Practical considerations for the use of
pre-mixed intravenous solutions
A statement by the Safer Medicines Group of
NSW TAG
March 2011
Distributed to:
- Drug and Therapeutics Committees
- Directors of Clinical Governance
We recommend you also inform:
- Directors of Pharmacy
- Directors of Nursing
- Nursing Unit Managers
- Procurement and Distribution
Introduction
The Medication Safety Self Assessment (MSSA) [1] recommends “commercially
prepared, premixed IV solutions are used whenever they are available on the
market”. This is particularly relevant for high-risk solutions. For example the MSSA
recommends: “Vials of concentrated forms of electrolytes (e.g. potassium chloride,
potassium phosphate, magnesium sulfate, and stock sodium chloride greater than
0.9%) that require dilution before IV use are not available as ward or imprest and/or in
automated dispensing cabinets on any patient care units (including in operating
room/anaesthesia stock).”
Recent research shows that the preparation of infusions is the most error prone step
in the medication management pathway.[2] Premixed intravenous solutions have
many safety benefits including removal of the need for drug-dose calculations when
making up an infusion. Additionally, using pre-mixed bags that have been
manufactured to ensure sterility, or prepared in an aseptically controlled environment
[3], may reduce opportunity for infusion-related sepsis and particulate contamination.
There is also removal of the need to fully mix solutions to which concentrated
solutions have been added prior to administration. Specifically manufactured
solutions may also offer the benefit of providing a concentration close to isotonicity
whereas ward-based admixtures will usually result in a solution which is hypertonic.
As more pre-mixed solutions become available on Australian market it is important to
be mindful of other practical considerations that may arise. These practical
considerations are described on the following page. They are accompanied by
relevant supporting evidence from the MSSA. The full text of the MSSA is available
at https://mssa.cec.health.nsw.gov.au/MSSA_introduction.html.
2
PRACTICAL CONSIDERATIONS
SUPPORTING EVIDENCE FROM THE MSSA
Selection errors - packaging and labelling issues
Premixed solutions often look identical. Manufacturer’s labelling on pre-mixed solutions
should be clear to ensure there is minimal risk of product selection errors
- Products with look-alike drug names and packaging that are known by the
hospital staff to be problematic are stored separately and/or are highlighted
with appropriate alerts in the pharmacy and ward/imprest areas. [MSSA 4.3]
- Auxiliary warnings or other label enhancements (e.g. TALL-MAN LETTERS
to accentuate differences in look-alike drug name pairs) are used on
packages and storage bins of drugs with problematic names, packages,
and labels.[MSSA 4.7]
Product standardisation
The number of available concentrations should be standardised and minimised within an - Concentrations for infusions of HIGH-ALERT drugs such as morphine,
heparin, insulin, and inotropes used for adult/paediatric patients are
institution and/or patient clinical area to avoid inadvertent under- or over-dosing through
standardised to a single concentration that is used in at least 90% of the
selection of an incorrect concentration.
cases. [MSSA 5.1/5.2]
Where the medicine is administered as a continuous infusion that is both dose and rate
dependent, each institution should support safe provision of pre-mixed solutions with a
DTC approved nomogram for determining the appropriate infusion rate for accurate
dose delivery in differing clinical situations.
Storage
- Drugs stocked in patient care units are carefully selected for each unit by
Storage of pre-mixed solutions may become an issue as an increasing number of
considering the needs of each patient care unit, staff expertise and
products become available on the market. Dedicated medication storage areas may not
familiarity with specific drugs, the risk of error with each drug, and the age
be large enough to store a variety of premixed solutions. Thus storage needs to be
and diagnoses of typical patients being treated on the units. [MSSA 5.17]
taken into account when ordering pre-mixed solutions. Storage of all S4 medicines must
Drugs stocked in patient care units are available in the least number of
be in an area with restricted access, kept locked unless in direct use. [4]
doses,
concentrations, and forms that will meet essential patient needs
As premixed solutions may look similar to other premixed solutions and infusion fluids,
between replenishment. [MSSA 5.18]
storage areas should be arranged in such a way to minimise mix-ups and wrong product
- Drug products stored in clinical areas are clearly laid out in a systematic
selection.
sequence which is clearly labelled and uniformly applied throughout the
The size and security of safes and temperature-controlled storage conditions should be
hospital. [MSSA 5.28]
examined when considering the use of pre-mixed S8 medicines. Safes are often
already crowded, refrigerators often not temperature-controlled, and the addition of premix solutions may increase the risk of selection error and diversion.
Pumps and devices
Wherever possible, smart pumps should be used without bypassing checks to support
accurate administration of pre-mixed solutions. Pumps should be programmed to
support standard concentrations of pre-mixed solutions.
- General infusion pumps with SMART PUMP TECHNOLOGY are in use with
full functionality employed to intercept and prevent wrong dose/wrong
infusion rate errors due to misprogramming the pump, miscalculation, or an
inaccurately prescribed dose or infusion rate. [MSSA 6.13]
When premixed infusions are not available
- IV solutions (injections and infusions) that are unavailable commercially are
Wherever possible, individually dispensed infusions of non-standard, complex and/or
prepared in the pharmacy unless needed in urgent lifesaving situations.
high-risk medicines should be prepared under controlled and standardised conditions in
[MSSA 5.16]
the pharmacy department
All staff will need to maintain mathematical skills in drug-dose calculation for preparing
infusions from standard concentrations. When solutions are made up on the ward it is
preferable for specialist/senior nursing staff (who are familiar with local policies for
concentrations & rates) to take responsibility for infusion preparation.
References
1. Medication Safety Self Assessment for Australian hospitals. Institute for Safe
Medication Practices (Adapted for Australian use by the NSW Therapeutic Advisory
Group and the Clinical Excellence Commission), 2007.
2. Where errors occur in the preparation and administration of intravenous
medicines: a systematic review and Bayesian analysis. Quality and Safety in Health
Care 2010;19:341-345
3. Therapeutic Goods Act 1989. Therapeutic Goods (Manufacturing Principles)
Determination No. 1 of 2009.
4. NSW Health: Medication Handling in NSW Public Hospitals: PD2007_077
4