1. Standard Operating Procedure for the Preparation and Administration of Injectable medicines in Clinical Areas Prescription, preparation and administration (by any route) of injectable medicines pose risks to patients. All human actions are prone to error. It is not possible to train humans to make no errors. Safe systems of work are therefore needed to minimise these risks. Step 1: Prescribing All prescription for injections must clearly specify the drug name, dose, frequency and route of administration. In addition, the prescription or a readily available local protocol must specify, where relevant, the following:  Name and volume of diluents and/or infusion fluid  Concentration of the final infusion  Rate/duration of administration There must be a second checker for all IV preparations and administrations, it is expected that calculations are worked out separately and brought together. Step 2: Preparation  Check the formulation, dose and diluents against the prescription and the product information. Beware of the risk of confusion between similar looking medicines: e.g. plastic ampoules and nebulas. Also check the route of administration.  Prepare the label for the prepared medicine.  Ensure that the area in which the medicine is to be prepared is uncluttered, clean and quiet.  Wash your hands.  Assemble everything you need: medicine, diluents, syringe(s) needle(s), swabs, gloves, blue tray. Check expiry dates and the integrity of packing and containers.  Put on a pair of disposable gloves and an apron.  Use a 70% isopropyl alcohol swab to disinfect the blue tray on which the injection will be prepared. The blue tray should be cleaned once a day with chlorprep.  Assemble the syringe(s) and needle(s) : peel open wrappers  Use a “Non-touch” technique i.e. avoid touching areas where bacterial contamination may be introduced e.g. syringe-tips, the surfaces of the plunger that go inside the syringe barrel, needles and vial tops Step 3: Withdrawing solution from an ampoule into a syringe  Swab the neck of the ampoule with an alcohol wipe and allow to dry for at least 30 seconds.  Snap open the neck of the ampoule.  Attach the needle (a smaller gauge needle is best to avoid drawing up any small particles of glass) to a syringe and draw the required volume of solution into the syringe. Tilt the ampoule if necessary.  Invert the syringe and tap lightly to aggregate the air bubbles at the needle end.  Expel the air carefully.  Remove the needle from the syringe and fit a new needle or sterile blind hub. Step 4: Withdrawing a solution from a vial into a syringe  Remove the tamper-evident seal from the vial and swab the rubber cap with an alcohol wipe. Allow to dry for at least 30 seconds.  With the needle covered, draw a volume of air into the syringe equivalent to the required volume of solution to be drawn up.  Remove the needle cover and insert the needle into the vial through the rubber septum.  Invert the vial. Keep the needle in the solution and slowly depress the plunger to push air into the vial.  Release the plunger so the solution is forced back into the syringe.  If a large volume of solution is to be withdrawn, use a push-pull technique: inject 5 ml of air and draw up 5 ml of solution at a time until the required total volume is reached. This technique helps to minimise the risk of generating an aerosol spray due to build-up of pressure inside the vial.  Invert the syringe and tap it lightly to aggregate the air bubbles at the needle end. Push the air back into the vial.  Fill the syringe with the required volume of solution; then draw in a small volume of air. Withdraw the needle from the vial.  Expel excess air from the syringe. Remove the needle and exchange it for a new needle or a sterile blind hub. Step 5: Reconstituting powder in a vial & drawing resulting solution into a syringe  Swab the rubber septum of the vial and the neck of the diluent ampoule with an alcohol wipe. Allow to dry for at least 30 seconds.  Use the procedure in Step 1 above to draw the required volume of diluent (e.g. water for injection or sodium chloride 0.9%) from the ampoule into the syringe.  Inject the diluent into the vial. Keep the tip of the needle above the level of the solution in the vial. Release the plunger. The syringe will fill with the air which has been displaced by the solution (if the contents of the vial were packed under a vacuum, solution will be drawn into the vial and no air will be displaced). If a large volume of diluent is to be added, use a push-pull technique (see Step 4 above).  With the syringe and needle still in place, shake the vial to dissolve all the powder, unless otherwise indicated by the product information.  Follow Step 2 above to withdraw the required volume of solution from the vial into the syringe. Step 6: Adding a medicine to an infusion  Prepare the medicine in a syringe using one of the methods described above.  Swab the rubber septum on the infusion container with an alcohol wipe. Allow to dry for at least 30 seconds.  Inject the medicine into the infusion container taking care to keep the tip of the needle away from the side of the infusion container. Withdraw the needle and invert the container at least five times to ensure thorough mixing before starting the infusion. Don’t add anything to an infusion container when it is hanging on the infusion stand since this prevents adequate mixing. Step 7: Diluting a medicine in a syringe for use in a pump or syringe driver  Prepare the medicine in a syringe using one of the methods described above.  Draw the diluent into the syringe to be used to administer the medicine from the pump or syringe-driver. Draw in some air and remove the needle.  Stand the diluent syringe upright. Insert the needle of the syringe containing the medicine into the tip of diluent (administration) syringe and add the medicine to it.  Fit a blind hub to the administration syringe and invert several times to mix the contents.  Remove the blind hub. Tap the syringe lightly to aggregate the air bubbles at the needle end. Expel the air. Refit the blind hub. Step 8: Labelling the container  All injections MUST be labelled immediately after preparation, except syringes for immediate bolus administration.  Place the final syringe or infusion in a tray for transport to the bedside and administration. Step 9:Administration  Greet and accurately identify the patient. Introduce yourself and any colleagues involved in the procedure to the patient and/or carer.  Check patient's identification on prescription chart and check patient’s allergy status.  Check that the patient and/or carer understand the treatment to be given and any potential side effects together with their management. Answer any questions they may have in a manner that meets their communication needs.  Observe the site of administration, clean the microclave with PDI wipes for 30 seconds, allow to air dry for 30 seconds  After administration Clean the microclave with PDI wipes for 30 seconds. Observe the patient and the site of administration to monitor for immediate adverse effects. The NMC Registered nurse must have an in-depth understanding of the side effects of injectable medicines, and their assessment, monitoring, prevention and management.  Record the administration in the patient's notes, prescription chart and/or patient-held records, as appropriate, according to local guidelines.  Dispose of waste materials (sharps etc) in accordance with local guidelines. Have a working understanding of local guidelines for waste and sharps handling and disposal  Recognise when you need help and seek advice and support from an appropriate source when the needs of the individual and the complexity of the case are beyond your competence and capability.