Category Archives: Medication Administration

NIOSH 2014 List of Antineoplastic & Other Hazardous Drugs in Healthcare Settings

This is an updated version of  the National Institute of Occupational Safety and Health (NIOSH) hazardous drugs list. So what’s new in this current update?

The text for the update to the 2014 list was updated and expanded to reflect the complexity of safe handling issues that have arisen over the past few years.  This was driven, in part, by the growing number of oral antineoplastic drugs and the addition of oral non-antineoplastic drugs.  The list was reformatted and some drugs have been deleted.

(a) Based on feedback from multiple sources, it was determined that the universal approach as described in the 2004 Alert on Hazardous Drugs for handling hazardous drugs was no longer feasible.

 (b) The list of hazardous drugs was separated into three categories: (Table 1) Antineoplastic drugs; (Table 2) Non-antineoplastic drugs; (Table 3) Drugs with adverse reproductive effects only; and (Table 4) Deleted drugs.

  (c)  It was noted that the majority of the antineoplastic drugs may have adverse reproductive effects and the drugs in the non-antineoplastic category that had adverse reproductive effects as a secondary reason for their listing was noted.

  (d) New drug listings for 2014 are indicated by red font and drugs in the non-antineoplastic category that also have adverse reproductive effects are indicated by blue font.

 (e) Also added is a matrix of common activities related to hazardous drug handling and recommendations for the use of personal protective equipment and ventilated engineering controls for each activity (Table 5).

 

Hazardous drugs include those used for cancer chemotherapy, antiviral drugs, hormones, some bioengineered drugs, and other miscellaneous drugs.  The NIOSH cautions that the list may not be all inclusive and recommend that each organization should create its own list of drugs considered to be hazardous. This perhaps explains why sometimes I notice a drug not on the hazardous list is considered hazardous by one organization but not by another.  In my experience, many oncology infusion centers follow the precautions recommended for hazardous drugs for all drugs they administer regardless of classification in a effort to standardize handling practices.

When a  drug is hazardous, various precautions should be applied when handling the drug.  Click here for the full publication of the 2014 NIOSH Hazardous Drug List.

NIOSH 2014

Acknowledgement:

Many thanks to Barbara MacKenzie and Thomas H. Connor for the  information and updates.

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Looking for RNs to take a SURVEY!

If you are a registered nurse currently working with/delegating/supervising “unlicensed healthcare personnel” (UHCP) also known as “unlicensed assistive personnel” (UAP), would you be interested in answering a short survey related to the use of unlicensed healthcare personnel in the provision of infusion therapy?

The survey is open to US registered nurses from all healthcare settings who work with, delegate/and/or supervise UHCP. The survey results will be integrated in a project for the Infusion Nurses Society.

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(Click sign ^^ above to take the survey)

If you have any questions, please use the comment section of this post. Your comment will reach me first and will not be posted publicly. I will reply as soon as possible.

Thank you so much! Your help and willingness is greatly appreciated!

 

 

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Q&A: When is a single use syringe considered used?

Q:  You will think I am a complete idiot but please explain when is a single use syringe considered used? I need to explain to my practice manager why I can’t re-use a syringe while reconstituting a powdered medication for injection. My practice manager is complaining that I am using too many syringes and needles which are not reimbursed by insurance. Thank you.

A:  You are correct, syringes should not be re-used; those are designed to be single use only. When the syringe is taken out of the sterile  packaging and the plunger is pulled  to withdraw the medication, then pushed completely in to expel the syringe content,  the internal barrel of the syringe is considered contaminated and must be discarded appropriately.  Any microorganisms, which might be placed onto the sides  (ribs) of a syringe plunger by finger contact while withdrawing the plunger, can be transferred to the inside of the barrel and enter the fluid pathway if the plunger is drawn in and out several times.  A syringe must only  be used once to draw up medication, and must not be used again even to draw up the same medication, from the same vial, for the same patient.

syringe parts

Syringe parts – photo from Concept in Sterile Preparation and Aseptic Technique

If you observe a nurse withdrawing fluid from a vial with a syringe, take note of where that person’s fingers are on the plunger of the syringe. Many have their fingers/palm wrapped around “ribs” of the plunger, with or without gloves, as they are pulling the fluid into the syringe. Once the syringe is full, then the plunger (where fingers were wrapped) now is pushed into the barrel of the syringe until empty. Imagine this scenario over and over when the same syringe is used over and over. I believe no nurse will “deliberately” harm a patient, unfortunately, there are nurses who should know better but fall into this poor practice for one reason or another. I  have witnessed some nurses “unknowingly” re-use a syringe and become embarrassed once the poor practice is brought to their attention.

It seems like you work  in a office or ambulatory setting, if that is the case, please refer to the CDC Guide for Infection Prevention for Outpatient settings. Click here for more information on infection control prevention.

I would also refer you to the CDC One and Only” campaign to raise awareness among patients and healthcare providers about safe injection practices. The campaign aims to eradicate outbreaks resulting from unsafe injection practices.  For more information on this campaign, go to their website  – http://www.oneandonlycampaign.org.

Thank you for your question and hope this will help you explain to your manager that patient safety comes first!

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References:

1. Perz JF, Thompson ND, Schaefer MK, Patel PR. US outbreak investigations highlight the need  for safe injection practices and basic infection control. Clin Liver Dis. Feb 2010;14(1):137-151; x.

2. Perceval A. Consequence of syringe-plunger contamination. Med J Aust. May 17 1980;1(10):487-489.

3. Huey WY, Newton DW, Augustine SC, Vejraska BD, Mitrano FP. Microbial contamination potential of sterile disposable plastic syringes. Am J Hosp Pharm. Jan 1985;42(1):102-105.

4. Olivier LC, Kendoff D, Wolfhard U, Nast-Kolb D, Nazif Yazici M, Esche H. Modified syringe design prevents plunger-related contamination–results of contamination and flow-rate tests. J Hosp Infect. Feb 2003;53(2):140-143.

 

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Why do nurses use the same alcohol swab over and over?

I know, this may come as a surprise to all of you, but the truth is, I have seen many nurses (even those highly trained and specialized) both in hospitals and outpatient settings, use the same alcohol swab over and over.

Imagine this scenario where a nurse is ready to withdraw medication from several vials. The nurse rips open a swab, then removes the swab from the package using the thumb and forefinger, literally touching the entire surface and both sides of the swab, then proceeds to disinfect the top of one vial. Then using the same swab, the nurse proceeds to disinfect the top of the next vial, and repeats the same until all vials are disinfected, still using the same swab. The swab is then laid on the work surface, and if additional disinfection of the vial is required, the nurse picks up the same swab and proceeds to use it again. The same observation is true when disinfecting Y-sites, connection hubs or needleless connectors attached to vascular access devices. Rip open an alcohol swab, pick up with thumb/forefinger, disinfect hub, then either lay swab on surface or disinfect another hub with same swab. Why do nurses re-use alcohol swabs?

When brought to their attention and nurses are asked – why are you re-using the alcohol swab? Often, I get a blank stare or I get this..“what do you mean”look, and I don’t get an answer. Sometimes I get this answer, “its alcohol, dummy!” or “it’s still wet”. I think back to my nursing school training and I tried to recall what my Fundamentals instructor told us about how to use alcohol swabs. I honestly don’t remember what we were told, whether or not to reuse, or use till dry…..maybe I skipped school that day.

I can’t find evidence based research about re-using alcohol swabs. The fact is that an alcohol swab (aka alcohol prep pad) contains 70% Isopropyl Alcohol and is sterile while in the package. When removed, we need to take great care not to contaminate it with our fingers before we even use it for disinfection. Discard after one use, even if the alcohol swab is still dripping wet. When disinfecting several vials, use one alcohol swab per vial; don’t share alcohol swabs between the vials. I am aware that there are non-sterile alcohol prep pads available in the market, often used by diabetic patients for insulin injections. If selected to be used for disinfection, discard after use. Alcohol swabs are inexpensive and always available. Let’s put this in perspective, if you are the patient, do you want your nurse re-using alcohol swabs on you?

So next time you are getting ready to open an alcohol swab, will you remember hold the swab properly and not to re-use?

alcohol2

 

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ICYMI: Check out these ASHP Guidelines

1. The ASHP Guidelines on Home Infusion Pharmacy Services – defines the role of the pharmacist in providing home infusion care to patients and to outline minimum requirements (indicated by use of the word “shall”) and best practices for the operation  and management of services provided by pharmacies in the home or alternate-site setting.  Home infusion services are provided by a variety of organizations, including hospitals, community pharmacies, home health agencies, hospices, and specialized infusion companies. Patients receive care in non-inpatient settings, such as their homes and ambulatory infusion centers, or in alternate-site settings, such as skilled-nursing facilities. Home infusion pharmacies may provide one or more of several service lines:

  •  Infusion therapies (e.g., intravenous, subcutaneous, intrathecal, epidural);
  • Specialty pharmacy services;
  • Ambulatory infusion center services;
  • Home health nursing;
  • Private duty nursing;
  • Respiratory equipment and clinical respiratory services;
  • Hospice services;
  • Home medical equipment and supplies (with or without oxygen service); or
  • Enteral products and supplies.

 

2. The ASHP Guidelines on Compounding Sterile Preparations –  these guidelines are intended to help compounding personnel prepare compounded sterile preparations( CSPs) of high quality and reduce the potential for harm to patients and consequences for compounding personnel. These guidelines are a revision of the 2000 ASHP Guidelines on Quality Assurance of Pharmacy Prepared Sterile Products,14 with the goals of providing more current recommendations and harmonizing the ASHP guidelines with United States Pharmacopeia (USP) chapter 797, Pharmaceutical Compounding–Sterile Preparations. These guidelines are generally applicable to all personnel who prepare CSPs and all facilities in which CSPs are prepared, pharmacists and other health care professionals responsible for the preparation, selection, and use of CSPs are urged to use professional judgment in interpreting and applying these guidelines to their specific circumstances. Users of these guidelines are cautioned that the information provided is current as of publication and are urged to consult current editions of original sources (e.g., laws, regulations, and applicable standards, including USP compendial standards) to ensure patient safety as well as legal and regulatory compliance.

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Click on title link for details of each of the guidelines.

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Reference:

American Society of Health-Systems Pharmacists (ASHP) – http://www.ashp.org

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Large Volume IV Solution Shortages

It just doesn’t seem right that the national crisis with “drug shortages” would include  large volume (1000mL) IV solutions we commonly administer to our patients:

  • 0.9% Sodium Chloride Injection
  • 0.45% Sodium Chloride Injection
  • Lactated Ringer’s Injection
  • 5% Dextrose Injection

 

IV

But the reality is there is a shortage, IV saline solution, in particular is on the list of national drug shortages and the shortage is not expected to resolve until May or June this year. Not having IV Saline solution available  is like not have bread and milk at the grocery stores.

So what can be done?  The American Society of Health-System Pharmacists (ASHP) released a list of conservation strategies that organizations might consider to manage the shortage.  Click here to view details of the document.

 

What can clinicians do to conserve?

  • Use oral hydration whenever possible.
  • Review the suggested clinical approaches and product conservation strategies in collaboration with the organization’s stakeholders and the Pharmacy and Therapeutics (P&T) Committee or other organization-wide medication policy group for applicability to the organization.
  • Implement an organization-specific action plan to conserve IV fluids where possible. Allow flexibility as the shortage status of specific products may change frequently. For example, Lactated Ringer’s
  • Injection may be more available than 0.9% Sodium Chloride Injection and vice-versa depending product availability and allocation schedules.
  • Develop medical staff-approved policies for substitution of IV solutions based on product availability within the organization. Example: an organization might allow substitution of Lactated Ringer’s Injection for 0.9% Sodium Chloride Injection or vice-versa depending on what is in stock. Table 1 provides a comparison of common intravenous fluid components.

 

Please feel free to share what you /your organization are doing to cope with this IV Solution Shortage.

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Vesicants and Extravasation

These two terms defined by the Infusion Nurses Society means:

Vesicant – an agent capable of causing blistering, tissue sloughing or necrosis when it escapes from the intended vascular pathway into surrounding tissue.

Extravasation – the inadvertent infiltration of vesicant solution or medication into surrounding tissue.

There are several chemotherapeutic agents with vesicant properties, and when inadvertently infused into the surrounding tissue from an infiltrated IV, these agents may have the potential to cause blisters, severe tissue injury or necrosis, known as extravasation. The damage to the tissue can occur from direct contact with the vesicant medication, from compression of surrounding tissues by a large volume of fluid or from severe vasoconstriction.

But chemo agents are not the only vesicants that cause extravasation injuries. There are non-chemo medications and solutions that have vesicant properties as well and can cause extravasation. Listed below are a few non-chemo agents:

  • Vancomycin
  • Nafcillin
  • Calcium Chloride
  • Potassium Chloride
  • Sodium Chloride
  • Calcium Gluconate
  • Dobutamine
  • Diazepam
  • Dopamine
  • Norepinephrine (Levophed)
  • Phenytoin (Dilantin)
  • Promethazine (Phernergan)
  • Propofol
  • Vasopressin
  • Radiologic contrast agents

As nurses, it is our responsibility to take preventive measures, monitor, identify signs/symptoms and institute prompt treatment per policy or as ordered. If you administer any of these agents, prevention is key and consider the following:

1. Location, location, location:  When selecting an IV site, avoid areas of flexion  – this includes the wrist, hand, and antecubital fossa.  Be mindful of any punctures to veins above the area you are about to stick. If patient had a recent blood draw from the antecubital fossa, use the opposite arm to find a suitable site.  Oh, btw, extravasation can also happen in patients with central venous access.

2. Bigger is not better: Use the smallest gauge IV catheter to administer the prescribed therapy.  Good flow rates are possible even with a small gauge catheter. Using an IV catheter too large for the vein will obstruct blood flow and might cause thrombosis distal to the IV site.

3. Know your medications: Were you surprised to see a medication listed above as a vesicant?  Medications and solutions with an osmolarity greater than 600 mosmol/L  and pH lower than 5 or higher than 9 should not be infused via a peripheral IV. Know the adverse events, if any for each medication. If in doubt, always ask our friendly pharmacists!!

4. Secure your IV device: Use a stabilization device to anchor and avoid movement of the catheter. When using a dressing, avoid obscuring the IV site to allow you to observe the site.

5. Check  IV patency and assess site: Key to early recognition of complications. Refer to your organization’s policy on frequency of IV site checks.  Infusion pumps will not tell you if an IV site in infiltrating. Always aspirate for positive blood return prior to use, but remember, checking for blood return or back flow of blood is good for patency but not a reliable method for assessing infiltration at IV site. If infusion continues to run when you apply digital pressure 3 inches above peripheral IV site in front of catheter tip – suspect infiltration

6. Policy/procedure for extravasation: Do you know if your organization has one for non-chemo agents? Have you even read it? What are you expected to do when extravasation happens?  Is there a rating scale to document the severity of the problem? Are you expected to complete an “incident report”? Can you photograph the site?

7. Hot or cold: Which do you use? What does your policy state about compress? Do you need an doctor’s order for this?

8. Antidote: Is there one for the medication you administered? Obtain physician’s orders for the appropriate antidote. How is it given?

9. Document, document, document!! I know, you’ve heard this before….if it’s not documented, you didn’t do it! Keep this in mind, you will not remember what happened in the past, so hopefully, your documentation can defend you.

10. Don’t forget the patient/family: Keep them informed and provide information regarding treatment and management.

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