IV Push Evidence-Based Practice Checklist
January 7, 2022 QSEN Institute
An Evidenced-Based Practice Guide for Administration of Intravenous (I.V.) Push Medications
For printable version copy and paste into new URL : https://drive.google.com/file/d/1sdsTDG5jkDXGelzu24oChJep1e4hPWxe/view
Loretta K Dorn, MSN, RN, CRNI ® Marlene Steinheiser PhD, RN, CRNI®, Candy Cross MSN-Ed, RN, Elizabeth Campbell MSN RN, CRNI ®, Visnja Maria Masina, DNP, RN, AGCNS-BC, Denise Dion MSN, RN, CNE, PCCN, Heather Witek BSN RN
Intravenous therapy is one of the most common practices performed by nurses with 90% of patients receiving some form of IV medication Adverse events can occur in any phase of the medication administration process. Intravenous push (IV push) medications can be particularly dangerous given the immediate bioavailability and the narrow therapeutic dose range. It may be difficult to reverse the effects once the medication is given intravenously. Thus, the use of evidence-based practice is extremely important in IV push medication administration due to the high potential for patient harm. While there are evidence-based practice standards available, the step between understanding the evidence and implementing the evidence does not occur in many institutions.
Data Collection: Practice Gaps Identified.
In 2012 and again in 2014, The Institute for Safe Medication Practices (ISMP) undertook a survey to understand risks associated with IV push medication practices. Surveys noted a lack of understanding of IV push medication risk, limited standardization of IV push practices, as well as several significant safety gaps. As a result of these survey findings, a two-day national invitational summit was held by ISMP in September of 2014 to address these concerns, identify evidence-based practices, and gain consensus on best practice statements. Participants included frontline providers, professional organizations, regulatory bodies, and product vendors from across the US. Following this summit, the ISMP Safe Practice Guidelines for Adult IV Push Medications was developed. Later, a Gap Analysis Tool (GAT) for Safe IV Push Medication Practices was created to assist organizations in evaluating their adherence to the best practice guidelines. This tool was designed to identify and manage targeted risks for IV push adult medication preparation and administration in healthcare facilities. It enables practitioners to identify specific challenges and to evaluate and improve current practices. The tool is recommended for all healthcare institutions nationwide to assist in determining the priorities for safe IV push medication practices.
Another example of the disparities seen in the practice of IV push was demonstrated at a large teaching hospital within an integrated health system in the Midwest., An interdisciplinary team familiar with IV push medication administration, used the ISMP GAT for Safe IV Push Medication Practices to assess current practices and to determine This project evaluated and compared the perceived adherence to the recommended safe practices. The results were compared with the national benchmark developed by the ISMP. This hospital demonstrated highest adherence in the domains of acquisition and distribution of adult IV push medications, reporting of errors, and drug information resources. However, the greatest opportunities for improvement were in the domains of practitioner preparation, practitioner administration, and competency assessment. The aggregate score suggested that there is an opportunity for improving the safety of IV push medications. The results demonstrated that Errors during dilution are common due to dilution practices with the misunderstanding that dilution is needed to achieve slow drug administration (94%) because of perceived discomfort avoidance (70%), extravasation reduction (33%), and accurate small-dosage measurement (25%). These results are consistent with the ISMP findings that nurses utilized dilution because of the need for patient comfort, concern over avoiding extravasation, and the need to control the rate of administration by having a larger volume of medication,
In 2019, two Arizona nurses also researched the topic after seeing a gap in education and conducted a survey that reported a lack of standardized curriculum for instructing safe IV push medication preparation and administration in nursing programs. These two nurses found a significant variation in how IV push medication preparation and administration was taught to pre-licensure nursing students. Many nursing faculties were teaching unsafe practices in preparing and administering IV push medications. The clinical faculty survey demonstrated that 83% of faculty responding teach dilution of medications, 39% teach dilution of opioids (which require no dilution prior to administration) and 49% teach dilution with a pre-filled syringe of normal saline.
The Quality and Safety Education for Nurses (QSEN) patient safety task force used the Arizona nursing program survey with a few updates, to understand teaching strategies in more detail. This survey was sent to existing Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN) distribution lists, which included most nursing programs across the United States. The aim of the survey was to determine if the results of the Arizona survey would be similar and verify the results. A total of 380 nursing programs responded to the survey. The survey noted the same lack of consistency in all areas of IV push training.
Importance of Evidence-Based Practice
Use of standardized practice is so important that the Institute of Medicine, now the National Academy of Medicine, set a goal that by 2020, 90% of all healthcare decisions would be based on evidence While evidence-based practice standards are available, challenges with implementation exist. Lack of adoption of evidence-based practice standards means potential for continued adverse events, negative patient outcomes, and continued lack of policy and practice standardization.
Use of evidence-based practice provides high quality, safe patient care, and has shown in every clinical situation to improve patient outcomes and decrease costs. It is also incredibly important that all nursing programs standardize the practice of nursing based on evidence-based practice strategies and incorporate those standards into their curriculum to minimize the potential for variation and practice to maintain the professionalism of nursing care. Even in the presence of evidence-based practices, nursing staff, hospital institutions, and nursing programs have been slow to adopt best practices when performing nursing tasks at the bedside.
Barriers to Evidence-Based Practice Implementation
Now more than ever it is imperative that nurses are taught best practices in nursing curriculum regarding IV push medication preparation and administration. Nursing students are receiving less clinical time in hospitals due to the pandemic and simulation is taking on a larger role in nursing programs. When student nurses are allowed clinical time with a hospital preceptor, that preceptor may unintentionally teach the nursing student that it is appropriate to dilute medications that do not require dilution prior to administration. Teaching nursing students best practices provide them the ability to be a catalyst for change in hospitals across the country.
The practice of IV push administration should be based on evidence-based practice and not in ritual or traditions or in how the individual nurse has always practiced. The Infusion Nurses Society (INS) Infusion Therapy Standards of Practice state that the practice of infusion therapy should be established in organizational policies, procedures, practice guidelines and standardized written protocols to establish clinical decision making. Many healthcare organizations and nursing programs do not have a step-by-step process for IV push medication administration assuming it is a straightforward process and one which all nurses should know.
Nurses are being challenged now more than ever to practice safely. The effects of the pandemic on healthcare have left long lasting effects such as burnout, post-traumatic stress disorders (PTSD), short staffing concerns, and low morale. Drug shortages have led to possible unsafe work arounds when preparing and administering adult IV push medications. Out- dated drug reference guides promote the unsafe and unnecessary dilution of medications manufactured in ready-to-administer syringes such as narcotics.
The practice of nursing care is often based on learning experiences in school and in the education provided to the new nurse during the transition to practice. Most studies have demonstrated that nurses receive practice standard information from colleagues and in the case of nursing students in transition to practice from the preceptor. Information passed on to collaborating nurses is very often based on previous practices, clinical assumption based on personal experience, opinions, and the nurse’s individual skills. This learned behavior has been left to nursing discretion and pharmacists may not be aware that this unsafe practice has been passed down from generation to generation of nurses. Pharmacists may also be contributing to this unsafe practice by omitting clear instructions and not providing the appropriate diluent for the few drugs that need to be diluted just prior to administration. If the proper diluent is not provided, nurses often use prefilled normal saline syringes to dilute medications, and this is an off-label use of these syringes as they are approved by the Federal Drug Administration as flush syringes only. They are not approved for the reconstitution or dilution of IV push medications.
There are multiple barriers to the understanding and then implementation of evidenced-based practice into bedside nursing. These barriers may include, not having enough time to do the research or reading creating a lack of awareness of the latest evidence. The institution may not have enough time or resources to implement changes into nursing bedside practice. Obstacles or barriers for promoting best practice for IV push medication preparation and administration, is the mentality “we have always done it this way” and the false belief that the practice of diluting medications that do not require dilution causes no harm. Unfortunately, this mentality exists among faculty and clinical educators of our future generation of nurses. Best practices continue to evolve, and educators must be open and be willing to keep up to date especially if they have accepted the responsibility of educating student nurses. Unnecessary dilution of medications at the nurse’s discretion is an unsafe learned behavior that needs to be put to rest.
Even very experienced nurses can have variation in practice. As an example, in November of 2019, at the INS National Academy, a round table discussion highlighted some of the issues faced with IV push medications. Some examples of variation include the misconception that a clinician must use a 10 mL syringe to administer IV push medication through a central vascular access device (CVAD). The INS Infusion Therapy Standards of Practice (2021) state that a clinician must use a 10 mL diameter sized syringe to establish patency of the CVAD. However, once patency is established, medications can be pushed in the most appropriate size syringe. If the clinician is using a ready to administer syringe for example, it is appropriate once patency has been established to administer in the prefilled syringe size. The roundtable discussion showed that there is some complacency involved. The nurses present at the discussion were a mix of new clinicians as well as seasoned certified infusion nurses. The discussion made it noticeably clear that the evidence-based practice in the literature is not well known. In fact, some nurses stated that they did not believe that a small syringe could be used to administer IV push medications after patency was confirmed. Of the responses, 20 percent felt that this was new information to them, and they were unfamiliar with the related INS Standards of Practice.
Providing an Evidence-Based Checklist
QSEN is a recognized organization that pursues strategies to build and develop effective teaching approaches to assure that future nursing graduates develop competencies in patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. As a result of the gap, the Quality and Safety Education for Nurses (QSEN) patient safety practice task force was formed, consisting of IV therapy experts dedicated to improving patient safety through the development of practice standards using evidenced-based guidelines. This task force developed an IV push administration standardized practice checklist addressing the noted areas of inconsistent education and competency validation. There are 3 sections in the checklist. The first includes key areas of practice to assess prior to beginning the preparation and administration of IV push medications. The second area of the checklist focuses on IV push medication preparation and the third upon IV push medication administration. The checklist is intended for use in all clinical practice settings with both student nurses and licensed nurses and can be used to standardize practice between nursing programs and clinical practice sites.
See Figure 1 for checklist
Next Steps: Tool Implementation and Re-Survey
The QSEN patient safety task force will re-survey nursing programs using the same CCNE and ACEN distribution lists to evaluate the utilization of this practice strategy one year after implementation to give nursing programs time to incorporate the strategy into practice.
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"Gap Analysis Tool (GAT) for Safe IV Push Medication." 13 November 2013. ISMP. <https://www.ismp.org/resources/gap-analysis-tool-safe-iv-push-medication-practices>.
Gorski, Lisa, et al. "Infusion Therapy Standards of Practice." Journal of Infusion Nursing 8th edition (2021).
Institute for Safe Medication Practices. "Safe Practice Guidelines for Adult IV Push Medications." 2015. Institute for Safe Medication Practices. <www.ismp.org/guidelines/iv-push>.
James-Reid, Sarah, et al. "Creating consensus-based practice guidelines with 2000 nurses." British Journal of Nursing 28 (2019): S18-S25.
Lam, Christine, Carolyn Schubert and Elizabeth Herron. "Evidence-based practice competence in nursing students preparing to transtion to practice." Worldviews on Evidence-Based Nursing (2020): 418-426.
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Rahmayanti, Elifa Ihda, Kusrini Kadar and Ariyanti Saleh. "Readiness, barriers, and potential strength of nursing in implmenting evidence-based practice." International Jounral of Caring Sciences 13 (2020): 1203-1211.
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Figure 1
Section A
Key points to review prior to preparation and administration of medication.
1. Check the accuracy of the medication order (review medication administration record [MAR], orders, current condition, past medical history [PMH], as well as allergies and associated reactions).
2. Assess for any patient contraindications to the medication or IV Push route of administration (e.g., hypotension, abnormal laboratory results, abnormal glucose levels, active bleeding), and evaluate patient safety, taking into consideration upcoming procedures, PMH.
3. Review the type of vascular access device (VAD) and determine the appropriateness of the device based on the medication to be given and organizational policy.
4. Perform the rights of medication administration (e.g., right patient, right medication, right dose, right route, right time, right patient education, right to refuse, right assessment, and right evaluation, right documentation).
5. Prepare medication in designated clean, quiet environment.
6. Adhere to standard aseptic non touch technique (ANTT®) when preparing, administering IV push medication, flushing, and locking VAD. (ANTT is a specific and comprehensively defined type of aseptic technique with a unique theory-practice framework based on an original concept of Key-Part and Key-Site Protection; achieved by integrating Standard Precautions such as hand hygiene and personal protective equipment with appropriate aseptic field management, non-touch technique, and sterilized equipment.) (Gorski, et al., 2021; Rowley, 2001; National Institute for Health & Care Excellence, 2012)
7. When a passive disinfection cap is first removed there is no need to disinfect the needleless connector. For subsequent access, the student/nurse should disinfect the needleless connector with vigorous mechanical scrub for 5 to 15 seconds using 70% alcohol or alcohol-based chlorhexidine solution (Gorski, Hadaway and Hagle).
8. Always assess the VAD site prior, during, and after administering IV Push medication, for signs and symptoms of complications, such as pain, infiltration, phlebitis, or extravasation.
9. Assess VAD site for patency using a single dose 5 to 10 mL 0.9% sodium chloride syringe. Patency is determined by evidence of brisk, bright red blood return and VAD flushes easily. Never forcibly flush a VAD.
10. Use commercially available or pharmacy prepared pre-filled syringes to reduce the risk of catheter associated blood stream infections (CABSI), save time during syringe preparation, and aid optimal flushing technique (Gorski, Hadaway and Hagle).
11. To the greatest extent possible, have pharmacy provide adult IV push medications in a ready to administer form to minimize the need for manipulation outside the pharmacy sterile compounding area. If using a Carpuject™ syringe, always use an appropriate cartridge holder (Institute for Safe Medication Practices).
12. Only dilute IV push medications when recommended by the manufacturer, supported by evidence in peer-reviewed biomedical literature, or in accordance with approved institutional guidelines (Institute for Safe Medication Practices). If reconstitution or dilution of a medication is necessary, take steps to provide ready access to the proper diluent and instructions for reconstitution or dilution to support safe practice. In some facilities, this consists of “pharmacy-prepared kits,” while in other facilities, this information is available in the medication administration record (MAR) in an expanded view as part of the MAR entry (Institute for Safe Medication Practices).
12. Do NOT dilute or reconstitute IV push medications by drawing up the contents into a commercially available, prefilled flush syringe of 0.9% sodium chloride (Institute for Safe Medication Practices).
13. Prepare one medication syringe at a time. Label all IV push medication syringes (include patient’s name, drug name, dose unless prepared at the bedside and immediately administered). Never pre-label an empty syringe in advance of use (Institute for Safe Medication Practices).
14. Rate: Administer a medication at the rate recommended by the manufacturer/MAR/drug reference guide using a watch or clock with a second hand. Follow with post-flush using a single-dose 5 to 10 mL 0.9% sodium chloride syringe. Administer the flush solution at the same rate of administration as the medication (Institute for Safe Medication Practices). Pushing too fast can result in adverse drug effects (Gorski, Hadaway and Hagle).
15. If locking the VAD:
Know the internal mechanism for fluid displacement of the needleless connector in use (e.g., negative, or positive displacement, neutral, or anti-reflux) (Gorski, Hadaway and Hagle) Follow manufacturers’ directions for use for flushing, clamping, and disconnection.
In the absence of manufacturer directions, consider the reported reflux volume for each type and use the following sequence:
a. Negative displacement–flush, clamp, disconnect.
b. Positive displacement–flush, disconnect, clamp.
c. Neutral and anti-reflux–no specific sequence required.
Section B
Medication Administration preparation:
1. Obtain the medication and complete first medication check. Medication checks should be performed as a comparison against the MAR or original order.
(The first medication check is when the medications are selected or retrieved from the automated dispensing machine or storage location. The second medication check occurs during the preparation of the medication for administration. The third medication check occurs at the patient's bedside just before medications are given.)
2. If preparation is needed, prepare the medication in a designated clean, quiet environment, away from sinks. Use aseptic non touch technique (ANTT) (Gorski, Hadaway and Hagle).
When necessary to prepare more than one medication in a single syringe for IV push administration, limit preparation to the pharmacy (Institute for Safe Medication Practices)
3. Gather equipment (e.g., appropriately sized syringe to draw-up correct dose of medication, filter needle, if necessary, cartridge holder, 70% alcohol).
To assess patency of a VAD, use a 10 mL diameter-sized syringe and once patency has been confirmed, IV push administration of the medication can be administered given in a syringe appropriately sized to measure and administer the required dose.
4. If using glass ampules-clean with 70% isopropyl alcohol prior to breaking glass neck of ampule. Use a filter needle when withdrawing medication from a glass ampule, then discard filter needle and change to the appropriate needle for administration as necessary (Gorski, Hadaway and Hagle).
5. When preparing medication from a vial, use aseptic technique. Needleless caps on vials are dust covers only and not considered sterile. Scrub the diaphragm of the vial using 70% isopropyl alcohol. Inject equal amount of air into vial before removing the medication.
6. Perform an independent double check by 2 clinicians (the administering RN and 1 additional RN) for the organization-specific components of selected high-alert medications that pose the greatest risk of harm (e.g., opioids, anti-coagulants). Have two RNs/licensed clinicians witness wasting controlled substances.
7. Proceed with barcode medication administration procedures as per organization’s policy.
8. Label all medication syringes prepared away from the bedside (including the patient’s name, drug name, dose) to prevent medication errors.
Section C: IV Push Medication Competency Checklist
This checklist is designed to assess the competency of nursing students and practicing nurses.
Student/Nurse: ________________________ Validator: _____________________ Date: ________
IV push medication______________________________________________
Met
Not met
- Medication Preparation and Safety – First Check
* Compares the label of the IV Push medication against the MAR
* If the dosage does not match the MAR, determine if you need to do a math calculation
* Check the expiration date
- Medication Preparation and Safety – Second Check
- Assess for any patient contraindications to the medication or IV push route of administration.
- Right medication
- Right dose
- Right route
- Right time
- Right patient education
- Right documentation
- Right to refuse
- Right assessment
- Right evaluation
- Prepares medication in designated clean, quiet environment
- Gathers all equipment without prompting and performs hand hygiene.
- Assess a current drug resource guide to determine if dilution by the nurse is recommended just prior to administration
- If dilution is required, pharmacy will provide instructions on the correct diluent and volume required.
- Only dilute medications when recommended by manufacturer, supported by evidence in peer-reviewed biomedical literature, or in accordance with approved institutional guidelines. (Never dilute IV PUSH medications by using a pre-filled syringe of 0.9% normal saline)
- Value’s own role in preventing errors: Student /Nurse verbalizes the potential risks associated with this activity and takes all necessary steps to avoid preventable harm to the patient.
- If preparing an IV PUSH medication requiring dilution away from the patient’s bedside, labels new syringe with patient’s name, name of drug, concentration of drug and initials of nurse preparing medication.
- Adheres to standard aseptic non touch technique (ANTT) when preparing IV PUSH medications.
- When preparing medications from a vial, uses aseptic technique and scrubs the diaphragm of the vial using 70% alcohol (vial caps are dust covers only and are not considered sterile).
- Injects equal amounts of air into vial prior to removing the medication.
- If using glass ampules—cleans top with 70% isopropyl alcohol prior to breaking glass neck of ampule. Uses a filter needle when withdrawing medication from a glass ampule, then discards filter needle and change to the appropriate needle
- Knocks on patient’s door and introduces self
- Performs hand hygiene and dons’ gloves
- Verifies patient’s name, date-of-birth, and allergies by comparing the patient’s identification name band to information found in the patient’s health record.
- Assess VAD signs of complications such as infection, phlebitis, or extravasation/infiltration, asking if the patient has any pain during palpation of the site and surrounding area, if any of these are noted does not use
- Medication Preparation and Safety – Third Check
- When was the medication last given
- Why is the patient receiving this medication
- Are there vital signs, labs, or clinical data to assess prior to administration?
- If passive disinfection cap is removed there is no need to disinfect the needleless connector.
- For subsequent access, the student/nurse should disinfect the needleless connector with vigorous mechanical scrub for 5-15 seconds using 70% alcohol or alcohol-based chlorhexidine solution. Allow needleless connector to dry.
- Proceeds with barcode medication administration procedures as per organization’s policy.
- Performs independent double check by 2 clinicians for the organization-specific components of selected high-alert medications that pose the greatest risk of harm. (e.g., anticoagulants).
- Have two RN’s/licensed clinicians witness wasting controlled substances.
- Assesses VAD for patency using a single dose 10 mL diameter-sized syringe of 0.9% sodium chloride. Patency is determined by evidence of brisk, bright blood return and VAD flushes easily.
- If assessing central line patency use a 10 mL diameter-sized syringe with 0.9% sodium chloride, once patency is confirmed, use the appropriated sized syringe to administer the medication. Never forcibly flush a VAD.
- Educates patient about medications being administered
- If continuous running IV fluid is compatible with medication, pauses IV infusion device, checks patency, disinfects needleless connector proximal or closest to the patient (if passive disinfection cap present, it is not necessary to scrub the Needleless cap). Clamps tubing above the injection site closest to the patient and administers IV push medication at the correct rate using a watch or clock with second hand.
- Appropriate rate is determined by pharmacy prepared instructions on MAR, manufacturer/organizational guidelines, or approved current drug reference guide.
- If administering through a saline lock, removes passive disinfection cap, if no passive disinfection cap is present, disinfects the needleless connector with vigorous mechanical scrub for 5-15 seconds using 70% alcohol or alcohol-based chlorhexidine solution. Allows needleless connector to dry.
- Administers IV PUSH medication at the correct rate using a watch or clock with second hand.
- Disinfects the needleless connector with vigorous mechanical scrub for 5 – 15 seconds using 70% alcohol or alcohol-bases chlorhexidine solution. Allows needleless connector to dry.
- Using a new prefilled syringe of 0.9% sodium chloride, flushes at the same rate recommended to administer the medication.
- If locking the VAD, knows the internal mechanism for fluid displacement of the needleless connector in use (e.g., negative, or positive displacement, neutral, or anti-reflux).
- Negative displacement – flush, clamp, disconnect.
- Positive displacement – flush, disconnect, clamp.
- Neutral or anti-reflux – no specific sequence required.
- If continuous IV is present unclamp tubing and resume infusion.
- If no continuous IV is present, apply new passive disinfection cap if available.
- Evaluates patient for immediate response to the medication and verbalizes when to return and how to evaluate for onset and peak effect of medication. Instructs patient to call if feeling any adverse effects.
- Disposes of all contaminated materials in sharps container or approved receptacle. Removes gloves and preforms hand hygiene.
- Document’s medication administration per organization’s policy.
- Throughout medication administration minimizes risk of harm to patients and providers through both system effectiveness and individual performance.