Proper Preparation of Multi-Chamber Bag

The following information is for organizations that store CLINIMIX (amino acid and dextrose) or CLINIMIX E (amino acid and dextrose with electrolytes) in their overwraps on nursing units or allow nonpharmacy personnel into the pharmacy to remove drugs after pharmacy hours. (Yes, some hospitals still allow nurses in the pharmacy after hours despite the risk of errors.) Clinimix has dextrose in one chamber and amino acids in the other. Clinimix E has dextrose and calcium in one chamber and amino acids and electrolytes in the other. A seal that separates the two chambers must be broken in order to mix the contents of both chambers prior to dispensing. In our October 21, 2010 newsletter, we wrote about a nurse who removed a bag of Clinimix E from the pharmacy (per protocol) after it was closed. Later, another nurse discovered that the container had been hung without breaking the seal between the chambers. Only the chamber containing concentrated amino acids and electrolytes had infused, including 30 mEq of potassium chloride. Since then, we’ve received several reports of nurses failing to properly mix this product, including three cases last week at just one hospital. It’s safest for pharmacy to dispense Clinimix products for each patient after proper mixing and labeling. If the product is available and still in its overwrap in automated dispensing cabinets (ADCs) or other areas outside the pharmacy, teach nurses how to activate this product using educational resources. These resources illustrate the dual-chamber bag technology and offer step-by-step bag activation training. Some hospitals report that errors have been reduced by applying a noticeable auxiliary label to the overwrap, advising that the product must be activated prior to hanging. We also contacted Baxter to request more visible labeling regarding the need to activate the product before use. In last year’s article, we mentioned placement of an auxiliary label on the port used to spike the bag; however, this would require first removing the overwrap. Product labeling states that once removed from the overwrap, mixed or not, Clinimix solutions may be stored under refrigeration for up to 9 days. Information about storage at room temperature is not available. Important strategies to prevent errors include: starting the initial infusion when the pharmacy is open; providing access to a preapproved formulary of medications via ADCs or other means chosen with safety in mind; and prohibiting access to the pharmacy by non-pharmacy staff. It should be noted that The Joint Commission standards do not permit pharmacy access after-hours by non-pharmacists.

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^{Institute for Safe Medication Practices (ISMP). Proper preparation of multi-chamber bag. ISMP Medication Safety Alert! Acute Care. 2011;16(5):2-3.}