Error Number 184. Failing to be cautious with the Add-vantage system

A number of I.V. medications you commonly administer are now available in a drug-delivery system called Add-Vantage (manufactured by Abbott Laboratories). This system includes a vial of undiluted medication that screws into a special minibag of diluent (5%dextrose or normal saline solution).

Living up to its name, this system offers several advantages. For example, you can catch potential errors by double-checking the labels on the vial and minibag of diluent before reconstituting and before administering it. Also, it eliminates needles, syringes, and separate diluent vials. And it doesn't require refrigeration or special storage because the drug and diluent aren't mixed until administered.

But no system is perfect. Here are two problems that have cropped up with Add-Vantage:

• Nurses have forgotten to remove the plug. When the plug remains in the vial, patients receive only the diluent-a medication error or omission. You should manipulate the container to remove the stopper and mix the contents of the vial with the piggyback fluid. To do this, push the vial inward to "puff up" the bag, then grasp the vial's inner stopper through the bag walls and pull it out of the vial. Invert the vial and minibag together several times to mix the drug and diluent.
• The system has malfunctioned. Even when nurses have removed the plug, the attached rubber stopper has remained in place, preventing mixing. This can be corrected by manipulating the plug back into the vial's stopper and starting over. If the problem goes undetected, plain diluent will be administered.

To reinforce the mixing step, Abbott Laboratories now distributes a special sticker to fit across the hanger of the I.V. minibag. The label, which must be removed before the bag is hung, reminds you to "Pull stopper and mix drug before use."

You can make sure that the contents of the vial have been emptied into the I.V. minibag by looking through the vial's clear bottom just before hanging the container. (Do this in good light; we've heard of night-shift nurses who've mixed the drug diluent• in darkened rooms, then found out in the morning that the vial didn't empty into the minibag.) If powder or fluid remains in the vial, or if the rubber stopper is still in place, something has gone wrong. Report malfunctions to your pharmacist. And remind him to inform Abbott Laboratories.