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One of the best-kept secrets in medication administration? IV push drugs. "It's becoming such a common occurrence," says Anne Malloy, BSN, CRNI, nurse educator for the Infusion Nurses Society, "not only for infusion nurses, but for almost every staff nurse." Yet little is documented about errors resulting from IV pushes, or even how many doses are given by this route.
National databases maintained by the US Food and Drug Administration (FDA), as well as the US Pharmacopoeia's MedMARx reporting system (see sidebar), don't ask specifically about IV push when medication errors are reported. But the data they collect hints that IV push medications are potentially dangerous.
A retrospective analysis of deaths related to medications reported to the FDA's Adverse Event Reporting System from 1993 to 1998 found that half the deaths were caused by an injectable drug. A little over half the patients had received only a single drug, and about a quarter of the deaths were caused by a central nervous system agent. Nearly 41% of the deaths stemmed from incorrect doses (usually overdoses), and in 16% of deaths, patients received the wrong drugs. But almost 10% of deaths occurred because nurses gave medications by the wrong route. Sometimes nurses incorrectly gave drugs IV that were intended to be administered orally or IM. Other nurses used the wrong amount of diluent or active ingredient or administered drugs at the wrong rate.1
Experts call for greater vigilance when administering "high-alert" drugs, especially medications that would be dangerous if diluted incorrectly or given too quickly - concentrated potassium chloride, IV calcium, IV magnesium, 50% dextrose, IV narcotics, and concentrated sodium chloride.2
Malloy summarizes the basic risk: "Once it's in there, you can't get it back." Assuming that nurses give the right drug, in the right dose, to the right patient, IV push medications call for additional "rights" - the right dilution or flush, the right speed, and the right monitoring.
Always follow the manufacturer's guidelines and hospital policy when diluent or flush is needed. The wrong diluent can lead to unwanted drug precipitation, and too much of the preservative found in some bacteriostatic preparations can cause adverse effects, including seizures. Although a single flush may be harmless, the cumulative effects of frequent flushes can cause difficulties.3
"Speed of administration is one of the biggest problems," says a director of nursing in a community hospital in Illinois. Pushing IV drugs over seconds rather than minutes makes many drugs dangerous. Digoxin administered too rapidly, for example, can cause deadly dysrhythmias. Rapidly pushed furosemide can lead to ototoxicity, including permanent hearing loss. Michael Cohen, RPh, MS, FASHP, president of the Institute for Safe Medication Practices, advises nurses to question orders for "IV bolus" or "IV push" medications that leave out the rate of administration. If the order is incomplete, question the prescriber directly. Also, check current drug references or contact a pharmacist to learn the safe speed.4
The Infusion Nurses Society recommends pushing IV medications slowly unless you have specific orders for faster administration for a drug that can be safely pushed. The society advises that two nurses verify dosage calculation for all IV push medications intended for infants and children.3
Shawn Becker, RN, BSN, director of patient safety initiatives at the US Pharmacopoeia Center for the Advancement of Patient Safety, cautions nurses to administer all IV medications at the right speed. She sees errors related to infusion pumps that are incorrectly programmed to give either too little medication or unintended boluses. "Nurses fail to program the pump correctly, use the wrong dilution, forget to double-check, or don't use the IV system as it's intended," she says.
"If you drill down [when investigating errors]," Becker adds, "you find that the nurse was distracted or rushed, so double-checking doesn't happen." Overall, distractions contributed to 46% of all the medication errors reported to MedMARx in 2001.5
Some IV medications can be pushed safely only when patients are continuously monitored to detect dysrhythmias, blood pressure changes, or other adverse effects. Because IV push medications start working almost immediately and with greater effect, even relatively safe drugs can cause problems. For example, giving narcotics or diphenhydramine IV push could send a standing patient staggering for a chair or falling to the floor.
Few research studies have compared the safety or advantages of IV push medications to those of continuous infusions. For patients receiving prophylactic antibiotics before surgery, IV push was as safe, and the push method was less costly because it eliminated the need for more expensive IV administration set-ups and the nurse spent less time.6 Another study of patients with myocardial infarctions found that somewhat more patients who received thrombolytics by IV push received the correct total doses than did patients treated with longer infusions.7
Comparing the two methods, continuous infusions provide more opportunities for errors and require more cooperation between nurses caring for the same patients over time. On the flip side, errors can be detected and corrected at any time during long infusions. IV push medications, on the other hand, rely on the competence of only one or two nurses, even if calculations must be verified. But when mistakes happen, they're dramatic and often difficult to reverse.
Nurses need easier access to information specifically about IV medications. "We use an IV medication resource manual that tells nurses the category of drug, the form of IV delivery - push, piggyback, or continuous flow - and the parameters around each medication - dilution, delivery rate, complications, and side effects to watch for," says
M. Susan Theodoropoulos, RN, MSN, director of education at Virginia Hospital Center, Arlington, VA. "Nurses use it every day. It was developed by our pharmacy in cooperation with staff nurses and staff development."
Regardless of how often you push IV medications, consider each one a high-alert drug. "IV medications are so dangerous, but because we give IV push meds so often, we take the risks too lightly," Becker says. "Nurses have to take responsibility for knowing about the drugs they give. They need to be more conscious of what they're doing and the details of the meds. It's too dangerous to make assumptions about IV drugs."