Error Number 106. Improperly mixing I.V. additives

A man who'd been vomiting for several days was admitted to the hospital emergency department (ED) for dehydration. There. the ED nurse started an infusion of D₅ W.

When the patient's doctor arrived, he asked the nurse to ad . 40 mEq of potassium chloride (KCI) to the patient's I.V. bag. The nurse carried out the order. Instantly, the patient cried out in pain, saying he felt a burning sensation going up his arm. The nurse stopped the infusion immediately and the pain subsided.

The doctor suspected that the nurse hadn't added the KCI properly. He'd seen reports in the literature about KCI pooling when it was added to a hanging, flexible plastic I.V. bag. When that happened, the patient essentially got a bolus of KCl, an extremely dangerousand irritating-substance. A bolus of this drug will cause intense pain at the infusion site and in the vein. It also creates the risk of transient hyperkalemia, which could lead to dysrhythmias.

When the doctor inquired, the nurse claimed she injected the KCI slowly, then had gently squeezed the bag. This confInned the doctor's suspicions that the drug hadn't been thoroughly mixed into the solution.

Pooling of a drug additive can occur when: (l) the bag is hanging with the injection port straight down; (2) the drug is added slowly; and (3) the needle of the syringe containing the additive is only partially inserted into the bag's injection port. Unless the bag is inverted several times to mix the solution, the drug could concentrate near the fluid exit port.

To prevent improper mixing, avoid adding medications to I.V. solutions that are already infusing. Ask your hospital to develop policies whereby a new container must be prepared and hung. If you have no alternative, follow these guidelines:

• Close the roller clamp on the I.V. line or turn the infusion pump off.
• Insert the syringe needle completely into the bag, up to the needle hub. Be sure to use a 1 1/2-inch needle. Using a shorter needle or inserting it only partially into the port can cause pooling of the additive .
• Inject the additive quickly. If the injection takes more than 5 seconds, it could cause pooling.
• After injecting the additive, remove the bag from the I.V. pole and invert it at least three times. Just squeezing or shaking the bag isn't enough to mix the drug into the solution.