Table 1

Summary of most pertinent safety issues and mitigating strategies

Nursing
Safety Concern	IV medication rate changes can have unexpected effects if there is common volume involved with the infusion.
Considerations/Strategy	When possible, medications should each flow independently through IV tubing without joining any other infusion prior to entering the blood stream. This may be impractical in critical care in which case the next best option is to use small-volume multi-line connectors that are attached as close to the patient’s venous access as possible.
Safety Concern	Improper secondary medication administration through extended tubing can lead to high residual volume left either unadministered or flushed in at an unsafe rate.
Considerations/Strategy	Ensure all secondary medication administrations are followed by an adequate flush volume to clear the entire single drug volume at the same rate used for the medication administration. Keep in mind this volume may contribute to fluid overload for at-risk patients which may necessitate intermittent infusions be delivered inside the patient room.
Safety Concern	When changing medication concentration for an already running medication the adjusted rate for the new concentration will affect what volume remains in the single drug volume.
Considerations/Strategy	The single drug volume must be purged of the prior medication before restarting the infusion, this could be done by changing the tubing entirely or re-priming with the new medication or concentration.
Safety Concern	Carefully consider the type of extension tubing being used.
Considerations/Strategy	Take the following into consideration given the specific patient situation: Small bore tubing = lower priming volume but potentially higher sensitivity to downstream occlusion and more potential for inaccurate flow (6). Higher rigidity tubing = More resistant to kinking or compression but higher sensitivity to downstream occlusion and more potential for inaccurate flow (6).

Pharmacists
Safety Concern	Carefully consider changes in medication concentration.
Considerations/Strategy	Higher concentration medications are generally administered at lower flow rates, increasing the risk for unplanned alterations in drug delivery, especially when common volumes are large.
Safety Concern	Medication container volumes must be considered for increased priming volumes, decreasing waste and also avoiding unnecessary infusion interruption due to frequent container changes.
Considerations/Strategy	Consider a larger container for initial setup if larger priming volumes are required while smaller volumes may be sufficient for subsequent container replacements depending on the continuous rates.
Safety Concern	Ensure secondary infusion flushes are appropriate.
Considerations/Strategy	Orders for flush volumes should be sufficient for flushing the entire length of tubing being used for secondary medication infusions, rates for these flushes should also be ordered or suggested based on the rate for the secondary medication being infused.
Safety Concern	Carefully consider the implications of delayed drug library updates.
Considerations/Strategy	When updates are needed, especially relevant to remove IVSP use, ensure installation across entire IVSP fleet is completed as quickly as possible.

Ordering Providers
Safety Concern	Flush for secondary medications
Considerations/Strategy	Ensure an adequate flush at an appropriate flow rate is ordered to follow secondary infusions especially when an order is required per facility policy.
Safety Concern	Adequate and appropriate venous access device use.
Considerations/Strategy	Collaborate regularly with nurses to ensure adequate venous access is available to decrease the number of medications flowing together through a common volume.