Intravenous administration of drugs
Administration of intravenous medication can be defined as the process within which a solution or medication is introduced, using a vein, into the circulatory system. This route of administration began to emerge from the 1850s. Today, it is estimated that the number of patients receiving intravenous treatment is as high as 85% of the population using hospital services. These figures may differ in maternity services, where a significant number of women have an uneventful childbirth experience. In spite of this, there will be a proportion of women requiring intravenous medication. Therefore, it is important that midwives understand the safety implications and the principles behind optimum administration of intravenous medication.
Although essential at times, the use of intravenous drugs does not come without risks. National data highlights that there are more than 85 000 reported medication incidents in the NHS per year. The high proportion of incidents highlights safety concerns, with scope for potential errors in: prescribing, administering medication, patient monitoring, patient factors, human factors and environmental factors. Besides this, there are a number of complications that can also arise when administering drugs using the intravenous route. These include: phlebitis, speed shock and extravasation. Research shows that, although rare, the risk of death is increased when errors occurred using intravenous administration of medication. Studies have highlighted inconsistencies in clinical practice in reference to the preparation and/or administration of intravenous medication, which could partially be due to the lack of standardised guideline to use in practice. The National Institute for Health and Care Excellence (NICE) published general guidelines for hospital use of intravenous fluid therapy in adults, but there is not specific national guidance for using intravenous medication. Instead, different organisations may choose to design Trust-specific guidelines, instructing practitioners on preparation procedures, compatibilities/incompatibilities and safety precautions. It is important to take into account patient variables such as dose-response relationship and inter- and intraindividual variability to ensure safe practice.
Administration of intravenous medication can take place using a variety of methods, which include: intravenous bolus, intermittent infusion or continuous infusion. The choice for using one method over another will be determined by the drug to be administered, the manufacturer’s advice, the medical prescription and the desired effect of the drug. The British National Formulary (BNF) has guidance on preparation of intravenous medication for all drugs licensed to be used in the UK. The equipment to use is as varied as there are manufacturers. Irrespective of this, the primary items required are included in Box 74.1 and Figure 74.1.
The Royal Marsden Manual of Clinical Nursing Procedures provides extensive step-by-step guidance relating to administration of intravenous drugs (Dougherty and Lister 2015). Consent must be obtained and the records checked for drug allergy. The following process constitutes a summary:
- In the patient’s prescription chart, check for patient’s details, drug, dose, date and time of administration, route of administration, prescriber’s signature and date, prescription advice and any potential interactions. Two qualified practitioners should undertake these checks.
- Wash your hands with soap and water or antibacterial alcohol gel.
- In an aseptic room, prepare the drug following the manufacturer’s and/or BNFs advice.
- Prime the line.
- Prepare the flush solution.
- Place all equipment in a clean tray and dispose of all needles, unless it is strictly necessary to use these during the administration process.
- Wash your hands before approaching the patient.
- Ensure the five rights of medication administration: patient, medication, dose, route and time. Some experts expand these to 10 rights, adding right education, documentation, right to refuse, assessment and evaluation.
- Inspect the insertion site.
- Wash your hands and put on protective equipment (gloves, apron).
- Clean the cannula cap or extension with 2% chlorhexidine swab.
- Flush the line with 10 mL of 0.9% of NaCl for injection. Ensure patency and patient’s response.
- Connect the primed intravenous line to the cannula whilst clamped. Insert the tubing into an infusion pump, if appropriate.
- Open the roller clamp and adjust the flow rate, as per prescription.
- Ensure the patient is comfortable.
- Remove gloves/apron; wash hands.
- Monitor the patient and the flow rate regularly.
- At the end of the infusion, disconnect equipment.
- Flush the line with 10 mL of 0.9% NaCl.
- Clean the injection site of the cap with 2% chlorhexidine swab.
- Safely discard the utilised equipment and document the intervention in the patient’s notes.
Midwives are the lead healthcare professional with expertise to care for women during the childbirth period, when pregnancy is uneventful; they also work as part of the multidisciplinary team in delivering care for women in need of specialist care by a qualified doctor. Midwives must always apply the four principles as guided by the NMC Code. In regards to administration of intravenous fluids, midwives must work under their scope of practice, meeting practice standards as stated by their regulatory body. Medicines management is one of the essential skills clusters in the Standards for Competence for Registered Midwives and specific guidelines exist within the NMC to support midwives’ practice. Midwives must ensure they adhere to the Trust’s policy and undertake any training that is required prior to administering intravenous medication. They must adhere to documentation guidelines, which includes incident reporting.