Unnecessary medication dilution is an unsafe practice that must be put to rest.

About 90% of hospitalized patients receive medication intravenously, making I.V. therapy one of the most common practices performed by nurses. Adverse events can occur at any phase of the medication administration pro­cess; however, I.V. push medications can be particularly dangerous given their immediate bioavailability and the narrow therapeutic dose range, which can make reversing any adverse effects difficult. Clinicians can access evidence-based practice standards, but in many organizations, a gap exists between understanding the evidence and implementing it.

Evidence-based practice

To emphasize the importance of standardized practice, the Institute of Medicine (now the National Academy of Medicine) set a 2020 goal that 90% of all healthcare decisions would be based on evidence. However, a 2020 systematic review by Migliore and colleagues found that evidence-based practice remains deficient, even though it increases quality, ensures safe patient care, and in every clinical situation has improved patient outcomes and decreased costs. Failing to follow evidence-based standards can result in adverse events, negative patient outcomes, and continued lack of policy and practice regulation.

When nursing school programs standardize curriculum using evidence-based strategies, they help minimize the potential for practice variation and maintain the professionalism of nursing care. Even in the presence of evidence-based practices, nursing staff, healthcare organizations, and nursing programs have been slow to adopt best practices when performing bedside tasks.

Barriers to implementation

Barriers to evidence-based I.V. push practice include limitations caused by the pandemic, potentially unsafe workarounds implemented in response to medication shortages, inaccurate information shared among nurses (including from preceptor to nursing student) based on previous practices, clinical assumptions based on personal experience, opinion, and individual nurse skill. Some nurses may be accessing conflicting drug references, which creates confusion about the unsafe and unnecessary dilution of medications manufactured in ready-to-administer syringes, such as narcotics.

Pharmacists may not be aware of unsafe I.V. push practice occurring in the organization, or they also may contribute to risky practice through unclear product label instructions and by including the wrong diluent for medications that require it. If nurses aren’t provided with the correct diluent, they may use prefilled normal saline syringes, an off-label use not approved by the Federal Drug Administration.

Other barriers to safe I.V. push administration include not having enough time or access to resources that might aid implementing changes to nursing bedside practice, the mentality that “we’ve always done it this way,” and the false belief that diluting medications that don’t require it causes no harm. Unfortunately, this belief exists among faculty and clinical educators as well. Best practices continue to evolve, and educators must stay up to date with current evidence. (See Practice misconceptions.)

I.V. push administration should be based on evidence, not ritual, traditions, or how an individual nurse has always practiced. The Infusion Nurses Society (INS) Infusion Therapy Standards of Practice state that organizations should establish safe infusion therapy practices in their policies, procedures, practice guidelines, and protocols.

Practice gaps identified

In 2012 and again in 2014, the Institute for Safe Medication Practices (ISMP) conducted a survey to understand the risks associated with I.V. push medication practices. Findings noted a lack of understanding of I.V. push medication risk, limited standardization of I.V. push practices, and several significant safety gaps. As a result, in September 2014, ISMP held a 2-day national summit to address these concerns, identify evidence-based practices, and gain consensus on best practice statements. Invited participants included frontline providers, professional organizations, regulatory bodies, and product vendors from across the United States.

After the summit, the ISMP developed the Safe Practice Guidelines for Adult IV Push Medications. Later, ISMP created the Gap Analysis Tool (GAT) for Safe IV Push Medication Practices to help organizations evaluate their adherence to best practice guidelines. Organizations use the tool to identify and manage targeted risks for I.V. push adult medication preparation and administration. It enables nurses to identify specific challenges and to evaluate and improve current practices. ISMP recommends the tool for all healthcare organizations to help set priorities for safe practice.

GAT in action

At a large teaching hospital within an integrated health system in the Midwest, an interprofessional team familiar with I.V. push medication administration used the ISMP GAT for Safe IV Push Medication Practices to assess current practices and determine compliance. The team compared results with the national benchmark developed by the ISMP. The hospital demonstrated high adherence in the domains of acquisition and distribution of adult I.V. push medications, error reporting, and drug information resources. Domains for improvement included nurse preparation, nurse administration, and competency assessment. The aggregate score suggested an opportunity for improving the safety of I.V. push medications.

The results demonstrated errors during dilution as a result of nurses believing that dilution is needed to achieve slow drug administration (94%), avoid patient discomfort (70%), reduce extravasation (33%), and ensure accurate small-dosage measurement (25%). These results are consistent with ISMP findings that nurses use dilution for patient comfort, to avoid extravasation, and to control the rate of administration with a large volume of medication.

In 2019, two Arizona nurses saw a gap in education and conducted a survey, which reported a lack of standardized curriculum for safe I.V. push medication preparation and administration in nursing programs. These nurses found a significant variation in how schools teach I.V. push medication preparation and administration to pre-licensure nursing students. Many nursing instructors taught unsafe preparation and administration practices. A clinical faculty survey demonstrated that 83% of the responding faculty teach medication dilution; 39%, opioid dilution (opioids don’t require dilution before administration); and 49%, dilution with a pre-filled syringe of normal saline.

To understand the gap in using I.V. push standards in education and then later in practice, the Quality and Safety Education for Nurses (QSEN) patient safety task force surveyed nursing schools across the United States using the Commission on Collegiate Nursing Education (CCNE) and the Accreditation Commission for Education in Nursing (ACEN) distribution lists. The task force wanted to determine if the results of the Arizona survey would be similar and to verify the results. A total of 380 nursing programs responded. The task force found significant variation and gaps in the use of evidence-based standards. Using this information, the QSEN group created an evidenced-based checklist for teaching and training nurses who administer I.V. push medications.

Evidence-based checklist

QSEN pursues strategies to establish effective teaching approaches that ensure graduates develop competencies in patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Its patient safety practice task force, which includes I.V. therapy experts dedicated to improving patient safety, created a standardized practice checklist, which addresses inconsistent education and competency validation. The checklist has three sections. The first includes key areas of practice to assess before preparing and administering I.V. push medications. The second section focuses on medication preparation; the third, on medication administration and competency assessment. Licensed and student nurses in all practice settings can use the checklist to standardize practice. (See Check it.)

Tool implementation and re-survey

To ensure licensed nurses and nursing programs can access the peer-reviewed checklist, the QSEN patient safety task force posted it on the QSEN website and the Infusion Nurses Society’s online learning center. The ISMP and Medication Safety Officers Society websites also acknowledge the checklist. In addition, a member of the QSEN task force presented the checklist at the 2022 QSEN International Forum.

The task force continues to disseminate the checklist among nursing programs and all healthcare organizations. The tool, which the task force originally developed to address inconsistencies in nursing student education related to I.V. push medication administration, has expanded to provide relevancy for licensed nurses. To address nursing education challenges and evaluate checklist use, the task force will re-survey the nursing programs, using the same CCNE and ACEN distribution lists, 1 year after implementation to allow time to incorporate the strategy into practice.

Loretta K. Dorn is director of the Clinical Center of Excellence and Education at Fresenius Kabi in Zurich, Illinois. Marlene M. Steinheiser is director of clinical education at the Infusion Nurses Society in Norwood, Massachusetts. V. Maria Masina is a clinical nurse specialist in advanced practice nursing at the Cleveland Clinic in Cleveland, Ohio. Candy Cross is a nursing education specialist at Banner Health in Mesa, Arizona. Elizabeth Campbell is a vascular access/infusion specialist at Newton-Wellesley Hospital in Newton, Massachusetts. Denise Dion is director of the nursing program at Central Arizona College in Coolidge. Heather Witek is senior clinical specialist of medical affairs at ICU Medical in Lake Forest, IL.

References

Institute For Safe Medication Practices. Gap analysis tool for safe IV push medication practice. November 13, 2018. ismp.org/resources/gap-analysis-tool-safe-iv-push-medication-practices

Institute For Safe Medication Practices. Safe practice guidelines for adult IV push medications. July 23, 2015. ismp.org/guidelines/iv-push

Gorski LA, Hadaway L, Hagle ME, et al. Infusion therapy standards of practice, 8th edition. J Infus Nurs. 2021;44(1S Suppl 1):S1-224. doi:10.1097/nan.0000000000000396

Lam CK, Schubert CF, Herron EK. Evidence-based practice competence in nursing students preparing to transition to practice. Worldviews Evid Based Nurs. 2020;17(6):418-26. doi:10.1111/wvn.12479

Migliore L, Chouinard H, Woodlee R. Clinical research and practice collaborative: An evidence-based nursing clinical inquiry expansion. Mil Med. 2020;185(Suppl 2):35-42. doi:10.1093/milmed/usz447

Ost K, Blalock C, Fagan M, Sweeney KM, Miller-Hoover SR. Aligning organizational culture and infrastructure to support evidence-based practice. Crit Care Nurse. 2020;
40(3):59-63. doi:10.4037/ccn2020963

Rahmayanti EI, Kadar KS, Saleh A. Readiness, barriers and potential strength of nursing in implementing evidence-based practice. Int J Caring Sci. 2020;13(2):1203-11.

American Nurse Journal. 2023; 18(4). Doi: 10.51256/ANJ042327

Key words: medication safety, I.V. push medications, medication dilution, evidence-based practice