I've noticed that some of my colleagues routinely dilute I.V. push medications with saline flush solution before administration to patients. Is this a good practice?—D.E., ILL.
Emily Wicker, PharmD, and Daniel J. Sheridan, MS, RPh, CPPS, reply: No, this is an unsafe practice. Small-volume I.V. medications intended for I.V. push administration over seconds to minutes are already in solution and do not need further dilution. Unfortunately, however, the practice you describe is still common. In a 2018 survey performed by the Institute for Safe Medication Practices (ISMP), 84% of practitioners said they dilute some adult I.V. push medications before administration.1
Diluting adult I.V. push medications before administration is dangerous for these reasons:2-4
- Dilution of I.V. push medications can lead to contamination of these sterile drugs. The manufacturing and preparation of I.V. push medications is highly regulated to reduce the risk of bacterial contamination. Additional manipulation of doses, such as dilution in a nonsterile environment, can introduce bacteria, increasing a patient's risk of infection. Whenever possible, any manipulation of I.V. solutions should be performed in a sterile environment by appropriately trained staff.
- Unnecessary dilution of I.V. push medications can also cause precipitate formation. Medications administered I.V. push are carefully studied and approved to be diluted with specific products to ensure medication stability. If a medication is diluted with an incompatible diluent, precipitate can form, leading to patient harm.4
- In addition, errors can occur if I.V. medications are further diluted and not properly labeled. Eighty-one percent of practitioners who participated in the 2018 ISMP survey reported utilizing saline flushes to dilute medications.1 When a medication is drawn into a saline flush syringe, the syringe will not be labeled for the added medication and could easily be confused with a syringe containing only saline flush solution.3 Consequently, a patient who is supposed to receive a saline flush may instead receive a diluted I.V. medication that was drawn into a saline flush syringe. Conversely, a patient who requires an I.V. medication that has been diluted in saline flush may receive only a saline flush and not the prescribed I.V. medication.
- Dilution of I.V. push medications can also lead to inaccurate dosing. Saline flushes are FDA-approved as medical devices, not medications, so they are not regulated to the higher standard required for solutions used to prepare medications.5 Consequently, the markings on a prefilled saline flush syringe may be less accurate than markings on syringes properly used in the preparation and administration of I.V. push medications, leading to dosing errors.3
Some medications may require dilution and preparation at the bedside. In these cases, nurses should follow the directions for proper dilution outlined in the manufacturer's drug label.4 For example, lorazepam injection should be gently mixed with an equal volume of sterile water for injection, 5% dextrose injection, or 0.9% sodium chloride immediately before I.V. administration as directed in the labeling.6
The ISMP's Safe Practice Guidelines for Adult I.V. Push Medications provides more details about risks associated with I.V. push medication preparation and administration as well as safe practices to reduce these risks.7 This free resource should be utilized to ensure that I.V. push medication preparation and administration practices are safe. Access it at www.ismp.org/guidelines/iv-push.
1. Institute for Safe Medication Practices. Part I: survey results show unsafe practices persist with IV push medications. Medication Safety Alert!
2. Spencer S, Ipema H, Hartke P, et al. Intravenous push administration of antibiotics: literature and considerations. Hosp Pharm
3. Burger M, Degnan D. Comparative safety, efficiency, and nursing preference among 3 methods for intravenous push medication preparation: a randomized crossover simulation study. J Patient Saf
4. Hertig JB, Degnan DD, Scott CR, Lenz JR, Li X, Anderson CM. A comparison of error rates between intravenous push methods: a prospective, multisite, observational study. J Patient Saf
5. Institute for Safe Medication Practices. Part II: survey results suggest action is needed to improve safety with adult IV push medications. ISMP Medication Safety Alert!
7. Institute for Safe Medication Practices. ISMP Safe Practice Guidelines for Adult IV Push Medications. 2015. www.ismp.org/guidelines/iv-push