1. Shastay, Ann MSN, RN, AOCN

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An unsafe injection and infusion practice has been brought to our attention-the dispensing and intravenous (IV) administration of a pharmacy-prepared product despite a visible precipitate. To ensure the safe IV delivery of medications and solutions, practitioners must be observant for potentially dangerous precipitates (Figure 1) often caused by drug or diluent incompatibilities (Newton, 2009). In an analysis of more than 300 drug incompatibilities reported to the Pennsylvania Patient Safety Authority between 2009 and 2016, almost one in five mentioned the formation of a precipitate (Grissinger, 2016). Precipitation reactions can be observed as crystals, haziness, or turbidity. If a precipitate is observed, the drug or solution should not be administered. The precipitate can lead to drug inactivation and subsequent therapeutic failures, catheter occlusions, and varying levels of harm due to particulate embolization, ranging from thrombophlebitis to multiorgan failure or even death (U.S. Food and Drug Administration, 2009). The consequences can be particularly severe in pediatric patients (Hopner et al., 2007).

Figure 1 - Click to enlarge in new windowFigure 1. Example of precipitate (LORazepam) in IV tubing.

Since 1998, a total of 23 cases of precipitation have been reported to the ISMP National Medication Errors Reporting Program (MERP). In 17 cases, a pharmacist or nurse noticed the precipitate and immediately stopped the injection or infusion. Some of these cases involved compounding or flushing errors in which the wrong diluent, flush or base solution, or concentration/dose was used, which resulted in the formation of a precipitate. However, in four cases, the medication or solution was administered despite observing the precipitate.


A patient with no previous cardiac or pulmonary disease died. A bag of calcium gluconate and potassium phosphate mixed in saline in the pharmacy appeared cloudy prior to administration, but the nurse still started the infusion. About an hour later, the patient was found in respiratory distress, which progressed to a fatal cardiac arrest. A different nurse had previously abandoned an attempt to administer the same solution due to its cloudy appearance, although she had not yet contacted the pharmacy. The nurse who administered the solution decided to hang it after referencing a flawed hospital protocol that stated products with precipitates could be infused under "close observation" due to the risk of "sudden death." An autopsy showed scattered pulmonary emboli, and the death was determined to be related to the infusion of the precipitated electrolyte infusion.


In the MERP database, there were two additional events in which nurses attempted to administer solutions despite observed precipitates. But fortunately, rapid IV line occlusions led to their discontinuation, although in one case, the solution was reinfused into another vein until that line also became occluded.


In 2015, ISMP learned of another event in which an 11-month-old baby received daily etoposide infusions over a 5-day period despite the presence of visible precipitates within the solution. Unfortunately, the dose of etoposide was mistranscribed as 33 mg/kg/day, instead of the correct dose of 3.3 mg/kg/day, for 5 days. The high concentration of the etoposide, which was diluted in 100 mL of normal saline, caused the drug to precipitate. Despite frequent occlusions and the need to constantly flush the IV access port, no one reported the precipitate or stopped the infusion. Had they done so, perhaps the 10-fold dosing error could have been detected before 5 days of therapy had been administered. The baby was closely monitored for possible liver, renal, bone marrow, neurologic, and respiratory damage secondary to etoposide toxicity and particulate administration.


ISMP is concerned that the reports of IV drug administration despite observed particulates is a signal of more widespread unsafe practices that illustrate the need for ongoing education and improved monitoring. Given the potential for harm associated with this unsafe practice, several opportunities exist to reduce the risk of errors.



Provide initial orientation and annual education on infusion safety and include new and temporary nurses. All nurses, pharmacists, and pharmacy technicians should be taught to observe medications and solutions for precipitates, and to avoid dispensing or administering an injection or infusion if precipitates are visible or a solution that should be clear is cloudy. Provide actual examples or pictures of drugs that have precipitated so practitioners who have never seen this reaction know exactly what to look for.


Also, be sure practitioners understand how to identify and avoid drug incompatibilities when preparing and administering medications or solutions or flushing IV lines (e.g., thoroughly flushing the line before administering an incompatible drug, administering certain medications through a separate injection port or site). The use of an in-line filter for solutions that are prone to precipitation can also help prevent particulates from entering the body; however, precipitates can still form in the tubing below the filter, and filters may become blocked, signaling a need to investigate (Grissinger, 2016).


Policies and Procedures

Review organizational policies and procedures related to infusion practices to ensure that the principles of infection control, aseptic technique have been incorporated. Policies and protocols should also be very clear regarding the need to avoid or immediately discontinue any injection or infusion if particulates are observed in medications or solutions.



It is essential to monitor adherence with proper infusion techniques in all settings where medications are prepared and administered.


5 Factors That Help People Stick to a New Exercise Habit

Studies have identified several factors linked to better exercise adherence. One study found that among previously inactive people with obesity who tried high-intensity training, those who enjoyed the exercise at baseline were more likely to stick with it. Encourage patients to try different types and combinations of physical activity until they find something they enjoy. The Physical Activity Guidelines for Americans recommends adults get at least 150 minutes of moderate-to-vigorous aerobic physical activity each week, along with at least two days of muscle-strengthening activity.


To boost self-efficacy, people can seek support from gym staff or friends, to build their knowledge around exercise technique. Learning yoga, weight lifting, or cycling in a group setting can better prepare people to be active on their own.


People can invite friends and family to join in the new exercise habit and/or seek out new social opportunities with people who share an interest in the same activities, and are more likely to stick with exercise if their friends are there too.


People can establish accountability by working out with a friend or a coach. Sharing their exercise journey online can also build accountability.


Health professionals can encourage patients to schedule weekly workouts in their calendar to make sure it fits into their day. Taking up a physical activity habit can be challenging, but encourage people to find activities that they enjoy, build skills and confidence safely, find social support and accountability, and fit physical activity into their daily routine.


Alexandra Black Larcom MPH, RD, LDN, Senior Manager of Health Promotion & Health Policy at IHRSA




Grissinger M. (2016). Analysis of reported drug interactions: A recipe for harm to patients. Pennsylvania Patient Safety Advisory, 13(4), 137-148. [Context Link]


Hopner J. H., Schulte A., Thiessen J., Knuf M., Huth R. G. (2007). Preparation of a compatibility chart for intravenous drug therapy in neonatal and pediatric intensive care units. Klinische Padiatrie, 219(1), 37-43. [Context Link]


Newton D. W. (2009). Drug incompatibility chemistry. American Journal of Health System Pharmacist, 66(4), 348-57. [Context Link]


U.S. Food and Drug Administration. (2009). Information for healthcare professionals: Ceftriaxone (marketed as Rocephin and generics). Retrieved from[Context Link]