IV Push Gap Analysis Tool (GAT) Helps Uncover National Priorities for Safe Injection Practices

In January 2019, the ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices was launched to help hospitals, long-term care facilities, and outpatient centers identify and manage targeted risks associated with the use of intravenous (IV) push medications in adults. The GAT, which reflects the 2015 ISMP Safe Practice Guidelines for Adult IV Push Medications, was made available at no charge, thanks to support from the Baxter Healthcare Corporation. The tool consists of 50 items designed to help evaluate adult IV push medication systems and practices associated with the acquisition and distribution of these medications; practitioner preparation, including aseptic technique and labeling; administration; drug information resources; competency assessment; and error reporting.

The open enrollment period for participation in the GAT was between January and April 2019 during which organizations could anonymously submit their GAT findings to ISMP to receive a GAT score. Recently, participating facilities received access to a workbook with aggregate data and worksheets that could be used to compare their experiences to that of demographically similar facilities and to plan improvements within their own organization. Now, ISMP is sharing some of the key findings with the healthcare community to identify challenges and ongoing national priorities with safely administering adult IV push medications.

Participant Profile

A total of 243 US healthcare facilities participated in the GAT and submitted their findings to ISMP through a confidential database. Most participants (n = 233) were from inpatient facilities, primarily hospitals. Data from the few participating outpatient facilities has been excluded from this analysis. The demographics of participating US hospitals were similar with respect to all US hospitals, although participants were more likely to be larger, rural, non-profit facilities providing general medical and surgical services.

Scoring Methodology

Each best practice item had four possible assessment choices: A = no activity (0 points), B = considered but not implemented (1 point), C = partially implemented (3 points), and D = fully implemented (5 points). The percent of facilities that reported no implementation (A and B), partial implementation (C), or full implementation (D) of the best practices was calculated. Then, the mean percent score for each item, each GAT section, and the entire GAT was calculated by dividing the average score achieved by facilities by the maximum possible score, and multiplying by 100. The mean percent score allows for the evaluation of collective performance within a familiar “report card” context.

Results

Overall Scores

The maximum score for the entire GAT was 250, and the mean score achieved by participating facilities was 196, resulting in an overall mean percent score of 78%. Differences were noted in the overall mean percent score based on facility demographics:

• Facilities that were part of a larger health system had a higher mean percent GAT score than single facilities (80% vs. 75%)

• Facilities with more than 25 licensed beds had a higher mean percent GAT score than facilities licensed for 25 beds or less (79% vs. 74%)

• Facilities located in urban settings had a higher mean percent GAT score than facilities located in rural settings (80% vs. 76%)

• For-profit facilities reported a higher mean percent GAT score than non-profit or government facilities (86% vs. 77%)

• Facilities that had a pharmacist present on site, around the clock, had a higher mean percent GAT score than facilities without a pharmacist on site, around the clock (80% vs. 76%)

Minor or no differences were noted in mean GAT scores based on location (Midwest, Northeast, West, South) or whether the facility served as a site for nursing students.

Section Scores

The lowest and highest scoring GAT items within each section of evaluated systems and practices are provided in Table 1 (page 6 of the PDF version). The following is a brief description of key findings within each of these sections.

Acquisition and distribution. This section of the GAT evaluated the purchase and dispensing of ready-to-administer medications and flush solutions. Overall, the average mean percent score for this section was 76%. While most participating facilities use commercially available or pharmacy-prepared prefilled syringes for flushing and locking vascular access devices (94% mean percent score, 86% full implementation), fewer facilities reported dispensing adult IV push medications in a ready-to-administer form to minimize the need for manipulation and product relabeling outside the pharmacy (61% mean percent score, 22% full implementation). In fact, 16% of participating facilities reported that they never dispense adult IV push medications in a ready-to-administer form, and 61% reported that they do not always purchase ready-to-administer medications even when they are commercially available.

Aseptic technique. This section of the GAT evaluated hand hygiene, disinfection of vial diaphragms and access ports, and use of personal protective equipment. Participating facilities scored the highest in this section, achieving a mean percent score of 87%. Facilities with 25 beds or fewer achieved a mean percent score higher than larger facilities for several aseptic processes, including vial disinfection procedures (84% vs 80%) and using a new syringe (and needle as necessary) for every IV push injection (98% vs. 94%), but lower mean percent scores regarding hand hygiene prior to (78% vs. 87%) and after (77% vs. 84%) drug preparation and administration. However, it is concerning that 11% of participating facilities reported no or only partial implementation of the best practice to use a new syringe for every IV push medication.

Practitioner preparation. This section of the GAT evaluated dilution and reconstitution of IV push medications, the use of a filter needle when appropriate, proper use of cartridge-type syringes, and inappropriate use of common-source containers (containers of solution used to prepare multiple doses of a drug or flush solution for multiple patients). Participants also scored high in this section, achieving a mean percent score of 80%. The highest scoring GAT items included using a filter needle or straw to withdraw IV push medications from a glass ampule when appropriate (93% mean percent score); diluting/reconstituting IV push medications immediately prior to use if it becomes necessary to prepare outside the pharmacy (88%); using sterile equipment and supplies (91%); having reliable drug information resources available (89%); and never using IV solutions in bags as a common source container outside the pharmacy sterile compounding area (89%).

The lowest scoring GAT items in this section suggest ongoing unsafe practices associated with dilution and reconstitution of adult IV push medications. Only about a third (31%) of participating facilities reported that IV push medications are never diluted or reconstituted by drawing up the contents into a commercially available, prefilled flush syringe. Another third (30%) suggested that this unsafe practice is allowed and perhaps is widespread (58% mean percent score). Only 34% reported that dilution and reconstitution always occur in a clean, uncluttered, and functionally separate location. Furthermore, less than half (48%) of the facilities were fully confident that IV push medications for adults are diluted only when recommended by the manufacturer, supported by evidence in peer-reviewed literature, or in accordance with approved institutional guidelines. 

Less than half of participating facilities (47%) reported that IV push medications prepared outside of the pharmacy are never withdrawn from commercially available, cartridge-type syringes into another syringe for administration, and only 64% were fully confident that associated syringe cartridge holders to support proper use are readily available.

Labeling. This section of the GAT evaluated IV push medication syringe labeling and availability of blank or preprinted labels. Overall, the average mean percent score for this section was 78%. The highest scoring GAT items in this section were related to a ban on pre-labeling of IV push medication syringes (87% mean percent score), and  immediately discarding unattended, unlabeled syringes containing any type of solution (86% mean percent score), although it is concerning that only 77% and 70% of facilities, respectively, reported full compliance with these best practices. The lowest scoring GAT items were associated with making sure blank or preprinted labels are provided to clinical units to support safe labeling practices (71% mean percent score) and preparing and labeling just one syringe at a time when multiple medications or solutions are prepared away from the bedside (73% mean percent score). Less than half of facilities (49% and 46%, respectively) reported full compliance with these best practices. 

Practitioner administration. This section of the GAT evaluated assessment of the access site and patient, barcode scanning prior to administration, IV push medication administration and flushing practices, and availability and permitted use of emergency rescue agents. Participants achieved a mean percent score of 80% for this section.

Barcode scanning of IV push flush solutions was the lowest scoring GAT item in this section (57% mean percent score), with 31% reporting that flush solutions were never scanned, and 31% reporting that flush solutions were always scanned prior to administration. Many more facilities reported barcode scanning of IV push medications prior to administration (78% mean percent score, 41% partial, and 53% full implementation). Another low-scoring GAT item dealt with including directions in protocols and/or coupled order sets that permit the emergency administration of rescue agents (67% mean percent score, 42% full implementation), although most facilities reported that antidotes and rescue agents are readily available where IV push medications are administered (85% mean percent score, 70% full implementation). Only about half of participating facilities (58%) reported that all IV push medications and any subsequent flush solutions are administered at the rate recommended by the manufacturer, supported by evidence in peer-reviewed literature, or in accordance with internal guidelines.

The highest scoring GAT items in this section, each achieving a mean percent score of 88%, involved conducting a clinical and vascular access site assessment prior to IV push medication administration, using a proximal connector to administer the medication through an existing IV infusion line, and flushing the line with an appropriate volume to ensure the entire medication has been administered. However, clinical and vascular access site assessment following the administration of IV push medications scored lower than assessment prior to administration (78% vs. 88% mean percent score).

Drug information resources. This section of the GAT evaluated the availability of drug references and defined key terms associated with IV push medications. Overall, the mean percent score for this section was 75%. Defining “IV bolus” and “IV push” in facility policies scored lowest in this section (50% mean percent score), and the availability of facility-approved IV push medication resources (85% mean percent score) and resources free of error-prone abbreviations (91% mean percent score) scored highest. 

Competency assessment. This section of the GAT evaluated privileging for preparation and administration of IV push medications, competency verification upon hire and ongoing, and feedback about errors and how to avoid them. Overall, participants scored the lowest in this section, achieving a mean percent score of only 67%. For-profit facilities scored much higher in this section than non-profit or government facilities (82% vs. 64%), as did facilities that were part of a larger system compared to single facilities (70% vs. 60%). Defining which practitioners can prepare (75% mean percent score) and administer (87% mean percent score) IV push medications scored highest in this section. The lowest scoring GAT items were related to competency assessments for IV push medication preparation and administration at the time of hire (59% mean percent score) and ongoing (44% mean percent score). Almost half of facilities (49%) reported no validation of IV push medication preparation and administration competencies on an ongoing basis, and almost one-third (32%) failed to validate competencies upon hire. Furthermore, only 42% of facilities consistently provide practitioners who prepare, dispense, or administer IV push medications with ongoing information about associated risks and errors that have occurred in the facility and have been reported by external   organizations, as well as strategies to minimize these risks and errors.

Error reporting. This section of the GAT evaluated internal and external reporting and use of the information for improvement. Participating facilities achieved a mean percent score of 78% for this section. Scores tended to rise as bed size increased (73% for the smallest facilities, 83% for the largest facilities). Reporting of adverse events, close calls, and hazardous conditions associated with IV push medications internally within the facility was the highest scoring GAT item in this section (88% mean percent score), while reporting these events to external safety organizations such as ISMP for shared learning was the lowest scoring item (60% mean percent score).

Conclusion

While the results of the GAT suggest adherence to some of the best practices in the ISMP Safe Practice Guidelines for Adult IV Push Medications, the results also point out significant opportunities for improvement. The following 10 best practices, which scored low on the GAT, represent key national priorities that should be assessed and considered for improvement in all US healthcare facilities:

1. Purchase or prepare and dispense IV push medications in a ready-to-administer form as much as possible.

2. Only dilute IV push medications when recommended by the manufacturer, supported by evidence in peer-reviewed literature, or in accordance with approved institutional guidelines.  

3. Never dilute or reconstitute an IV push medication by drawing the contents into a commercially available prefilled flush syringe of 0.9% sodium chloride.

4. Never withdraw IV push medications from commercially available, cartridge-type syringes into another syringe for administration.

5. Barcode scan all IV push flush solutions prior to administration. (While it may seem unnecessary to scan a saline flush syringe, given that it contains no active medication, there may be look-alike prefilled syringes that do contain active medications that may harm the patient.)

6. Include directions in protocols and/or coupled order sets that permit the emergency administration of rescue agents.

7. Administer all IV push medications and any subsequent flush solutions at the rate recommended by the manufacturer, supported by evidence in peer-reviewed literature, or in accordance with internal guidelines.

8. Assess practitioner competency for IV push medication preparation and administration at the time of hire and on an ongoing basis.

9. Provide practitioners who prepare, dispense, or administer IV push medications with ongoing information about associated risks and errors (internal and external), and strategies to minimize these risks and errors.

10. Report errors, close calls, and hazardous conditions associated with IV push medications to external safety organizations such as ISMP for shared learning.

While the period for participation in our recent national assessment of adult IV push medication systems and practices has concluded, a PDF version of the ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices will remain available on our website for use by facilities. We encourage inpatient and outpatient facilities to use the GAT to identify facility-specific opportunities for improvement.