High Alert Medications: The PINCH Drugs

What is the most common cause of preventable morbidity and mortality in hospitals?

Medication errors

What is a sentinel event?

Errors causing significant injury including death

What have been developed to prevent errors from reaching the patient?

Policies

What are high alert medications?

Medications identified as causing harm if given incorrectly

What do the policies focus on?

Focus on infusions of high alert drugs rather than any other routes of administration or use

What does infusion of PINCH drugs require?

Special vigilance because errors with these can be fatal

As a general rule, what does the infusion of PINCH drugs require?

The use of an IV pump to ensure accurate flow rate

What is just as dangerous as too much of a drug?

Too little

What does the P in pinch stand for?

Parenteral nutrition and potassium

What is Parenteral nutrition also called?

TPN, total Parenteral nutrition

What is Parenteral nutrition?

Hypertonic solution with a high dextrose concentration and other additives

How is Parenteral nutrition always administered?

On a pump

What do the nurses have to do when administering TPN?

2 nurses check TPN label against original order

How can potassium infusion be given?

Via different routes, and the route determines the level of concern

When administering potassium orally or via a feeding tube, is a double check required?

No because that route has a high safety margun

What is it good nursing practice to do before administering potassium?

Check the potassium levels

If potassium is added to IV fluid in a premixed bag, is a double check required?

No

If the pharmacy adds potassium to the IV bag is a double check required?

No

If the nurse is performing the function of pharmacy and adding potassium to the bag of fluids, do they need a double check?

Yes the other nurse should check the order, the amount drawn up and added to verify it is all correct

Why is potassium in IV fluid always on a pump?

To maintain the ordered flow rate because administration of both too much or too little potassium has cardiac implications

When potassium levels are critically low the physician may order what?

A small amount of potassium to be given over a shorter amount of time called an IV piggyback

What is the protocol when administering an IV piggyback of potassium?

2 RNs will verify that the patient's potassium level warrants the administration of a mini bag and 2 RNs will also verify the patient's identity and ensure that the slow rate does not exceed 10mEq per hour

What is the maximum infusion rate of potassium on an IVPB?

10mEq per hour

What does the I in pinch stand for?

Insulin infusion aka insulin gtt "drip"

How is insulin administered?

By injection either subcutaneously or IV

Which route of administration is most common for insulin?

Subcutaneous

What is required before administering insulin via any route?

Critical assessment of the patient's blood sugar kevel

What is the protocol for an insulin subq injection?

Used to be that you needed a double check but not anymore

What is a continuous infusion of insulin?

Insulin drip and it is used for more seriously ill patients

What does an insulin drip require?

An infusion pump and 2 RNs must double check that the correct rate is set when starting the infusion as well as any time there is an ordered rate change

Can insulin be administered IV push?

Yes, and it requires a double check on the amount drawn up

What is the n in pinch?

Narcotics

What are narcotics?

controlled substances with legal requirements and restrictions

What does the law require for administering a controlled substance via any route?

2 RNs verify any wasted amounts of the drug

Why do the nurses need to document amounts wasted of controlled substances?

All quantities of controlled substances must be accounted for and this includes witnessing the disposal of patches removed from a patient

How can narcotic infusions be administered?

As continuous infusions or using PCA

What does PCA stand for

patient controlled analgesia (where the patient pushes a button to deliver an ordered dose)

Narcotic infusions may use

IV piggybacks or syringes as delivery methods

What kind of pump do narcotic infusions use?

A locked pump to ensure the flow rate and to prevent diversion of the controlled substance

When will the nurses double check with narcotics?

With initial set up, with any rate change, any bag/syringe change, any shift change

What does the C in pinch stand for?

Chemotherapy aka antineoplastic agents

What are chemotherapy agents?

Cytotoxic in nature and special handling of these is required

What do oral antineoplastics require?

Double check

What do most hospitals require for the nurse to administer chemo especially through IV?

A special certification

What do IV push and IV chemo infusions require?

2 RNs to double check the bag or syringe against the initial order for accuracy

What will chemotherapy infusions always use?

An infusion pump and policies may require 2 RNs to double check the rate set on the pump

How can chemotherapy be administered?

PO, IV infusion or IV push

What does the h in pinch stand for?

Heparin

What is heparin?

an anticoagulant that comes in many different strengths administered subcutaneously or IV

What policy change is heparin undergoing?

Sub q hearing injections required a double check but no longer

What should the nurse verify before administrating heparin through any route?

Pertinent lab values like the most recent PTT

When administering heparin IV push, the nurse should

Always verify the amount drawn up before administeing

When heparin is administered as an infusion, it is reffered to as a

Heparin drip

Heparin drip (IV gtt) will always

Use an infusion pump and 2 RNs will verify the patient, lab value, and bag prior to initiating drip, they will also check the initial flow rate and any rate changes made

What is heparin flush?

A very dilute form of IV heparin used with some patient to keep their IV catheters free of blood clots and flowing

How is heparin flush given?

Intravenously and no double check is required due to its dilute concentration

What does the double check process for any of the PINCH drugs include?

That 2 RNs visually inspect the amount to be administered as well as documenting who performed the check therefore both the primary nurse and verifying nurse share equal responsibility when signing off on a medication double check