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Dilution is no solution

Deutsch, Lynn MSN, RN, CRNI, VA-BC

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doi: 10.1097/01.NURSE.0000659316.76576.58
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THE INFUSION NURSES SOCIETY (INS) annual conference in 2019 was an exceptional experience with engaging speakers and insightful symposia. One of the topics that piqued my interest was the program on I.V. push medication administration. Much has been published on this topic since 2015, when the Institute for Safe Medication Practices (ISMP) issued its Safe Practice Guidelines for Adult I.V. Push Medications.1 In 2016, the INS addressed I.V. push medication administration in its Infusion Therapy Standards of Practice.2 Yet confusion still surrounds the practice of diluting I.V. push medications, a practice associated with a high risk of errors.

Unsafe practices revealed

ISMP conducted several surveys on medication safety between 2010 and 2014. The respondents reported several reasons for diluting medications, primarily rate administration and patient comfort. Many unsafe practices were discovered with dilution and labeling of medications. In addition, ISMP identified at-risk behaviors that could potentiate medication errors. From this analysis, ISMP developed a short list of crucial steps to follow:1

  1. Administer medications in ready-to-use forms.
  2. Use sterile technique when preparing or administering I.V. push medications and locking and flushing solutions.
  3. Dilute medications only when recommended by the manufacturer.
  4. Do not withdraw I.V. push medications from a commercially prepared cartridge-type syringe into another syringe due to risk of contamination.
  5. Never dilute or reconstitute medications using a commercially prefilled syringe of normal saline solution.
  6. Label all I.V. push medications prepared away from the bedside to prevent medication errors.
  7. Administer I.V. push medications and subsequent flush solutions according to the manufacturer's recommendations. Always use a second hand on a clock or a watch to ensure the rate is not too fast, which could cause an adverse reaction.
  8. Assess the patency of central venous access devices and peripherally inserted central catheters with 10 mL of normal saline (0.9% sodium chloride solution) for blood return. Administer medications in the smaller syringe instead of transferring medications into a 10-mL syringe.

In 2016, Shastay wrote a continuing-education article on safe practices for I.V. push medications.3 She noted that many graduate nurses learn I.V. therapy/I.V. push techniques during their new-hire orientation—not during their clinical rotations as students. Many institutions in which students perform clinical rotations do not allow prelicensure students to administer I.V. medications, leading to various practice and knowledge deficits among nurses.

In 2017, Lenz and colleagues examined several studies and organizations that published recommendations to mitigate the risks of contamination during the preparation and administration of I.V. push medications.4 They found that the unnecessary dilution of medications, presence of unlabeled syringes, and lack of clean areas to prepare medications outside of the pharmacy compounding rooms increased the potential for drug contamination.

In 2018, ISMP conducted another survey on I.V. push medication administration and found that healthcare professionals were still using unsafe practices. For example, the respondents reported an increase in using commercially prepared saline syringes for diluting I.V. push medications. The increase was due in part to the drug shortage crisis that impacted how medications were prepared in the pharmacy.5,6

Last year, the American Nurses Association also addressed this issue.7 The prevalence of this subject across different publications reflects a singular goal: to stress the importance of educating nurses to administer I.V. push medications safely. Educational programs for frontline staff who administer medications need to include best practices from ISMP guidelines and the INS standards to help dispel myths around I.V. push medication administration.

Unsafe practices take root

I did not learn to dilute I.V. push medications in nursing school. When I began my career as a hospital nurse in 1980, patients were connected to infusions. The dilution of I.V. push medications became common practice in the late 1990s when saline locks were introduced.

Fast-forward to 2016, when I began teaching Level 2 prelicensure nursing students at the local community college while continuing to work as a vascular access nurse. In the hospital, I did not notice if staff were diluting I.V. push medications—I was more concerned about preventing central line-associated bloodstream infections and teaching the nurses proper technique for catheter hub disinfection.

The Level 2 core curriculum imparts to the student principles of infusion therapy and safe I.V. medication administration. The students are taught the correct technique for diluting I.V. push medications as part of their I.V. skill competencies. As I was assisting with the assessment, I was shocked to discover the students were taught to dilute using saline syringes and normal saline vials—the college had adopted the same practices for dilution as the local hospitals.

As a new faculty member, I was hesitant to upset the status quo, but I was determined to teach my students the importance of evidence-based practice (EBP) and its impact on patient care. Every semester in preconference, I give my students a copy of the ISMP guidelines and the INS standards of practice as references on how to administer I.V. medications. During the first week of their clinical rotation, the students shadow a nurse. In postconference, we reflect on the day. Students often report that clinical nurses are diluting medications in saline syringes.

As both a professor of nursing and a vascular access infusion specialist, I needed to step out of my comfort zone in order to make changes in both my college and hospital workplaces. Prelicensure students need to be taught to integrate EBP in their practice and need to witness clinical nurses practicing safe I.V. push medication administration. Concurrently, nursing faculty need to update their curriculum to ensure that it includes current best practices.

Spader states many nurses believe incorrectly that medications need to be diluted for patient comfort.7 Medications can be given safely in a small amount using the proper syringe size and instilled over the time the manufacturer recommends, followed by a postflush at the same rate. Nurses must follow manufacturer's guidelines concerning whether dilution is necessary and, if so, how it should be done. The ISMP guidelines clearly state that practitioners should avoid manipulating I.V. medications outside of the pharmacy's sterile compounding area.1

Dispel myths in the workplace

How can infusion experts initiate changes in the workplace to ensure safe I.V. medication administration? I believe we need to educate our colleagues in all of the institutions in which we practice. We need to help dispel the myths of I.V. push dilution and share the latest EBP with our leadership and nurse educators to protect our patients from harm. I hope all of you will step out of your comfort zone and help make the necessary changes in your workplaces.


1. Institute for Safe Medication Practices. Safe practice guidelines for adult I.V. push medications. 2015.
2. Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016;39(suppl 1):S77–S81.
3. Shastay AD. Evidence-based safe practice guidelines for I.V. push medications. Nursing. 2016;46(10):38–44.
4. Lenz JR, Degnan DD, Hertig JB, Stevenson JG. A review of best practices for intravenous push medication administration. J infus Nurs. 2017;40(6):354–358.
5. Institute for Safe Medication Practices. Part 1: survey shows results show unsafe medication practices persist with IV push medications. ISMP Medication Safety Alert! 2018;16(11).
6. Institute for Safe Medication Practices. Part II: survey results suggest action is needed to improve safety with adult I.V. push medications. ISMP Medication Safety Alert! 2018;16(12).
7. Spader C. A matter of I.V. push drug safety. Am Nurse Today. 2019;14(4):20–21.

I.V. push drug administration; medication errors; medication administration

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