Regenstrief Center for Healthcare Engineering and Purdue University College of Pharmacy, West Lafayette, Indiana (Dr Degnan); University of Iowa Hospitals & Clinics, Iowa City, Iowa (Ms Bullard); University of Iowa Stead Family Children's Hospital (Ms Davis).
Daniel D. Degnan, PharmD, MS, CPPS, FASHP, is a clinical research associate at the Regenstrief Center for Healthcare Engineering and an associate director of the professional program laboratory at the Purdue University College of Pharmacy. Before working at Purdue, he spent 10 years as the medication safety officer at a health system in Indiana.
J Infus Nurs. 2020 May/Jun;43(3):146-154. doi: 10.1097/NAN.0000000000000366.
Unnecessary dilution of ready-to-administer (RTA) syringes could increase the risk of patient harm attributed to errors related to incorrect dose, improper labeling, and the potential for microbial contamination. Although published guidelines endorse the use of commercially available RTA syringes, recent surveys indicate that best practices are not always implemented. The purpose of this article is to review the existing literature and to assess the incidence and nature of errors related to the unnecessary dilution of RTA intravenous (IV) push medications in the inpatient clinical setting. The PubMed database was searched to identify studies of errors related to the use of RTA syringes for IV push medications within the last 10 years. An additional search was conducted using other search engines to identify relevant articles in the grey literature. This literature review concludes that unnecessary dilution of IV push medication in RTA syringes is an unsafe practice that occurs routinely. This practice increases the risk of patient harm through errors related to incorrect dose, improper labeling of syringes, and the potential for microbial contamination of the product. Greater awareness of the risks associated with unnecessary dilution of RTA syringes is still needed to eliminate this unsafe IV push medication administration practice and to thereby further improve outcomes.
不必要地稀释即用型（RTA）注射器可能会增加与剂量错误、标签不当以及潜在微生物污染相关的患者伤害风险。尽管已发布的指南认可使用市售的即用型 RTA 注射器，但最近的调查表明，最佳实践并非总是得到执行。本文旨在回顾现有文献，并评估在住院临床环境中不必要地稀释 RTA 静脉（IV）推注药物相关错误的发生率和性质。在 PubMed 数据库中搜索了过去 10 年中与 RTA 注射器用于 IV 推注药物相关的错误的研究。还使用其他搜索引擎进行了额外的搜索，以确定灰色文献中的相关文章。本文献综述的结论是，不必要地稀释 RTA 注射器中的 IV 推注药物是一种不安全的做法，经常发生。这种做法会增加与剂量错误、注射器标签不当以及产品潜在微生物污染相关的患者伤害风险。仍需要提高对不必要地稀释 RTA 注射器相关风险的认识，以消除这种不安全的 IV 推注药物管理做法，从而进一步改善结果。
