Safe Injection Administration
Clinical Skills
Safe Injection Administration
Clinical Skills and Simulation Team
Safe Injection Administration
Aims & Outcomes
Aims & Outcomes
The aim of this module is to facilitate learning regarding the purpose and procedure of Safe
Injection Technique.
The learning outcomes for this module are for the student to be able to:
 Describe the need for administration of medicine by injection.
 Discuss how the drug is safely managed and administered.
 Appreciate and be able to manage the potential risks associated with the process.
 Describe the checks required with regard patient safety.
 Consider which may be the most appropriate injection site for delivery of the injection.
 Evaluate own knowledge of safe injection administration and formulate an action plan to
compensate for any deficits.
Safe Injection Administration
Introduction
Introduction
Injections are sterile solutions, suspensions or occasionally, emulsions. They are prepared by dissolving,
emulsifying or suspending the active ingredient in water for injection or a suitable diluent liquid.
The term injection describes the giving of this medicine by means of a needle and syringe.
Injections are invasive, and strict aseptic technique is required during preparation and administration to minimise
the risk of infection.
Giving injections is a regular and commonplace activity which doctors may be expected to carry out. Good
injection technique can make the experience for the patient relatively painless, however, mastery of the
technique is essential. The procedure may involve some discomfort, and, as the risk of tissue or nerve damage
exists, selecting a suitable site is an important concern.
Safe Injection Administration
Preparation – Checking details
Preparation – Checking details
It is vitally important that you carry out a
number of checks before you start preparing
the drug prescribed for a patient. Do not
assume that the prescription has been
written up correctly. Ask the patient details of
their name and if they have any allergies.
Check against the prescription chart. Check
the details about the indication for the drug,
dose, route, and contraindications with the
BNF. Make sure the date and time are
correct.
R
• Right Patient
R
• Right Drug
R
• Right Dose
R
• Right Time
R
• Right Route
Safe Injection Administration
Drug Preparation-Reconstitution of a powdered medicine
Drug Preparation-Reconstitution of a powdered medicine
Drug prescribing and calculation of dose is an important skill that is discussed in another
module.
For the preparation of a drug e.g. reconstitution of a power to a fluid, a clean environment e.g.
Treatment room must be sought-no drugs should be drawn at the bedside. Ensure you have a
current prescription, and technical drug information before preparation.
Safe Injection Administration
Gloves & Aprons
Gloves and Aprons
Many trusts require staff to wear gloves and aprons for the preparation of drugs and during the
injection procedure, to avoid cross contamination by bacteria.
Gloves will also protect the administrator from absorption of medication via the skin but will not
protect against sharps injury. Universal precautions should therefore always be taken.
Safe Injection Administration
Drug Preparation – Procedure (1 of 7)
Drug Preparation - Procedure
• Read all drug labels carefully.
• Assemble your equipment: Sharps bin, medicine/ampoules, diluent, syringe, needles, alcohol
swab if using, gloves, disposable tray.
• Remove the foil or plastic cap from the ampoule or twist off the plastic cap of the medicine.
Safe Injection Administration
Drug Preparation – Procedure (2 of 7)
Drug Preparation - Procedure
• If you have a small glass ampoule, break open at the marked area using an ampoule breaker,
or by using an alco-wipe to snap at the line of weakness.
Safe Injection Administration
Drug Preparation – Procedure (3 of 7)
Drug Preparation - Procedure
• Clean the top of the diluent with an alcohol swab
• Twist off the plastic top.
Safe Injection Administration
Drug Preparation – Procedure (4 of 7)
Drug Preparation - Procedure
• Draw up the required amount of diluent with a syringe and green needle.
• Place the vial on the surface of the trolley.
• Insert the green needle into the vial and inject the diluent.
Safe Injection Administration
Drug Preparation – Procedure (5 of 7)
Drug Preparation - Procedure
• Agitate the bottle with the needle still in place.
• Ensuring the powder is mixed with the diluent, gently draw back the reconstituted drug into
the syringe.
• Ensure you keep the ‘eye’ of the needle immersed in the drug at all times. This will ensure you
do not draw up any air into the syringe.
Safe Injection Administration
Drug Preparation – Procedure (6 of 7)
Drug Preparation - Procedure
Carefully dispose of the drawing up
needle and replace with a fresh one of
an appropriate size for either SC or IM
injection.
NB: SHARP SAFETY
Needles are only ever removed from
syringes in this way when they are
UNUSED. When a drug has been
administered, the needle and syringe
are placed straight into the sharps box
unseparated.
Safe Injection Administration
Needles and Syringes
Needles & Syringes
Subcutaneous
Only 1-2ml is injected via the subcutaneous
route, so using a 5ml syringe is usual. Needle
choice is an orange (25 gauge). This is short,
and unlikely to penetrate the muscle layer. For
insulin administration, a special low dose, 1ml
syringe is used for accurate drug
measurement.
Intramuscular
Needles should be long enough to penetrate
the muscle but still allow a quarter of the
needle to remain external to the skin. In an
adult, needle choice is usually a green (21
gauge) or blue (23 gauge). For children a blue is
the obvious choice.
Safe Injection Administration
Skin Cleansing
Skin cleansing - to swab or not to swab
Cleansing a site with an alcohol impregnated swab and allowing it to dry is known to reduce the
incidence of bacteria before giving an injection. However, inconsistencies exist in current
research and in practice. Skin swabbing repeatedly before a SC injection can pre-dispose the
skin to hardening by the alcohol. It is therefore not recommended for SC injections.
The World Health Organization (WHO) Best Practice Guidance for Injections (2010)
recommends:
For IM immunizations : suggests soap and water is sufficient
For IM therapeutic drugs: an alcohol swab should be used.
If skin disinfecting is practiced, the skin should be cleansed with an alcohol swab for 30
seconds, and allowed to dry for 30 seconds. It is otherwise ineffective.
Safe Injection Administration
Gloves for administration of IM or SC injections
Gloves - to wear or not to wear
Gloves should always be worn whilst preparing a drug (e.g. reconstituting a powder) to protect
against contamination of the injection being prepared and to protect the operator for
inadvertent skin contamination.
However, as with the question of skin cleansing, there is some debate regarding the need to
wear gloves (non sterile) for SC and IM injections. Locally, you will note that many Health Care
Professionals will wear gloves to administer SC and IM injections in for instance ward areas,
whilst for immunisations and vaccines this is very unlikely.
We would advise that you check local policy if possible and in the case of vaccines, always check
the drug leaflet. For some, eg Varicella vaccine gloves should be worn.
Hot Tip!!
To avoid confusion during summative assessment we recommend that you cleanse your hands
appropriately (WHO Guidelines), wear gloves if you are preparing a drug for administration but
you do not need to wear gloves if performing a routine IM or SC injection.
Safe Injection Administration
Gloves for administration of IM or SC injections
Gloves - to wear or not to wear
The World Health Organization (WHO) Best Practice Guidance for Injections (2010)
recommends:
Safe Injection Administration
Key Checks before injecting
Key Checks before and after injecting
Prior to administering a drug by SC or IM route, there are common steps to observe.

Check prescription including allergies.

Prepare medication as per prescription.

Ensure you have the right patient, right time, right dose.

Obtain consent.

Ensure the patient is comfortable.

Select site.

Following injection, observe site for at least 15 minutes, checking for swelling, discomfort
or pain.
Safe Injection Administration
The Subcutaneous route
The Subcutaneous route
The subcutaneous (SC) route is used for a slow sustained absorbtion of medication, up to 1-2ml being injected
into the subcutaneous tissue. Amongst the drugs that may be injected using this route are insulin or
anticoagulants, which require a slow steady release. The technique is relatively pain free, and sites are often
suitable for frequent injections.
Safe Injection Administration
The Subcutaneous route
The subcutaneous route - Suitable injection sites
Sites recommended for sub-cutaneous injection are
the lateral aspects of upper arm and thighs and the
peri umbilical region of the abdomen.
Upper arms are a favourable choice, and least likely to
cause discomfort to the patient.
Avoid areas of bruising, tenderness, hardness,
infection or inflammation.
The amount of subcutaneous tissue may vary at sites.
In view of this, care should be taken to ensure the
muscular layer is not penetrated, particularly when
administering Insulin, as inadvertent I/M injection can
cause rapid absorption and hypoglycaemia.
Safe Injection Administration
The Subcutaneous route – Procedure
The Subcutaneous route - Procedure
• Lift up a roll of skin.
• Insert needle at 90 ̊angle. Leave some of the shaft exposed.
• Inject the medication with a slow steady pressure.
• Withdraw needle quickly whilst placing a gauze square over the site.
• Dispose of sharps immediately.
• Document procedure.
1.
2.
3.
Tips
Don’t administer irritant injections.
Don’t aspirate the needle.
Don’t massage the site-it may
damage underlying tissues.
Safe Injection Administration
The Intramuscular Route
The Intramuscular Route
Intramuscular injections deliver medication into well perfused muscle, providing rapid systemic action and
absorbing fairly large doses, these being from 1ml in a deltoid, to 5ml in the ventrogluteal site (half these doses
in children).
The choice of site should take in to account the general physical condition of the patient, age, and the amount of
drug being delivered. The chosen site should be inspected for contraindications of inflammation, infection, or
swelling. If the patient is elderly frail with reduced muscle mass, ensure you ‘bunch up’ the muscle to ensure
adequate bulk before injecting.
We have listed four popular sites for administering IM injections.
Safe Injection Administration
The Intramuscular route – Deltoid (1 of 2)
The Intramuscular route – Deltoid site
The deltoid muscle- Used for vaccines such as tetanus toxoid
and hepititis B. The densest part of the muscle can be found
by identifying the acromial process and the point on the
lateral arm in line with the axilla.
Injection
site
Safe Injection Administration
The Intramuscular route – Deltoid (2 of 2)
The Intramuscular route – Deltoid site procedure
•
•
•
•
•
•
•
•
•
Expose the entire shoulder and arm area.
Ask the patient to relax, elbow flexed.
Palpate the lower edge of the acromial process.
Site the needle at 2.5cm below the acromial process.
Stretch the skin at the site.
Insert needle at 90 ̊angle. Leave 1/3rd of the shaft exposed.
Aspirate for a few seconds to ensure the needle is not sited
in a blood vessel.
Inject the medication with a slow steady pressure (1ml over
10 sec).
• Withdraw needle quickly whilst placing a gauze square over
the site
• Dispose of sharps immediately.
• Document procedure.
Safe Injection Administration
The Intramuscular route – The Dorsogluteal site (1 of 2)
The Intramuscular route – The Dorsogluteal site
Using the gluteus maximus muscle, this
has been a popular and traditionally used
site. It is still often seen used on wards,
but should be dropped in favour of
ventrogluteal
site,
because
of
complications associated with it, namely
possible damage to the sciatic nerve or
the superior gluteal artery. If, for any
reason, you cannot use the ventrogluteal
site, a good term to remember for siting
is to use the ‘upper outer quadrant of the
outer upper quadrant’ of the gluteus
maximus.
Safe Injection Administration
The Intramuscular route – The Dorsogluteal site (2 of 2)
The Intramuscular route – The Dorsogluteal site procedure
 Draw an imaginary line between the superior iliac spine and greater trochanter.
 Inject in the area above the imaginary line.
 Stretch the skin at the site.
 Insert needle at 90 ̊angle. Leave 1/3rd of the shaft exposed
 Aspirate for a few seconds to ensure the needle is not sited in a blood vessel.
 Inject the medication with a slow steady pressure (1ml over 10 seconds).
 Withdraw needle quickly whilst placing a gauze square over the site
 Dispose of sharps immediately.
 Document procedure.
Safe Injection Administration
The Intramuscular route – Ventrogluteal (1 of 2)
The Intramuscular route - Ventrogluteal site
This is a safer option which accesses the gluteus medius muscle.
It avoids all major nerves and blood vessels, and research reports
no contraindications. The area also has the benefit of having a
relatively consistent thickness of adipose tissue (3.75cm)
compared with 1-9cm on the dorsogluteal site. The patient can be
prone, semi-prone or supine for using this injection site.
Safe Injection Administration
The Intramuscular route – Ventrogluteal (2 of 2)
The Intramuscular route - Ventrogluteal site procedure.
 Place palm of your right hand over the greater trochanter of the patients left hip (or vice versa).
 Extend index finger to touch anterior superior iliac crest.
 Stretch middle finger to form a V. Thumb points towards the front of leg.
 Needle should enter the V at 90 ̊. Leave 1/3rd of the shaft exposed.
 Aspirate for a few seconds to ensure the needle is not sited in a blood vessel.
 Inject the medication with a slow steady pressure (1ml over 10 sec).
 Withdraw needle quickly whilst placing a gauze square over the site.
 Dispose of sharps immediately.
 Document procedure.
Safe Injection Administration
The Intramuscular route - Vastus Lateralis (1 of 2)
The Intramuscular route-Vastus Lateralis site
This is a large muscle that is situated laterally to the femur.
The drug absorption rate is faster here than from the gluteus
maximus, but slower than the deltoid.
The site has traditionally been used for children, but research
indicates the ventrogluteal site to be a safer option.
Risks associated with incorrect siting are accidental damage to
the femoral nerve or muscle atrophy through overuse.
Injection
site
Safe Injection Administration
The Intramuscular route - Vastus Lateralis (2 of 2)
The Intramuscular route-Vastus Lateralis site procedure
• In adults measure a hands breadth laterally down from
the greater trochanter, and a hands breadth up
from the knee.
• Identify the middle third of the quadriceps muscle as
the injection site.
• Stretch the skin at the site.
• Inject the needle at 90 ̊ angle. Leave 1/3rd of the shaft
exposed.
• Aspirate for a few seconds to ensure the needle is not
sited in a blood vessel.
• Inject the medication with a slow steady pressure
(1ml over 10 sec).
• Withdraw needle quickly whilst placing a gauze square
over the site.
• Dispose of sharps immediately.
• Document procedure.
Injection
site
Safe Injection Administration
The Intramuscular route – Aspiration
The Intramuscular route – To Aspirate or Not to Aspirate
Aspiration, commonly performed during IM injection is meant to ensure that the needle tip is at the desired
location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a
lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration
both make logically sound claims. However, due to scarcity of available data, there is no evidence that this
component of the procedure is truly beneficial or unwarranted.
There are many types of safety syringes available on the market. Auto Disable (AD) syringes are designed as a
single use syringe, with an internal mechanism blocking the barrel once depressed so it cannot be depressed
again. The widespread use of auto-disable (AD) syringes – most of which are not designed to aspirate – has
not been linked to adverse effects due to the elimination of the aspiration procedure prior to injection of
vaccines. (Sepah et al, 2014).
For deep IM injections especially in sites other than the deltoid region, we would recommend aspiration to
ensure the needle tip is not placed in a blood vessel. This is supported in the literature (Rodger and King,
2000).
Hot Tip!!
To avoid confusion during summative assessment we recommend you use aspiration during an IM procedure
unless the question is in particular regarding vaccinations and you are dealing with a pre loaded syringe.
Safe Injection Administration
Complications
Complications
Complications that occur as a result of infection can be prevented by strict aseptic
precautions.
Sterile abscesses may occur as a result of frequent injections to one site or poor local
blood flow.
Sites that are paralysed or oedematous will have less ability to absorb a drug, and should
not be used.
Wherever complications arise as a result of injection administration, senior guidance
and assessment of the situation should be sought immediately.
Safe Injection Administration
Checklist (1 of 2)
Checklist
 Wash hands, apply gloves for preparation of drug.
 Consult drug chart- right patient, right drug, right dose, right
date/time, right route – use the BNF to do these checks.
 Check for allergies.
 Select appropriate syringe and needles.
 Prepare medication to correct dose.
 Explain procedure to patient and obtain consent.
 Assist patient to comfortable position.
 Select appropriate site-give rationale.
 Clean site with 70% isopropyl alcohol swab if appropriate.
Safe Injection Administration
Checklist (2 of 2)
Checklist
 ‘Bunch up’ skin for SC injection
 Stretch skin for IM injection
 Angle needle at 90 ̊. Leave 1/3rd shaft exposed.
 For deep IM injection aspirate. If blood appears, withdraw
needle, replace, and start again.
 Do not aspirate if giving a pre loaded vaccine IM. Check
protocol for drug.
 Do not aspirate for SC injection.
 Depress plunger slowly for IM (1ml/10 seconds).
 Withdraw needle and use gauze to apply gentle pressure.
 Dispose of sharps in appropriate container.
 Document procedure.
Safe Injection Administration
References
References
WHO (2010). WHO best practices for injections and related procedures toolkit. WHO.
http://www.who.int/injection_safety/9789241599252/en/
Green Book – Chapter 4 Immunisation Procedures:
https://www.gov.uk/government/publications/immunisation-procedures-the-green-book-chapter-4
Yasir Sepah , Lubna Samad , Arshad Altaf , Nithya Rajagopalan & Aamir Javed Khan (2014). Aspiration in
injections: should we continue or abandon the practice? F1000 Research.
http://f1000research.com/articles/3-157/v1
Rodger MA, King L: Drawing up and administering intramuscular injections: a review of the literature.
Journal of Advanced Nursing. 2000; 31(3): 574–582.
SW – Dec 2014