Jan 4, 2018 - Likewise, the CNO Medication Standard applies equally to RNs and RPNs and does not distinguish between the
RPNAO Statement Regarding RPN Medication Practice Direct IV Injection (Push) Medication Administration
This document is intended to address the myth that RPNs cannot administer IV push drugs below the drip chamber and to provide information for RPNs in addressing this change in practice resulting from the mini bag shortage.
Background There is currently a shortage of small volume parenteral solutions (IV mini bags) for use in IV medication administration, due to an interruption in production in Puerto Rico following hurricane related damage. The Food and Drug Administration (FDA) in the United States is closely monitoring the situation and is issuing regular updates. As noted in this January 4, 2018 press release, FDA is anticipating that the shortage situation will improve early in the year. However, it remains important to conserve supplies of small volume parenteral solutions. One of the conservation strategies recommended by the American Society of Health-System Pharmacists (ASHP) and the University of Utah is the use of direct IV medication administration (IV push) whenever possible. As a result, RPNs may be required to administer medications by direct IV injection (IV push) when they have been previously administering them by different route such as IV infusion.
Direct IV Medication Administration – RPN Practice The administration of all medications, including those given by the direct IV injection or “push” IV route is governed first by legislation, and then by College of Nurses (CNO) practice standards and guidelines and finally by organizational policy. All nurses must in each clinical situation determine if the performance of a particular procedure is within the nurse’s scope of practice and if it promotes safe patient care. Because this will vary from nurse to nurse, nursing leaders and nursing teams need to enable ongoing discussion to determine which nurse can best provide care to the patient, considering the patient’s condition, the nurse’s scope of practice (knowledge, skill, experience, CNO category) and the conditions of the practice environment in which care is to be delivered.
Authority to Perform CNO notes that “the Nursing Act, 1991 does not differentiate between RNs and RPNs in the administration of medication.” Likewise, the CNO Medication Standard applies equally to RNs and RPNs and does not distinguish between the categories of nurse with respect to medication practice. At the legislative and regulatory levels, RPNs are not prohibited from administering IV medications by direct injection (push). Nurses must have a clear, complete and appropriate order to be authorized to administer a prescription medication, including one given by IV push. ASHP states that it is best practice to include the actual rate of IV push administration specific to a given drug and that terms such as IV push (unspecified), IV bolus (unspecified), slow or fast/rapid IV push be avoided. Organization policy or protocol about the administration of IV push medication may outline limits to practice based on medication type, patient care environment and/or nursing role. However, in an urgent or unusual situation such as this supply shortage organizations might implement provisional or temporary policies to address the new circumstances, with the intent to review and revise the existing document(s) once the situation stabilizes. In any event, RPNs should be knowledgeable about and adhere to any organizational practice documents that pertain to the administration of IV push medication.
Competence Nurses must have the necessary knowledge, skill and judgment to safely administer a medication by IV push. This must be evaluated in each situation considering the nurse’s knowledge, experience and category, the patient’s condition (including the likely response to the medication administered by IV push) and the practice environment. Nurses need to recognize the limits of their own competence and obtain assistance when needed. Nurses must also refrain from performing a practice when they are not competent in either the cognitive or the technical aspects of that practice. These standards of competence apply to both RNs and RPNs administering medication by IV push. Nurses that do not have established competence in the administration of IV push medications should collaborate with their employers to have competence evaluated and competence development supported prior to autonomous practice.
Safety CNO requires nurses to “take appropriate action to resolve or minimize the risk of harm to a client from a medication error or adverse reaction” as well as to collaborate to create a safe medication practice environment. Risk of a harmful patient outcome is increased with the administration of medication by IV push due to a number of factors, not the least of which is wide variation in practice and “on the job” nurse to nurse training. Most nurses do not develop competency in direct IV injection while in their basic programs due to placement agency restrictions on student practice. The Institute for Safe Medication Practices (ISMP) conducted studies of IV push practices. In a 2014 study, 83% of 1773 nurse
participants identified that they further dilute IV push medications even when the medication is dispensed as a unit dose item. Nurses also readily identified that they use a single dose syringe to administer multiple IV push doses, rather than wasting medication remaining in the syringe after the initial dose is given. These types of practices increase the risk of adverse patient outcomes from IV push medications. Specific guidelines for the safe preparation and administration of IV push medications are available from ISMP for use by nurses and health care organizations. Safety also includes management of patient outcomes. CNO expects that nurses will be able to anticipate potential outcomes of a procedure prior to performing it and that they will have the authority, competence and resources to manage these outcomes should they occur. In order to properly anticipate potential outcomes of medications administered by IV push, nurses need to understand the mechanism of action, the patient’s condition and how rapid IV medication administration may impact patient response. As with other aspects of practice, autonomous RPN practice with respect to direct IV injection medication administration will occur in more stable practice environments and with patients that are at lower risk for negative outcomes and that have more predictable outcomes. In less stable practice environments and/or with more unpredictable patients that are at higher risk for negative outcomes, there will be more need for RPNs to consult or collaborate with RN colleagues to safely provide this care. _____________________________________________________________________________________
Frequently Asked Questions Does CNO state that RPNs cannot give IV push medications? No. CNO provides standards for medication administration that do not specifically differentiate between RN and RPN practice. CNO also provides standards and guidelines to help determine safe and effective use of nurses in the provision of care. However, your employer may have medication policies or protocols that limit RPN practice.
Are there drugs that RPNs should not give by IV push? Yes. There are medications that should not be given by IV push. As well, there are medications that when given IV push may be beyond the scope of a RPN because of the patient assessment required or because the management of potential outcomes is beyond the scope of the RPN.
My organization policy doesn’t follow the ISMP IV push guidelines. What should I do? It’s important to share your knowledge about this with the appropriate leader or committee in your organization so that you can understand your organizational policy fully and advocate for changes if needed. Perhaps this is a Safe Medication Committee or your Nursing Practice Council. Or it could be your manager or Chief Nursing Executive. CNO expects nurses to advocate for safe practice and to refrain from performing a procedure that they do not belief they can safely and competently perform. Do RNs need to supervise RPN practice with respect to IV push meds? All nurses are accountable for all the care that they provide, whether provided autonomously or collaboratively with other members of the care team. When competence is being assessed or certified, it is often necessary for one nurse to observe and evaluate another nurse. Once competence is established, if it is appropriate for a RPN to administer a medication by direct IV push, there is should be no need for another nurse to supervise. ..........
About RPNAO Founded in 1958, RPNAO is the voice of registered practical nursing in Ontario. There are approximately 41,000 RPNs working in Ontario, playing a vital role in the province’s health care system. For more information about RPNAO, its mandate and how RPNs contribute to Ontario’s health care system, please visit rpnao.org. For further information: Dianne Martin, Chief Executive Officer 905-602-4664 ext. 226
