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Part II: Survey Results Suggest Action is Needed to Improve Safety with Adult IV Push Medications

Problem: In our November 1, 2018 newsletter, we shared the findings from a recent 2018 ISMP survey of 977 practitioners (mostly nurses) on adult intravenous (IV) push medication practices and compared these results to related ISMP surveys conducted between 2010 and 2014. The 2018 survey revealed five unsafe practices associated with IV push medications that have persisted or worsened in the past decade:

  1. Using prefilled syringes or cartridges as vials (withdrawing some or all medication from the prefilled syringe or cartridge into another syringe for administration)
  2. Diluting adult IV push medications unnecessarily despite their availability in a ready-to-administer form (e.g., manufacturer or pharmacy-prepared syringes, single-dose vials)
  3. Diluting or reconstituting an IV push medication in a prefilled 0.9% sodium chloride (saline) flush syringe that is rarely relabeled (see “Is it really saline?”)
  4. Failing to properly label syringes of IV push medications prepared away from the patient’s bedside
  5. Clinicians preparing or manipulating IV push medications on patient care units instead of pharmacy dispensing ready-to-administer syringes of medications

The survey also identified conditions that foster and perpetuate these five unsafe practices, including:

  • Ongoing drug shortages, which have led to:
    • A declining number of adult IV push medications dispensed in ready-to-administer syringes
    • An increase in IV push medications being dispensed in unfamiliar formulations (concentrations and packages) and volumes greater than needed 
    • Administering medications by the IV push route that were previously administered by infusion (which may continue after resolution of the drug shortage)
    • Unsafe drug conservation practices (e.g., using partial doses from prefilled syringes, cartridges, or single-dose vials and saving the remainder for future use)
  • Mistaken beliefs associated with IV push drug administration:
    • A 10 mL syringe must be used to administer IV push medications via an implanted port or peripherally inserted central catheter (PICC)
    • Syringe labeling is not necessary if only one drug or one syringe is prepared, or if syringes can otherwise be distinguished by visual appearance or location
  • System vulnerabilities:
    • Lack of syringe (cartridge) holders to administer IV push medications in manufacturers’ prefilled syringes/cartridges
    • Use of prefilled syringes without a needleless connector or removable needle to attach to an IV access port
    • Variability in procedures used to administer IV push medications to ensure slow administration, avoidance of patient discomfort, and a reduction in the risk of extravasation
    • Recommendations for unnecessary dilution in drug references
    • Lack of available labels for self-prepared syringes
    • Organizational policies that do not require labeling of self-prepared syringes
    • Perpetuation of unsafe IV push medication practices during professional education, orientation, and on-the-job training (e.g., unnecessary dilution)

In Part II, we offer recommendations for the safe preparation and administration of adult IV push medications based on the survey results. We are also providing practitioners with access to a new gap analysis tool that can be used to evaluate an organization’s adherence to the ISMP Guidelines for Safe Practice of Adult IV Push Medications.1

Safe Practice Recommendations: ISMP recommends the following actions to reduce the risk of medication errors or other adverse patient outcomes associated with adult IV push medication administration.

Assessing Unsafe Practices

Conduct a gap analysis. ISMP strongly encourages all organizations to conduct an assessment of adult IV push medication practices using our recently launched ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices. The GAT will help facilities identify and address the five unsafe behaviors identified in the recent ISMP survey as well as conduct a broader analysis of compliance with all the evidence- and expert consensus-based best practices found in the ISMP Guidelines for Safe Practice of Adult IV Push Medications.1 The GAT will also help facilities identify opportunities for improvement and track their progress over time. The tool is available for FREE thanks to support from the Baxter Healthcare Corporation.

Dispensing Ready-to-Administer Prefilled Syringes

Dispense prefilled syringes. When possible, dispense IV push medications in ready-to-administer prefilled syringes in the correct concentration and volumes needed for common or patient-specific doses. If prefilled syringes are not available commercially, pharmacy should prepare and dispense syringes of medications in patient-specific doses. If stability conditions do not allow for such preparation, commercially available single-dose vials should be dispensed. All prefilled parenteral syringes should allow administration via a needleless system (e.g., have a luer connector or removable needle). To facilitate use of manufacturer’s prefilled cartridge syringes, be sure designated syringe (cartridge) holders are readily available and practitioners know how to access and use them.

Establishing Practices Around Dilution

Seek alternatives when possible. For medications where dilution may be needed for patient comfort or to reduce the risk of extravasation or injury during IV push administration, have the pharmacy determine if alternatives exist that do not need to be diluted, or if the medication can be administered via a syringe pump or small volume IV infusion.

Be clear about dilution. Establish a facility-specific policy regarding which, if any, adult IV push medications should be diluted prior to administration, where the medication should be diluted (pharmacy, if possible), and guidelines for how the medication should be diluted and administered. Communicate the policy and guidelines to appropriate practitioners.

Pharmacy dilution. When possible, require pharmacy to prepare all IV push medications that must be diluted according to the manufacturer’s guidelines or facility’s policy. The syringe of diluted medication should be labeled for each patient with the patient’s name, drug name, strength, dose, directions for administration (e.g., slow IV push over 3 to 5 minutes), and the beyond-use date/time.

Nurse/frontline practitioner dilution. If stability requires a medication to be diluted immediately prior to IV push administration, provide the medication in a single-dose vial (not a prefilled syringe) along with specific directions for dilution via written or electronic guidelines or checklists that provide the appropriate diluent, standard diluent volumes, and resulting concentrations (e.g., mg/total volume). Also provide dilution instructions on the medication administration record (MAR) or another document that is readily accessible prior to drug administration. Be sure directions for withdrawing the patient’s dose are included, as well as proper labeling of the drug’s concentration after dilution. Encourage nurses/frontline practitioners to always reference the facility’s policy and guidelines when diluting medications, and to call the pharmacy with questions (as commercial drug references may provide less specific or different recommendations compared to the facility’s policy and guidelines).

Do not dilute in flush syringes. Eliminate the use of saline flush syringes for diluting and administering medications. These syringes are considered medical devices, not medications, and have not been evaluated or approved for the dilution and administration of IV push medications (see “Is it really saline?” below).

Coaching and Educating Practitioners

Dispel myths. Conduct educational programs to dispel myths that lead to unsafe practices associated with IV push medication administration. For example, an update may be in order based on the Infusion Nurses Society (INS) guidelines that note it is safe to use a syringe that is appropriately sized (e.g., 3 mL) for the administration of IV push medications via an implanted port or PICC once patency has been confirmed using a 10 mL (or 10 mL diameter-sized) syringe to flush the line.2 Also, dispel any misunderstandings regarding the benefits and risks of diluting all adult IV push medications prior to administration in the absence of manufacturers’ recommendations (which may differ from some drug reference recommendations).

Coach practitioners to see the risk. Hold discussions with practitioners and present educational programs to help them clearly see the risks associated with these five unsafe practices. In particular, emphasize the unacceptable risks associated with: withdrawing a medication from a prefilled syringe and transferring it into another syringe; diluting medications dispensed in a ready-to-administer form, particularly opioids, anxiolytics/antipsychotics, and antiemetics; using a prefilled saline flush syringe to dilute or reconstitute a medication (see “Is it really saline?”); and failing to label a syringe prepared away from the patient’s bedside, even if only one syringe or medication has been prepared, or if practitioners believe they can distinguish multiple syringes by visual appearance or location alone. When appropriate, recognize the role that drug shortages may play in these unsafe practices, and let practitioners know how the organization will manage the shortages in a way that reduces the need to engage in these practices. 

Assess orientation content. Review orientation program content to ensure that new practitioners are not being taught unsafe adult IV push administration practices, such as unnecessary dilution or dilution using a flush syringe, and to ensure they are being taught the best practices found in the ISMP Guidelines for Safe Practice of Adult IV Push Medications.1 Consider creating an orientation checklist of competencies associated with IV push medication administration based on the ISMP Guidelines.

Safe Labeling of Self-Prepared Syringes

Make labeling an expectation. Establish policies and procedures that require practitioners to label all IV push medications prepared away from the bedside (or not administered immediately if prepared at the bedside), even if only one syringe or medication has been prepared. Provide practitioners with the required content for all medication labels and be sure this expectation is communicated to all practitioners. 

Provide patient care units with labels. To facilitate proper labeling of self-prepared syringes, provide patient care units with blank, preprinted, peel-off, and/or automated labels (e.g., labels for patient-specific or unit-dose medications that are created or printed from automated devices such as an automated dispensing cabinet). Avoid using tape to create a label or taping a medication vial to the syringe as a method of labeling. Handwriting on the tape may not be legible, may smear, or the tape may fall off; and the syringe and vial may come apart during transport. Pursue more accurate and safe ways to label self-prepared syringes.  

Other Recommendations

Reduce variability with IV push administration. Establish a clear procedure for administering IV push medications to ensure slow administration, avoidance of patient discomfort, and a reduction in the risk of extravasation. Be sure practitioners do not mistakenly believe that further dilution of ready-to-administer medications is the only way to achieve these goals.

List the rate of administration. For quick reference, include the rate of administering all IV push medications on the MAR.


  1. ISMP. Guidelines for safe practice of adult IV push medications. 2015. www.ismp.org/node/97  
  2. Infusion Nurses Society. Infusion therapy standards of practice (standard 40, flushing and locking, practice criteria D3). J Infus Nurs. 2016;39(1S):S1-S159.


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