Admixing Sterile Injectables and Infusions in Patient Care Areas Can Lead to Errors

HORSHAM, PA—Sterile, injectable medications and infusions are frequently prepared outside of the pharmacy, and frequently in less than ideal locations such as the patient’s bedside or nursing station counters. A recent survey from the Institute for Safe Medication Practices (ISMP) explores the extent to which safe admixing practices are being implemented outside the pharmacy, and some of the biggest safety challenges involved--almost one-third (31%) of respondents were aware of or personally experienced errors when admixing sterile injectable medications in the last year. Survey results were published in the November 5, 2020 issue of ISMP’s Medication Safety Alert!^® Acute Care newsletter.

The majority of the 444 survey participants were nurses (77%) and certified registered nurse anesthesia providers and anesthesiologists (8%). Most respondents worked in acute care or specialty hospitals (81%), with the remainder in ambulatory surgery centers (5%), infusion centers (3%), and physician practices or clinics (3%) or long-term care (1%). ISMP asked respondents to indicate how frequently admixing outside the pharmacy occurs; their agreement with five best practices associated with preparation of sterile, injectable medications and/or infusions; how often and what types of medication errors related to admixing are occurring in their organizations; and what the biggest safety challenges are.

The most common types of sterile injectables prepared outside of the pharmacy according to survey participants were:

• IV push medications, mostly medications transferred from vials to syringes (e.g., opioids, antiemetics, antibiotics, proton pump inhibitors)
• IV intermittent infusions, mostly minibag diluent containers with an integral vial adapter for the medication vial
• IM injections, mostly vaccines, antipsychotics, and antibiotics (these may involve mixing a drug powder and then transferring into a syringe)

Highlights of the survey findings include:

• More than 80% of respondents indicated that admixing occurs at times in less than ideal locations, including at the bedside (37%), on a counter or nursing station desk (28%), and on a mobile computer workstation (16%)
• More than a quarter of respondents (28%) reported often or always admixing IV continuous infusions or titrations outside the pharmacy, particularly insulin, vasopressors, and lifesaving drug infusions required during emergencies
• When asked about best practices associated with admixing sterile injectables outside the pharmacy, 49% of respondents who were preparing them indicated that they had not been formally trained in this task. Frequently, those with formal training indicated that competencies in this area are not verified annually or at all
• Only 35% of all respondents reported that they were required to have another practitioner independently double check that certain medications and infusions were admixed properly prior to administration, but most respondents reported that all (30%) or certain (44%) high alert medications (e.g., vasoactive agents, oxytocin, insulin, heparin, opioids, thrombolytics) required an independent double check
• The most common errors that respondents reported that they personally experienced included wrong preparation technique (21%), incorrect diluent/diluent volume (20%), incorrect dose/concentration (19%), and labeling errors (19%)
• The most commonly-cited safety challenge (20% of comments) was feeling rushed through the admixing process, especially during emergencies requiring lifesaving high-alert medications, while also having to follow standards that were established for routine situations instead of urgent care
• Other prevalent safety challenges included experiencing constant interruptions and distractions (16% of comments) and concerns about the sterility of the preparation area, admixing process, and end product (12% of comments)

For a copy of the ISMP newsletter article summarizing survey results, visit: https://ismp.org/resources/ismp-survey-provides-insights-preparation-and-admixture-practices-outside-pharmacy. Access may require free registration.

About the Institute for Safe Medication Practices

The Institute for Safe Medication Practices (ISMP) is the nation’s first 501c (3) nonprofit organization devoted entirely to preventing medication errors. ISMP is known and respected for its medication safety information. For more than 25 years, it also has served as a vital force for progress. ISMP’s advocacy work alone has resulted in numerous necessary changes in clinical practice, public policy, and drug labeling and packaging. Among its many initiatives, ISMP runs the only national voluntary practitioner medication error reporting program, publishes newsletters with real-time error information read and trusted throughout the global healthcare community, and offers a wide range of unique educational programs, tools, and guidelines. In 2020, ISMP formally affiliated with ECRI to create one of the largest healthcare quality and safety entities in the world, and ECRI and the ISMP PSO is a federally certified patient safety organization by the U.S. Department of Health and Human Services. As an independent watchdog organization, ISMP receives no advertising revenue and depends entirely on charitable donations, educational grants, newsletter subscriptions, and volunteer efforts to pursue its life-saving work. Visit www.ismp.org and follow @ismp1 to learn more.

For more information, contact:
Laurie Menyo, Director of Strategic Communications
(610) 825-6000, ext. 5310
lmenyo@ecri.org