Intravenous Admixture Services Research Articles

Centralized intravenous additive services (CIVAS): The state of the art in 2010

In hospitals, the major part of the drugs is administered by intravenous way and the majority of the reconstitution of injectable drugs are carried out right before the administration to the patient by the nursing staff. The risks and errors related to the preparation and the administration of the injectable drugs are numerous. The standardization then the centralization of the preparations and reconstitution by the hospital pharmacy make it possible to reduce these various risks and errors. In addition to the preparation of the mixtures of parenteral nutrition as well as doses of anticancer chemotherapy, many other treatments can be taken in charge, such as antibiotics, antiemetics and pain treatments. Consequent equipment is necessary but the realization of these treatments proves non-overdrawn insofar as a certain quantity of production is reached. The reconstitution of the intravenous treatments by a centralized intravenous admixture service guarantees the chemical stability and the microbiological quality of the ready-to-use injectable drugs and contributes to the quality and the total management of the care of the patient.

Investigation on occupational exposure to 5-fluorouracil in pharmacy intravenous admixture service of a hospital

To investigate the level of occupational exposure to 5-fluorouracil (5-Fu) in the pharmacy intravenous admixture service (PIVAS) of a hospital, and identify the sources of 5-Fu contamination. The 5-Fu concentrations in air, on the surface of different areas in PIVAS and personal protective equipments were detected using UV-vis spectrophotometry. The 5-Fu in air could not be detected. The 5-Fu concentrations on five different surfaces of biological safety cabinets were (22.00 +/- 6.35), (13.99 +/- 2.46), (14.13 +/- 0.72), (7.25 +/- 1.19) and (9.87 +/- 1.23) ng/cm2, respectively, which were significantly higher than those [(3.14 +/- 0.04), (5.43 +/- 0.65), (2.26 +/- 0.17), (2.26 +/- 0.17) and (3.63 +/- 0.46) ng/cm2] of corresponding controls (P < 0.05 or P < 0.01). The 5-Fu concentrations of the floor under cabinets [(18.19 +/- 5.22) ng/cm2], the floor in front of cabinets [(10.25 +/- 2.57)ng/cm2], the office floor [(11.64 +/- 2.53) ng/cm2], the terrace floor [(99.89 +/- 14.06 ) ng/cm2], the floor beside trash can in dressing room [(24.54 +/- 0.23) ng/cm2] were significantly higher than those of control [(3.36 +/- 0.11 ) ng/cm2] (P < 0.05 or P < 0.01). The 5-Fu concentrations of the tables in preparation room [(7.22 +/- l.04) ng/cm2] and the tables in office [(11.81 +/- 1.18) ng/cm2] were significantly higher than those of control [(5.56 +/- 0.14) ng/cm2] (P < 0.05 or P < 0.01). The 5-Fu concentrations of the indoor handle in preparation room were significantly higher than those of controls (P < 0.05 or P < 0.01). 5-Fu concentrations on the surfaces of outdoor handle and floor beside door in preparation room were not significantly increased compared with controls (P > 0.05). The 5-Fu concentrations on the surfaces of infusion bags, transfer box, transfer trays were significantly higher than those of controls (P < 0.05). The differences of 5-Fu concentrations between outer and inner masks and controls were not significant (P > 0.05). The 5-Fu concentrations of gloves of preparing and checking staffs were significantly higher than those of controls (P < 0.05 or P < 0.01). The preparing and checking process of 5-Fu and the treatment of medical wastes are major sources of 5-Fu contamination.

Developing the pharmacist's role in pharmacy intravenous admixture service, and improving the rational drug use

Objective To utilize the facilities of pharmacy intravenous admixture service center (PIVAS) to strengthen the role of hospital pharmacist and improve the rational use of drugs. Methods 1200 outpatient prescriptions between June and July 2003 before developing PIVAS and 1200 outpatient prescriptions between June and July 2009 after developing PIVAS were collected. The type, prescriptions amount and percentages of irrational drug use were compared and analyzed in two groups. Result 262prescriptions were found unreasonable between June and July 2003 and the percentage of irrational drug use was 21.83%; then 68 prescriptions were found between June and July 2009, the percentage was 5.67%, the prescriptions of irrational drug use decreased significantly. Conclusion The developing of PIVAS can strengthen the relation of pharmacists and clinic; and the pharmacists have developed fully an important role inPIVAS. Key words: PIVAS; Rational drug use; Role of pharmacist

Analysis of the nurses' errors in PIVAS and countermeasures

目的 为保障静脉药物配置安全,减少和避免药疗差错提供参考.方法 根据药品说明书、 、 等相关规定,对2006年8月至2009年8月我院静脉药物配置中心配置护士差错进行分析,并针对性地制定了控制措施.结果 静脉药物配置护士内错率为0.005%;差错率为0.003 6%.主要发生在未实行两步稀释法、漏做标记、混淆药品规格、药物剂量不准确、全营养混合液顺序有误等工作环节.结论 配置护士必须加强药学知识和药品说明书的学习,加强职业道德教育,提高责任心,及时修正其不良行为,才能将差错发生率降至最低,保证药物安全性和有效性。

Analysis of nurses' errors in pharmacy intravenous admixture services and the counter-measures

Objective To ensure the safety of pharmacy intravenous admixture and to make a reference for the reduction and avoidance of the medication errors.Methods The errors which were made by the nurses of PIVAS during the time from August 2006 to August 2009 were analyzed in accordance with drug package inserts,Chinese Pharmacopeia,and Clinical Medication Information,meanwhile the countermeasures were formulated.Results The internal ratio of errors in the pharmacy intravenous admixture service was 0.005% and the ratio of errors was 0.003%.The errors occurred mainly in the following steps:unpracticed two-step dilution,the missing marks,confusion of drug specifications,missing medicine as well as the wrong orders of total nutrient admixture (TNA).Conclusions The nurses of pharmacy intravenous admixture services(PIVAS)must strengthen the study in pharmaceutical knowledge and drug package inserts,strengthen the education in professional ethics,improve the responsibility,correct the bad behavior in order to make the ratio of erros lowest and ensure the drug safety and effectiveness. Key words: Pharmacy intravenous admixture service; Analysis of errors; Drug safety

Effect of freezing, long-term storage and microwave thawing on the stability of a mixture of diclofenac and sodium bicarbonate in glucose 5% polyolefin Bags

Preparation in advance of intravenous solution could be efficient to improve quality assurance, security, time management and cost saving of drug delivery. The aim of this study was to investigate the stability of a mixture of diclofenac 75 mg/100 ml and sodium bicarbonate 42 mg/100 ml in 5% glucose polyolefin bags after freezing, long-term storage, and microwave thawing. The stability of five polyolefin bags containing approximately 75 mg/100ml of diclofenac and 42 mg/100ml of sodium bicarbonate in 5% glucose prepared under aseptic conditions was studied after freezing for 2 months at -20 degrees C, thawing in a microwave oven with a validated cycle, and stored at 5 + or - 3 degrees C. Diclofenac concentrations were measured by high-pressure liquid chromatography using a reversed-phase column, a mobile phase consisting of 40% of acetonitrile (v/v) in KH(2)PO(4) buffer 0.02 M, pH 8.40 + or - 0.05, and UV detection at 276.0 nm. Visual inspection, microscope observation, spectrophotometric measurements and pH measurement were also performed. No colour change or precipitation occurred in the preparations. No microaggregate was observed with optical microscopy or revealed by a change of absorbance. Based on a shelf-life of 90% residual potency, diclofenac was stable for at least 30 days after freezing and microwave thawing, period where 95% lower confidence limit of the concentration-time profile remained superior to 90% of the initial concentration. During this period, the pH values of drug solutions have not been altered. Within these limits, diclofenac in 5% glucose infusion may be prepared and frozen in advance by a centralized intravenous admixture service, then thawed before use in clinical units.

Analysis of non-rational use of drugs in Pharmacy Intravenous Admixture

Objective Finding out methods to solve non-rational use of drugs though studying nonrational prescriptions in pharmacy intravenous admixture,so that improve the drug therapy.Methods Pharmacy intravenous admixture services(PIVAS)heing a working platform,2160 non-rational prescriptions in 2008 were retrospective analyzed,which based on the compatibility of drugs,such as stability,compatibility,the time giving medicine,drug concentration,choice of menstruum,the single dosage and the accumulated dose,the compatibility of Chinese tradition medicine and foreign medicine.Results Last year 509596 prescriptions were checked-up,in which 2160 belonged to non-rational use of drug prescriptions and taken up 0.42%.In those prescriptions,non-rational using drugs mainly showed as follows:(1)unreasonable choosing of menstruum,(2)incorrect drug concentration,(3)improper combining of medicines,(4)unreasonable dose of drugs,(5)improper linking up of medicines.Conclusions Finding out the non-rational use of drug prescriptions is to avoid side effects of medicine,so as to comply with the health economics principle. Key words: Pharmacy intravenous admixture; Non-rational use of drug; Monitoring

Analysis in coordination strategy between nurses and pharmacists in pharmacy intravenous admixture services

Objective To disucss the coordination strategy between nurses and pharmacists in phar-macy intravenous admixture services (PIVAS) during the handling of clinical work. Methods Ques-tionnaires were adopted to investigated relative staff for information collection and analysis by combina-tion of specified post responsibility of nurses and pharmacists in PIVAS and experience from clinical work. Results We proposed the sixteen-word guideline of clear duty, study and respect each other to achieve win- win development. Conclusions The coordination of nurses and pharmacists in PIVAS is important in clinical work, the countermeasures summarized from clinical practice has certain instructive significance to coordinate their relations. Key words: Pharmacy intravenous admixture services; Nurse; Pharmacist; Coordination

The uptake of technologies designed to influence medication safety in Canadian hospitals

There are many technologies designed to improve medication safety. Although limited evidence supports their use, there are pressures to implement them. To determine the uptake of technologies designed to improve medication safety, plans for adopting technologies, attitudes towards technology use, and perceptions of medication error. Methods We performed a cross-sectional survey of pharmacy directors at Canada's 100 largest acute-care hospitals. Seventy-eight per cent of surveyed hospitals responded. Responding hospitals averaged 499 beds and 29% were teaching facilities. Hospital frequently used clinical pharmacy services (97% of hospitals), pharmacy-based intravenous admixture services (81%), computerized decision support modules for pharmacy order entry systems (77%), unit-dose drug distribution systems (75%) and computerized medication administration records (67%). Hospitals infrequently used bar-coding (9% of hospitals) and computerized physician order entry (9%). A majority of respondents and hospitals favoured expanded use of new technologies and planned for increased uptake. Respondents chose as their hospital's next investment: automated dispensing (33%), bar-coding (25%) and computerized physician order entry (12%). Canadian hospitals appear poised to make sizeable investments in poorly evaluated technologies that address medication safety.

Effects of pharmacy intravenous admixture services on nurses and patients

目的 探讨启用静脉药物配置中心(PIVAS)对患者和护理人员的影响.方法 采用回顾性调查和问卷调查比较我院门诊输液患者实施PIVAS前后与配液有关的输液反应率、输液患者满意率和输液患者的疗程.结果 启用PIVAS大大降低了所配置液体被污染的机率,由此降低了输液反应的发生率(P＜0.05),患者对护理服务的满意度提高,除化疗患者外,91%的患者输液疗程小于3 d,而启用静脉配置中心以前,仅82%的患者疗程小于3 d.结论 建立静脉药物配置中心,护理服务水平,治疗水平和管理效益均获提高.PIVAS值得向医院推广。

Long-term stability of sodium folinate in dextrose 5% polyolefin bags at 4°C

Preparation of intravenous solutions in advance could be an efficient approach to improve quality assurance, security, time management, and cost saving of drug provision. The purpose of this paper is to investigate the stability of sodium folinate solutions at 3.2 mg mL-1 in 5% dextrose polyolefin bags at 4degreesC. The stability of five polyolefin bags of solution containing approximately 3.2 mg mL-1 of sodium folinate in 5% dextrose prepared under aseptic conditions and stored at 48degreesC have been studied over 30 days. Sodium folinate concentrations have been measured by high performance liquid chromatography and the results have been analysed by regression analysis. Solutions have been visually inspected and pH measured. No colour change or precipitation occurred in the preparations. Based on a shelf-life of 90% residual potency, sodium folinate solutions have been observed to be stable for a period of at least 30 days at 4degreesC, where lower confidence limits of the results value remain above 90% of the initial concentration. During this stability period, the pH values of infusions have been observed to decrease slightly without affecting chromatographic parameters. Within these limits, sodium folinate in 5% dextrose infusion may be prepared and stored in advance by a centralized intravenous admixture service.

Effect of Freezing, Long-Term Storage, and Microwave Thawing on the Stability of Ketorolac Tromethamine

Ketorolac tromethamine is a nonsteroidal agent with potent analgesic and moderate antiinflammatory activity. Advance preparation of intravenous solution could be useful to improve quality assurance, time management, and cost-savings of drug delivery. To investigate the effect of freezing, long-term storage, and microwave thawing on the stability of ketorolac tromethamine in dextrose 5% infusion. Five polyolefin bags of solution containing ketorolac tromethamine 20 mg per 100 mL of dextrose 5% were frozen for 3 months at -20 degrees C, thawed in a microwave oven with a validated cycle, and stored at 4 degrees C. The concentration of ketorolac was measured by HPLC. Visual inspection and pH measurement were also carried out. No color change or precipitation was observed. Ketorolac was stable for at least 60 days under refrigeration after freeze-thaw. Throughout this period, the lower confidence limit of the estimated regression line of the concentration-time profile remained >90% of the initial concentration, and the pH value decreased slightly without affecting chromatographic parameters. Within these limits, ketorolac tromethamine in dextrose 5% infusion may be prepared and frozen in advance by a centralized intravenous admixture service, then thawed before use in clinical units.

Long-term stability of vancomycin hydrochloride in intravenous infusions

Vancomycin is often used in antibiotic infusions for hospitalized patients and it is advantageous to prepare such intravenous solutions in advance. The objective of this study was to investigate the long-term stability of this antibiotic stored at 4 degrees C in polyvinyl chloride (PVC) bags. Five bags each of 0.5 or 1 g vancomycin hydrochloride per 100 ml of 5% dextrose were studied for 2 months by high-performance liquid chromatography, visual inspection and pH measurement. No colour change or precipitation was observed. The pH values of the preparations increased significantly over the period of study without influencing the antibiotic concentration. Based on a shelf-life of 90% residual potency, the vancomycin solutions were stable for at least 58 days at 4 degrees C. From a chemical stability viewpoint, the antibiotic may be prepared in advance by a centralized intravenous admixture service for use within the limits described.

Long-term stability of cefuroxime and cefazolin sodium in intravenous infusions.

Cefazolin and cefuroxime sodium are often used as antibiotic infusions for hospitalized patients. Because advance preparation of these intravenous solutions is efficient, the stability of both antibiotics stored at 4 degrees C in polyvinyl chloride (PVC) bags was studied. Five bags of solutions containing either 1 g of cefazolin sodium or 1.5 g of cefuroxime sodium per 100 ml of 5% dextrose were studied for 1 month by high-performance liquid chromatography (HPLC), visual inspection and pH measurement. No colour change or precipitation was observed. The pH values of both drugs increased significantly over the period of study. Based on a shelf-life of 90% residual potency, the cefuroxime sodium concentration was stable for 13 days when stored at 4 degrees C, and the cefazolin sodium concentration was stable for at least 30 days at 4 degrees C. Within these limits, both antibiotics may be prepared in advance by a centralized intravenous admixture service.

Offsite intravenous admixture center shared by health-system facilities.

The creation of an offsite i.v. admixture center shared by four affiliated health care facilities is described. The i.v. admixture center was developed to consolidate the admixture services of four Carilion Health System (Roanoke, Virginia)-affiliated facilities: Roanoke Memorial Hospital (RMH), RMH's Cancer and Rehabilitation Center, Community Hospital of Roanoke Valley (CHRV), and the Roanoke Memorial Home Health Parenteral Therapy Program. The proposed advantages of a shared i.v. admixture service included providing full i.v. services for CHRV, increasing the ability to prepare home i.v. admixtures on a daily basis, increasing space for preparing i.v. admixtures, avoiding adding admixture staff members at any of the facilities, reducing supply duplication and admixture waste, and standardizing and improving quality. The Carilion Admixture Center was built in Carilion's materials management building at a total cost for construction and new equipment of $80,000; it opened in April 1992. The facility is responsible for providing piggyback admixtures, premixed piggyback solutions, injectable antineoplastic agents, total parenteral nutrient solutions, prefilled syringes for pediatric patients, large-volume solutions containing additives, and all admixtures required for the home health care patients. The facility was certified as a Class 20,000 environment. Start-up problems included computer glitches and a heavier-than-anticipated workload during the first year of operation. Nearly 700,000 i.v. admixtures were compounded at the center between October 1992 and September 1994. There were 95 reports of missing doses during the day shift at RMH between November 1992 and January 1993; only 6% were due to errors at the admixture center. The estimated total cost avoidance for salaries, benefits, and nonbillable supplies for October 1992 through September 1994 was $437,000. Intravenous admixture services provided by three hospital facilities and one home health agency were successfully consolidated into one shared offsite center.

Cost evaluation of a new iv device in an Israeli hospital.

A new device for IV admixtures has been developed in Israel, the Vialink minibag. It consists of a partly filled minibag, attached by rubber tubing to a sterile receptable into which various types of vials containing drugs can be firmly inserted. Time and motion studies were conducted to determine the time and cost associated with the preparation, dispensing and administration of reconstituted parenteral antibiotics via CIVAS (within minibags or Vialink bags) and preparation by nurses in wards in minibags. CIVAS with minibags was least expensive, followed by Vialink minibags. Self preparation on the ward by nurses was found to be the most expensive system. Only 55% of all IV admixtures can be prepared by the Vialink system. As only one hospital in Israel has CIVAS, the study provides a solid justification for implementing pharmacy intravenous admixture services in all Israeli hospitals. The advantages and disadvantages of each method are discussed. CIVAS (minibags and Vialink) permits the individualised preparation of sterile admixtures for each patient and provides advantages in terms of efficiency, economy and prevention of errors.

Justification of a Pharmacy Intravenous Admixture Service in an Australian Hospital

The time and cost of i.v. admixture preparation by hospital pharmacy staff members in an established admixture unit was compared with that by nurses working on wards. The preparation time of antimicrobial admixtures was determined by using a stopwatch. The total cost of preparing an admixture by pharmacy and nursing staff was calculated by combining the respective labor costs (preparation time x average salary rates weighted for overtime) with the cost of disposable items. The mean +/- S.D. time for admixture preparation in the pharmacy was 3.38 +/- 0.38 minutes, whereas preparation by nurses required 14.37 +/- 1.55 minutes. The mean +/- S.D. total cost (in Australian dollars) of admixture preparation was $1.42 +/- 0.34 per dose, and $4.59 +/- 0.46 per dose, respectively. Centralization of admixture preparation would reduce the time required by 18.32 hours for every 100 admixtures prepared, equivalent to an annual cost avoidance of $112,420 for every 100 admixtures prepared each day. Centralizing the preparation of i.v. admixtures in a hospital pharmacy resulted in significant time savings and cost avoidance.

The Pharmacist's Role in Controlling Bloodborne Infections with Emphasis on Procuring Safe Injection Systems

The hospital's department of pharmacy plays an important role in lessening the risk of bloodborne disease transmission through its influences in the coordination and control of the hospital's drug distribution system, intravenous (IV) admixture service and purchasing decisions with regard to injectable drug products. A review of drug distribution systems has shown that the unit-dose system is the most advantageous in terms of accuracy, safety, time savings and overall costs to the institution. Needlestick injuries are an occupational hazard for healthcare workers. Today, the need for safety in medication administration is a priority in injectable medication systems. Pre-filled cartridges offer a number of advantages, one of which is their safety in preventing needlesticks, through facilitating administration of medication quickly and easily and disposal of the needle immediately thereafter.

Hospital pharmacy practice in India.

The status of pharmacy practice was evaluated at six hospitals in India. Common drugs were available at private hospitals but the pharmacies at government hospitals had fewer than half of the needed drugs. Selection of the best generic drug appeared difficult because the bioavailability and pharmacokinetic data generally were not available. The hospitals did not have formularies. No unit dose and intravenous admixture services had been implemented. The patient profiles were not maintained. The pharmacists did not appear to provide any professional, educational, or clinical services to patients or physicians. Serum concentrations of drugs were not measured for monitoring therapy. A lack of clinical education and training of pharmacists, lower status and salaries in the hospital pharmacy compared with industry and government, and overall limited resources appear to be the important reasons for the present status of pharmacy practice.

Inexpensive Microcomputer for Intravenous Admixture Service Applications

A microcomputer system for maintaining data on intravenous piggyback (IVPB) admixture use and for generating labels for IVPB admixtures is described. The system was developed in a 558-bed hospital where the pharmacy compounds 500-800 i.v. admixtures daily. The objectives were to (1) provide an electronic profile with quick patient-search capabilities, (2) reduce time spent and errors occurring in labeling, (3) decrease duplication and consequent waste of admixtures, and (4) improve collection of drug-use statistics. Software was developed by the pharmacist to achieve these objectives. When a drug order is entered, files are automatically searched for duplication. Every 24 hours, labels for the entire patient profile are printed and statistics are generated on types of drugs used, number of each type of drug, total number of patients on IVPBs, and total number of IVPBs. A user's manual was developed and staff-training sessions were held before the system was implemented. In the first 24 months of operation, most computer downtime was caused by hardware problems. Four man-hours per day were saved in typing time (+7000 annual cost reduction). Waste of approximately six admixtures daily was prevented (+5000 annual savings). Total software development and implementation cost +5000, and hardware cost +4200. The total cost of the system was thus realized during the first year of operation.