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Ed Lybarger CRNI
Giving total dose of ordered drug: admixed bags or minibag plus vs. prefilled medication bags

I work for a LTC pharmacy and recently one of our LTC facilities was given a pharmacy citation by a state examiner for infusing the entire amount of a premix bag of antibiotic instead of the exact number of milliliters indicated on the bag. An example is Vancomycin 500 mg in 100 ml, printed on the bag by the manufacturer. Apparently, the solution of drug is batch prepared at the appropriate concentration and the premixed bags are filled with the solution at this concentration. However, due to manufacturer's quality control or internal policies, there may be a slight over-fill (or under-fill) of the bag. So, in the instance cited, if the nurse gives the entire bag, the patient may receive other than 500 mg of the drug.

This is not an issue if the drug is admixed at the pharmacy, or at the facility using the minibag plus system, since the exact dose of the drug in the vial is mixed with whatever volume of fluid is contained in the bag of solution. The correct dose is only given if the entire volume is infused.

Our pharmacy has always instructed the nurses to give the entire volume of a bag of intermittent medication, including the premixed ones. Our IV pharmacists and nurses are of the opinion that this has been the standard of practice in the industry, but we are having trouble finding documentation about this issue, one way or the other. One of the pharmacists believes there is a pharmacy standard allowing +/- 5% in the dosage given vs dosage ordered. In addition, is there deliberate overfill to account for the volume of solution that remains in the tubing after administration?

What is your practice? Are we incorrect in our assumptions? Was the state examiner being too picky? Do you know of any articles or standards related to this issue? Thanks in advance. Ed