?

Return — When should I return for reassessment of the patient’s response?

Safety — What should the patient be taught regarding safe use of this medication during hospitalization and at discharge?

Patients and caregivers who administer medications independently should be taught to consistently apply medication verification cues (Goldspiel et al., 2015; Gorski, 2017).

Minimizing Interruptions

There is a significant association between medication errors and interruptions during the administration process. Clinicians, patients, and families should be educated about the importance of avoiding interruptions during all phases of medication administration (Dall’Oglio et al., 2017).

When preparing multiple infusions, each infusion should be set up completely before beginning preparation of the next one. The complete setup process includes labeling the administration set and pump, spiking and hanging the solution container, connecting the set to the pump, and programming the pump. This sequential approach reduces cognitive load and minimizes the risk of cross-contamination or mislabeling errors (Kane-Gill et al., 2017; Institute for Safe Medication Practices, 2020).

High-Alert Medication Safeguards

High-alert medications require additional safeguards due to their potential to cause significant patient harm when errors occur.

Standardization strategies include using standard order sets, standardized drug concentrations, and consistent dosing units across the organization. Organizations should improve access to drug information, limit access to high-alert medications through secure storage and quantity restrictions, and implement supplementary labeling and automated alerts (Kanjia et al., 2019; Koeck et al., 2021; Lapkin et al., 2016).

Centralized preparation through pharmaceutical reconstitution and admixture services minimizes errors and optimizes medication delivery. When feasible, medications should be prepared and dispensed from the pharmacy or obtained as commercially prepared solutions (Rashed et al., 2019; Coutsouvelis et al., 2020; Jessurun et al., 2022).

Independent double-checks should be performed by two clinicians for high-alert medications that pose the greatest risk of harm, including opioids, insulin, heparin, and chemotherapy agents. Organizations must develop a standardized process for performing double-checks and educate staff accordingly. A checklist may improve consistency and effectiveness of the verification process (Douglass et al., 2018; Koyama et al., 2020).

Standardized Communication

Organizations must use approved, standardized nomenclature for all medication-related communication. A list of error-prone drug names, abbreviations, symbols, and dose designations should be maintained and used to implement safeguards against medication errors. Effective strategies include using both generic and brand names on orders and labels, including the indication for the medication on the label, and modifying the appearance of look-alike drug names using approved tall man (mixed-case) lettering with bolding (Kane-Gill et al., 2017; Goldspiel et al., 2015; Billstein-Leber et al., 2018; Kuitunen et al., 2021).

Technology Integration

Barcode Verification

Barcode scanning technology, or equivalent verification systems, should be used immediately prior to medication administration as one component of a comprehensive infusion safety strategy. Barcode scanning is associated with decreased risk of medication errors and has become standard practice in acute care organizations, with emerging evidence supporting its use in long-term care settings (Lapkin et al., 2016; Shah et al., 2016).

The only exception to immediate pre-administration scanning occurs when its use would result in a clinically significant delay and potential patient harm, such as during cardiac arrest. Clinicians should be aware that errors may still occur when staff create workarounds that bypass the safety mechanisms inherent in barcode technology. The effectiveness and limitations of verification technology should be analyzed through organizational quality improvement processes (Westbrook et al., 2020; Kuitunen et al., 2021).

Smart Pump Technology

Electronic infusion pumps equipped with dose error reduction systems (DERS), commonly called smart pumps, are associated with reduced risk for infusion-related medication errors. These systems provide error interceptions for issues such as incorrect rates and reduce adverse drug events (Institute for Safe Medication Practices, 2020; van der Sluijs et al., 2019; Sutherland et al., 2022).

To maximize effectiveness, organizations must ensure drug libraries are current and clinically relevant. Regular education and training should address usability issues and emphasize avoidance of workarounds. Both routine users and new staff members require ongoing competency assessment. Failure to comply with appropriate use protocols, overriding of alerts, and use of incorrect drug libraries contribute to the risks associated with smart pump technology, particularly with high-risk medications (Giuliano et al., 2018; Jones et al., 2021; Joseph et al., 2020; Marwitz et al., 2019; Skog et al., 2022).

Medication labels should maintain consistency in format and content from the electronic infusion pump drug library to the infusion reservoir labeling to health record documentation. This continuity reduces transcription errors and supports accurate medication verification (Schnock et al., 2018; Estock et al., 2018; Lusk et al., 2022; Mikhail et al., 2019).

Vascular Access Device Assessment

Patency Verification

Vascular access device (VAD) function and patency must be assessed prior to administration of parenteral solutions and medications and during continuous infusions as clinically indicated.

During continuous infusion, patency assessment is warranted when any of the following conditions are present: sluggish infusion during gravity administration, frequent infusion pump alarms, fluid leakage from the insertion site, patient-reported pain during infusion, or signs and symptoms suggestive of infiltration or extravasation.

To assess patency during continuous infusion, attach a syringe to the lowest injection port on the administration set without disconnecting the administration set from the VAD hub.

Alternative Patency Assessment

When blood return is sluggish, absent, or when assessment of blood return is contraindicated due to the patient’s hemodynamic status (such as in patients dependent on vasopressor delivery for hemodynamic stability), VAD patency should be evaluated through alternative indicators. These include ongoing clinical response to the infusing medication, absence of resistance during flushing, visual and tactile site evaluation, and patient symptom reports.

For peripheral VADs (including short peripheral intravenous catheters, long peripheral catheters, and midlines) that no longer demonstrate positive blood return, the frequency of site assessment and evaluation of the venous pathway should be increased to minimize the risk and severity of complications including infiltration, extravasation, and occlusion. When using a peripheral VAD for vesicant administration, transition the infusion to a new VAD when clinically feasible. Administration of certain antineoplastic vesicants via peripheral access is contraindicated in the absence of blood return.

Special Considerations for High-Risk Infusions

In situations involving high-risk medications with significant line volume (such as vasopressors and inotropes), aspirating for blood return may be contraindicated when interruption of the infusion or inadvertent bolus could cause clinically significant deterioration in the patient’s condition. In these circumstances, blood return can be evaluated when the infusion is paused for other clinically necessary reasons such as solution container changes, blood draws, or tubing changes. The frequency of insertion site assessment and monitoring of clinical response to medications should be increased accordingly.

First-Dose Administration in Non-Acute Settings

Certain medications carry an appreciable risk of severe allergic or anaphylactic reactions or other unpredictable responses upon first administration. Examples include antimicrobials and immunoglobulins. When these medications are administered in non-acute care settings such as home care or skilled nursing facilities, specific conditions must be evaluated and verified prior to administration (Gorski, 2017; Gorski, 2023; Billstein-Leber et al., 2018; Norris et al., 2018).

Required Conditions for Safe First-Dose Administration

The patient must have no documented history of allergy to medications in the same therapeutic class as the prescribed agent. The patient must be alert, cooperative, and capable of responding appropriately to questions and instructions. There must be reasonable geographic access to emergency services should a severe reaction occur.

The first dose must be administered under direct clinician supervision with immediate capability to respond to life-threatening hypersensitivity or anaphylactic reactions. The patient must be observed for at least 30 minutes after the infusion of the first dose is completed.

Clinicians must recognize that the first exposure to a medication may not result in an allergic reaction, and that the risk of reaction exists with subsequent exposures. Patients and caregivers must be educated regarding signs and symptoms of reactions and appropriate actions to take if a reaction occurs.

Appropriate emergency medications must be available in the home with corresponding orders for their use. Epinephrine is essential for management of anaphylaxis. Clinicians who administer first doses must have completed a basic life support provider course and demonstrate competency in managing anaphylactic reactions.

Preparation and Timing

Solutions and medications should be prepared for administration as close as possible to the time of actual administration. This applies to spiking infusion containers and priming administration sets. This practice minimizes the risk of contamination and ensures medication stability (Pandya et al., 2019).

Whenever feasible, solutions and medications prepared and dispensed from the pharmacy or commercially prepared solutions should be used. Medications should not be added to infusing solution containers due to the risk of contamination, incompatibility, and dosing inaccuracy.

Solution Container Replacement

Current evidence is insufficient to establish a definitive recommendation for the frequency of routine replacement of intravenous solution containers, with the exception of parenteral nutrition solutions, which require replacement every 24 hours. Research suggests that routine replacement at predetermined time intervals may not be necessary, as one study found no relationship between length of time in use and likelihood of colonization. Further research in this area is warranted (Rickard et al., 2009).

Patient and Caregiver Education

Comprehensive patient and caregiver education is essential for safe infusion therapy. Education should address the infusion administration method, expected outcomes, and signs and symptoms that warrant reporting to clinicians. This includes symptoms that may develop after the patient leaves the healthcare setting. Education should be documented and patient comprehension verified.

Monitoring and Evaluation

Ongoing evaluation and monitoring of patient response to prescribed therapy is required throughout the course of treatment. Documentation must include patient response, any adverse events encountered, and interventions implemented. Laboratory test results must be communicated to appropriate team members. The effectiveness of therapy delivery must be assessed continuously to ensure the prescribed therapy is achieving its intended clinical goals (Gorski, 2023).

Adverse Event Reporting and Discontinuation

Reporting Requirements

Adverse events and medication discrepancies associated with medications and biologic agents must be reported to the appropriate department within the organization and to applicable external reporting organizations. Medication errors should be regularly monitored, and aggregate results should be communicated to staff as a preventive measure.

Criteria for Discontinuation

Infusion medications and solutions should be discontinued under the following circumstances:

Upon receipt of a discontinuation order from the authorized provider.

In the event of a severe reaction including anaphylactic reaction, speed shock, or circulatory overload. In these emergencies, the code team or rapid response team must be notified immediately (where available), and the provider must be contacted without delay (Gorski, 2023).

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