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Willingness of staff to give oral meds IV is disconcerting


From the May 20, 1998 issue

PROBLEM: When a patient's peripherally inserted central catheter (PICC) line became clogged, his nurse remembered that an enzyme product called Viokase® (pancrelipase) powder was used in the past to unclog a PEG tube. She mentioned this to an inexperienced medical resident. The resident was unfamiliar with using Viokase for this purpose so he asked a pharmacist. Whether or not it was clearly communicated that the drug was being considered for an IV catheter is unknown, but the pharmacist did confirm that Viokase was sometimes used to clear tubes and catheters. The resident wrote the order for Viokase, and it was administered. The patient arrested, but was successfully resuscitated, and there were no permanent sequelae

SAFE PRACTICE RECOMMENDATION:Obviously, medications such as Viokase that are meant for oral use should never be administered through IV lines. This needs to be taught at the very basic level of training. We are surprised that many practitioners do not understand this (in our March 12, 1997, issue we wrote about the case of a nurse in Denver who crushed and administered oral medications IV to an 86-year-old patient who couldn't swallow). Anyone who administers medications must be properly trained to identify what can and cannot be given through each type of line. This applies not only to healthcare professionals, but to patients and their caregivers who administer any products through lines of home IV therapy patients. Increasingly, caregivers have to administer medications via different routes, and they need to understand the consequences of, for example, injecting an oral substance into IV lines (our March 26, 1997 issue described the case of a mother who almost injected her child with ginger ale to unclog a PICC line after seeing this done when her child was in the hospital with a clogged enteral feeding tube). Finally, using medications in an unusual way or for a non-FDA approved indication may increase error potential. If a product is to be used in any unusual way, a protocol should be developed, and staff should be educated. Limiting access to these products, or requiring supervision by someone familiar with the protocol, can also reduce incorrect use.

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