Further reading

Good practice for the

preparation of injectable
medicines in clinical areas

Dougherty L and Lister S (Eds). The Royal Marsden Hospital Manual of Clinical Nursing Procedures (6th edition),
Blackwell Publishing, Oxford, 2004.
NMC standards for medicines management (2008).
RCN Standards for Infusion Therapy (2005), RCN, London
If you would like to know more about how Baxter can help you, contact: pharmacy_services@baxter.com

Adverse events should be reported. Reporting forms and information can be found at
www.mhra.gov.uk/yellowcard. Any adverse events relating to Baxter products can also be reported
direct to Baxter Pharmacovigilance on 01635 206360, or by email to vigilanceuk@baxter.com

A step-by-step guide for nurses, doctors and all

Surecall Baxter Medical Information:
Clinical and technical information at the
speed you need supporting the optimum
use of Baxter products for patients.

Tel: 01635 206 060

Fax: 0870 850 7075
email: pharmacy_services@baxter.com
www.baxterhealthcare.co.uk

Tel: 01635 206 345

Fax: 01635 206 071
email: surecall@baxter.com

Baxter Healthcare Ltd, Wallingford Road, Compton, Berkshire, RG20 7QW.

Baxter is a trademark of Baxter International Inc.
Copyright (July 2006), Baxter Healthcare Corporation. All rights managed.

other healthcare professionals who prepare and

UK/MG19/13-0017 - December 2013

Baxter Healthcare Ltd:

Pharmacy Services, Hospital Products,
Wallingford Road, Compton, Newbury,
Berkshire RG20 7QW.

administer injections

Pharmacyservices

Introduction

Contents

Increasing numbers of medicines are being prepared and given by healthcare professionals in clinical areas. There are risks
associated with these procedures, partly due to lack of essential information about injectable medicines.

General preparation

The aim of this guide is to inform healthcare professionals involved in the preparation of medicines, how to safely prepare
injectables. It is based on the template standard operating procedures for prescribing, preparing and administering injectable
medicines in clinical areas. These are outlined in the National Patient Safety Agency (NPSA) patient safety alert 20: promoting safer
use of injectable medicines, 28 March 2007.*

 ithdrawing solution from

W
an ampoule (glass or plastic)
into a syringe

We should do everything possible to make sure that the right drug is given in the right dose, by the right route,
by the right person, to the right patient and at the right time.1

 ithdrawing solution or

W
suspension from a vial
into a syringe

The objective of this guide is to provide clear step-by-step guidelines that healthcare professionals can use, in conjunction with
their own policies and procedures, to minimise these risks. It can be used as part of a training process and subsequently as a
practical reminder of good IV practice.
All injections should be prepared by following the NPSA patient safety alert 20, manufacturers product information, local guidelines
and the relevant guidance in this booklet.
We hope that you find this guide useful and we will be evaluating its usefulness through our clinical nurse teams in the near future.
However, if you have any comments, we would like to hear from you at pharmacy_services@baxter.com

Ensure there are up-to-date protocols and procedures for prescribing, preparing and administering injectable medicines
in all clinical areas.
NPSA patient safety alert 20.
* Note that the NPSA is now part of NHS England.
Reference: 1 Bates DW et al. Consensus development conference statement on the safety of intravenous drug delivery systems: balancing safety and cost. Hospital
Pharmacy. 2000; 35:150155

Page

 econstituting powder
R
in a vial, drawing the
resulting solution/suspension
into a syringe

Adding a medicine
to an infusion bag

 iluting a medicine in

D
a syringe for use in a
pump or syringe driver

10


Reconstituting powder or
solution in a vial using a
reconstitution device to
be administered by infusion

Page

11
or

Adding a drug to a bag with

integral reconstitution device

12

Adding a drug to a bag

using a vial with
integrated transfer device

13

Using ready-to-
administer bags

14

Labelling injection
and infusion containers

14

Checks to be made before

administering any injection

15

Further reading

16

General preparation
The basic steps that should be followed before any injection or infusion procedure is started:

Read the prescription carefully

Confirm the prescription relates

to the patient being treated.
Check the patient is ready to
have the medication. There may
be a written instruction, such as
a Patient Group Direction.

Assemble everything you need

Assemble sharps bin, medicine

ampoule(s)/vial(s), diluent,
syringe(s), 21g, 23g, 25g
needle(s), alcohol wipes,
disposable protective gloves,
clean re-usable plastic tray. Check product expiry dates and
packaging, and read their labels carefully. Also check that
products were stored correctly (e.g. in a refrigerator). Prepare a
label for the prepared medicine (see page 14).

Clean preparation area

Area should be clean,

uncluttered and as free from
interruptions and distractions
as possible.

Check that:

T he formulation, dose,
diluent, infusion fluid and rate
of administration correspond
to the prescription and
product information
T he patient has no known allergy to the medicine
Y ou understand the method of preparation
Calculate the volume of medicine solution required, write it down
and get it checked by another qualified person.

Wash your hands

Wash hands thoroughly

according to local policy.
Put on a pair of disposable
gloves.

Use a non-touch technique

Avoid touching areas where

bacterial contamination may
be introduced e.g. additive
port, syringe-tips, needles, vial
tops. Never put down a syringe
attached to an unsheathed
needle.

Prepare plastic tray and products

Disinfect a plastic tray with a

70% alcohol wipe or spray.
Peel open wrappers on syringes
and needles carefully. Arrange
all ampoules/vials, syringes and
needles neatly in the tray.

Prepare the injectable medicine

using one of the following stepby-step procedures

Also follow manufacturers

product information or local
guidelines.

Withdrawing solution from an ampoule (glass or plastic) into a syringe

Withdrawing solution or suspension from a vial into a syringe

Tap the ampoule gently to dislodge

any medicine in the neck. Snap open
neck of the glass ampoules, using an
ampoule snapper if required.

Attach a needle to a syringe.* Draw

required volume of solution into the
syringe. Tilt the ampoule if necessary.

If the ampoule contains a suspension

rather than a solution, it should be
gently swirled to mix the contents
immediately before they are drawn into
the syringe.

Invert the syringe and tap lightly to

aggregate the air bubbles at the
needle end. Expel the air carefully. Fit
a new needle or sterile blind hub.

Remove tamper-evident
seal from vial. Wipe rubber
septum with an alcohol wipe.
Allow to dry for at least 30
seconds.

With the needle sheathed,

draw into the syringe a
volume of air equivalent to
the 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. Slowly depress
plunger to push air into the
vial. Release the plunger so
that solution flows back into
the syringe.

If the vial contains a

suspension rather than a
solution, it should be gently
swirled to mix the contents,
immediately before they are
drawn into the syringe.

Attach the prepared label to the

syringe.

Keep the ampoule and any unused

medicine until administration is
complete.

If a large volume of solution is

to be withdrawn use a pushpull technique: repeatedly
inject small volumes of
air and draw up an equal
volume of solution until the
required total is reached. This
equilibrium method helps
to minimise the build-up of
pressure in the vial.

Alternatively, pierce rubber

septum with a second needle
to let air into the vial as
solution is withdrawn. The
tip of the vent needle must
be kept above the solution to
prevent leakage.

 ith the vial still attached,

W
invert the syringe. With the
needle and vial uppermost,
tap the syringe 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.

Note: The neck of some plastic ampoules is designed to connect directly to a syringe without the use of a needle, after the top of the ampoule has
been twisted off. This is easier with a luer slip syringe and there is less chance of contamination.
*Y
 our local policy should be referred to as some organisations may advocate the use of filter straws or filter needles when drawing from glass
ampoules.

Note: The vial(s) and any unused medicine should be kept until administration to the patient is complete.

10

E xpel excess air from the

syringe. Remove the needle
and exchange it for a new
needle or a sterile blind hub.
Attach the prepared label to
the syringe.

Reconstituting powder in a vial, drawing the resulting solution/suspension into a syringe

Adding a medicine to an infusion bag

Remove tamper-evident seal from the

vial and wipe the rubber septum with
an alcohol wipe. Allow to dry for at
least 30 seconds.

U se the procedure on page 6 to

withdraw the required volume of
diluent (e.g. water for injections
or sodium chloride 0.9%) from
ampoule(s) into the syringe.


Inject
the diluent into the vial. Keeping
the tip of the needle above the level
of the solution in the vial, release the
plunger. The syringe will fill with the
air that 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
procedure on page 7).


Prepare
the medicine in a syringe
using one of the previously described
methods.

Check wrapper of the bag is

undamaged. Remove wrapper and
check the bag itself in good light. It
should be intact and free of cracks,
punctures/leaks. Check infusion
solution is free of haziness, particles
and discolouration.


Remove
the tamper-evident seal on
additive port or wipe rubber septum
on the bag with an alcohol wipe. Allow
to dry for at least 30 seconds. Lay the
bag flat on a clean surface.

If volume of medicine to be added is

more than 10% of the initial contents
of the bag, e.g. more than 50ml to a
500ml or 100ml to a 1 litre infusion,
an equivalent volume must first be
removed with a syringe and needle.


Inject
the medicine into the bag
through the centre of the injection port.
Keep the tip of the needle away from
the side of the bag!

Withdraw the needle. Invert the

container at least five times to ensure
thorough mixing before starting the
infusion.

 heck the appearance for absence of

C
particles, cloudiness or discolouration.
Attach the prepared label to the bag.

With the syringe and needle still in

place, gently swirl the vial to dissolve
all the powder, unless otherwise
indicated by the product information.
This may take several minutes.

Follow the relevant steps in the

procedure on page 7 to withdraw the
required volume of solution from the
vial into the syringe.

A lternatively, the rubber septum may

be pierced with a second needle
to let air into the vial as solution is
withdrawn. The tip of the vent needle
must always be kept above the
solution to prevent leakage
(see the procedure on page 7).

Attach the prepared label to the

syringe.

Note: If a purpose-designed reconstitution device is used, the manufacturers instructions should be read carefully and followed closely.

Note: Do not add anything to any infusion container other than a burette when it is hanging on the infusion stand since this makes adequate
mixing impossible.
Before adding a medicine to a hanging burette, administration must be stopped. After the addition has been made and before administration is
re-started, the contents of the burette must be carefully swirled to ensure complete mixing.

10

11

Diluting a medicine in a syringe for use in a pump or syringe driver

1

Prepare the medicine in a syringe

using one of the previously described
methods.

Draw the diluent into the syringe to be

used for administration by the pump or
syringe driver. Draw in some air (slightly
more than the volume of medicine
needed) and remove the needle.

Stand the diluent syringe upright.

Insert the needle of the syringe
containing the medicine into the tip of
the diluent (administration) syringe and
add the medicine to it.

Alternatively, a disposable sterile

connector may be used to connect two
syringes together directly.

Check that:
The total volume of injection solution
in the syringe is as specified in the
prescription and that the infusion can
be delivered at the prescribed rate by
the administration device chosen

Fit a blind hub to the administration

syringe. Invert several times to mix the
contents.

Remove the blind hub. Tap syringe

lightly to aggregate the air bubbles at
the needle end. Expel the air and refit
the blind hub.

Reconstituting powder or solution in a vial using a reconstitution device

for administration by infusion
1


Remove
wrapper from bag.
Remove the tamper-evident
seal on the additive port or
wipe the rubber septum on
the infusion container with an
alcohol wipe. Allow to dry for
at least 30 seconds.

Remove tamper-evident seal

from vial. Wipe the rubber
septum with an alcohol wipe.
Allow to dry for at least 30
seconds.

Open the outer wrapper of the

reconstitution device, leave
the device in its opened outer
wrapper.

Connect the reconstitution

device to the drug vial, without
removing the outer wrapper
from the part of the device to
be connected to the bag.

Remove the outer wrapper

from the device and connect
the device into the bag port.

Squeeze bag to fill half of the

drug vial with diluent.

Swirl vial gently to mix and

check the appearance.

Invert vial/bag assembly.

Squeeze the bag to allow the
dissolved medicine to go back
into the diluent bag. Remove
the reconstitution device
with vial.

Shake bag gently to mix.

Check the appearance
for absence of particles,
cloudiness or discolouration.

10

Carefully check the syringe for cracks

and leaks and then label it, noting
the requirements specific to syringe
drivers.

T he rate of administration is set

correctly on the administration
device and according to the
manufacturers instructions
Note: Check that the rate of administration is set correctly on the device before fitting the syringe, priming the administration set and starting the
infusion device.

Cover the additive port of the

bag with a cap. Attach the
prepared label to the bag.

12

13

Adding a drug to a bag with integral reconstitution device

Adding a drug to a bag using a vial with integrated transfer device


Remove
tamper-evident seal from the
vial. Wipe the rubber septum with an
alcohol wipe. Allow to dry for at least
30 seconds.

Peel back the foil cover from the end of

the reconstitution device.

Push the adaptor firmly down onto the

vial until a clear snap is heard. The
vial is now safely pierced.

Bend the frangible connector up and

down to break the seal.

Remove cap from vial.

Connect device to bag.


Push
down the transparent
mobile part of the device to
activate the system.

Squeeze the diluent bag to fill

half of the vial with diluent.

Remove the wrapper from the

infusion bag. Remove the
tamper-evident seal on the
additive port or wipe the
rubber septum on the infusion
container with an alcohol
wipe. Allow to dry for at least
30 seconds.

Swirl vial gently to mix and

check the appearance.

Invert vial/bag assembly,

squeezing bag to transfer
medicine back into the bag.

Shake bag gently to mix

products. Check the
appearance for absence
of particles, cloudiness or
discolouration.

Attach the prepared label to

the bag.


Squeeze
the fluid into the vial until half
full. Shake to dissolve the drug.

Invert and squeeze air into the vial to

displace fluid back into the bag.

Shake bag gently to mix products.

Check the appearance for absence of
particles, cloudiness or discolouration.

Attach the prepared label to the bag.

The vial remains

permanently attached,
showing clearly the drug
being administered.

Note: Do not detach vial from reconstitution device at any time.

Note: Do not detach vial from reconstitution device at any time.

14

15

Using ready-to-administer bags

1

Checks to be made before administering any injection

C
 heck the medicine is due for administration and has not
already been given

Assemble everything you need including flushing solution(s)

Explain and discuss the procedure with the patient
Check wrapper of the bag is
undamaged. Remove wrapper and
check the bag itself in good light.
It should be intact and free of cracks
and punctures/leaks.

Check infusion solution is free of

haziness, particles and discolouration.

Confirm that the prescription relates to

the patient being treated by checking
all of the following:

Also check, where relevant:

3 Full name

3 Concentration or total quantity

of medicine in the final infusion
container or syringe

3 Address
3 Date of birth

Labelling injection and infusion containers

3 Hospital number
3 NHSnumber
Then re-check all the following:

All injections, including medicines and flushes, should

be labelled immediately after preparation. The only
exceptions are syringes intended for immediate push
(bolus) administration when they have not left the hands
of the person who prepared them between preparation
and administration.

Labels used on injectable medicines prepared in clinical areas should

contain the following information:

There should never be more than one unlabelled

syringe in a tray at any one time, nor must an
unlabelled syringe be fitted to a syringe driver or
similar device.
Flag labelling should be used to make sure that the
volume gradients on syringes are not obscured.

The patients name

Diluent

Name of the medicine

Final volume

Strength

Expiry date and time

Route of administration

N
 ame of the practitioner
preparing the medicine

Place the final syringe or infusion and the empty ampoule(s)/vial(s)

in a clean plastic tray for transport with the prescription to the bedside
for administration.

3 Prescribers signature
3 The approved medicine name
3 The dose and frequency
of administration
3 The date and route
of administration
3 The allergy status of the patient

3 Brand name and formulation of the

medicine

3 Name and volume of diluent and/or

infusion fluid
3 Rate and duration of administration

Check appearance of infusion already in progress

C
 heck that an appropriate access device is in place. Flush
it immediately before and after administration of a medicine
and between doses of different medicines administered
consecutively, according to local policy
C
 heck the administration site for signs of leakage, infection
or inflammation

3 Type of rate-control pump or

device(s) to be used
3 The age and weight of any patient
under 16 years of age
3 Date on which treatment should
be reviewed

If any question arises; do not hesitate to contact the

pharmacist or healthcare practitioner who ordered the
medication for more information.