Advanced Pharmacology: Metformin; Theoretical and nursing: Pregnancy and STD; Capstone project (Due 26 and 48 hours)

R E S E A R CH

Co-administration of multiple intravenous medicines: Intensive care nurses' views and perspectives

Mosopefoluwa S. Oduyale MPharm1 | Nilesh Patel PhD, BPharm (Hons)1 |

Mark Borthwick MSc, BPharm (Hons)2 | Sandrine Claus PhD, MRSB, MRSC3

1Reading School of Pharmacy, University of

Reading, Reading, UK

2Pharmacy Department, John Radcliffe

Hospital, Oxford University Hospitals NHS

Foundation Trust, Oxford, UK

3LNC Therapeutics, Bordeaux, France

Correspondence

Mosopefoluwa S. Oduyale, Reading School of

Pharmacy, University of Reading, Harry

Nursten Building, Room 1.05, Whiteknights

Campus, Reading RG6 6UR, UK.

Email: [email protected]

Funding information

University of Reading

Abstract

Background: Co-administration of multiple intravenous (IV) medicines down the

same lumen of an IV catheter is often necessary in the intensive care unit (ICU) while

ensuring medicine compatibility.

Aims and objectives: This study explores ICU nurses' views on the everyday practice

surrounding co-administration of multiple IV medicines down the same lumen.

Design: Qualitative study using focus group interviews.

Methods: Three focus groups were conducted with 20 ICU nurses across two hospi-

tals in the Thames Valley Critical Care Network, England. Participants' experience of

co-administration down the same lumen and means of assessing compatibility were

explored. All focus groups were recorded, transcribed verbatim, and analysed using

thematic analysis. Functional Resonance Analysis Method was used to provide a

visual representation of the co-administration process.

Results: Two key themes were identified as essential during the process of co-admin-

istration, namely, venous access and resources. Most nurses described insufficient

venous access and lack of compatibility data for commonly used medicines (eg, anal-

gesics and antibiotics) as particular challenges. Strategies such as obtaining additional

venous access, prioritizing infusions, and swapping line of infusion were used to man-

age IV administration problems where medicines were incompatible, or of unknown

or variable compatibility.

Conclusions: Nurses use several workarounds to manage commonly encountered

medication compatibility problems that may lead to delays in therapy. Organizations

should review and tailor compatibility resources towards commonly administered

medicines using an interdisciplinary approach. Developing a clinical decision-making

pathway to minimise variability while promoting safe co-administration practice

should be prioritised.

Relevance to clinical practice: This study highlights several ways ICU nurses are able

to manage challenges associated with co-administration and the need for the devel-

opment of a more robust and comprehensive compatibility resource that is relevant

to everyday practice through collaboration between nurses and pharmacists.

Received: 17 July 2019 Revised: 25 November 2019 Accepted: 20 December 2019

DOI: 10.1111/nicc.12497

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,

provided the original work is properly cited.

© 2020 The Authors. Nursing in Critical Care published by John Wiley & Sons, Ltd on behalf of British Association of Critical Care Nurses.

156 Nurs Crit Care. 2020;25:156–164.wileyonlinelibrary.com/journal/nicc

14785153, 2020, 3, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/nicc.12497, W

iley O nline L

ibrary on [17/11/2022]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

K E YWORD S

co-administration, compatibility, functional resonance analysis method, intravenous

1 | BACKGROUND

Patients admitted to intensive care units (ICU) are prescribed numerous

medicines delivered by continuous intravenous (IV) infusion. The num-

ber of prescribed IV infusions usually exceeds the number of venous

access sites or available lumens. Intensive care nurses are then forced to

request additional venous access, or alternatively co-administer either

continuous or intermittent infusions down the same lumen using a

Y-site connector, meaning the medicines mix in the venous access

lumen before entering the bloodstream. Medicines administered in this

way are at risk of physicochemical incompatibilities. Medicine incompat-

ibilities are considered to be in vitro physical or chemical reactions that

occur between two or more IV medicines combined in the same cathe-

ter lumen.1 Physical incompatibilities cause visible changes, often pre-

senting as precipitates, whereas chemical incompatibilities are not

visible and are considered significant when more than 10% degradation

of one or more of the medicines in solution occurs.2

Physicochemical reactions may impair the therapeutic efficacy of

the medicines or result in venous catheter occlusion, toxic compound

formation, embolism, or local/systemic inflammatory reactions.1,3-6

There are cases of life threatening pulmonary embolism, ventricular

failure, and ineffective therapy in humans, prompting the Food and

Drug Association to issue safety alerts.7-11 These adverse effects

harm patients and increase costs for hospitals.12 Thus, compatibility

must be assured prior to the co-administration of medicines.

Nurses are at the forefront of co-administration practice; however,

the majority of co-administration studies focus on frequencies of com-

bining incompatible medicines, generation of compatibility data, and

clinical complications of incompatibilities13-16 (Benlabed et al, 2018).

There is an evidence gap regarding nurses' experience of processes

involved in co-administration of multiple medicines down the same

lumen and potential challenges experienced. Because the problem is

common,17 an understanding of the process based on nurse experiences

could prove useful by improving our knowledge, and revealing potential

practical interventions. This could help make patient care more efficient,

minimise challenges encountered by nurses during the process of co-

administration, and ultimately promote safer co-administration practice.

Co-administration of multiple medicines down the same lumen can

be viewed as a complex socio-technical system involving interaction

between people, technology, and devices in a physical and organisational

environment. Viewed like this, outcomes of services provided are inter-

connected and non-linear,15 and so can be investigated using a non-linear

method such as Functional Resonance Analysis Method (FRAM).16 The

FRAM results in a model that is a visual representation of all the activities

connected to the process of co-administration of medicines. Using FRAM

reveals interconnections and adjustments made within work processes

that a linear approach may be unable to discover. A key advantage of

FRAM is that it can be used to assess how things go right as well as how

things go wrong. This helps to identify not only what happens in the pro-

cess, but also the “how” and “why” aspects of the process.17 Several

studies show FRAM to be useful in exploring the effectiveness of work

systems and in understanding everyday performance in health care

processes to inform guideline implementation.17,21,22

Therefore, FRAM may provide new perspectives on the process

of co-administration which can then be used to improve the system

of work, quality, and safety of patient care.

2 | AIM

The overall aim was to explore the everyday practices surrounding co-

administration of multiple IV medicines by ICU nurses down the same

lumen, the challenges encountered during the process of co-administration,

and investigate how compatibility is assessed andmanaged in practice.

WHAT IS KNOWN ABOUT THIS TOPIC

• Co-administration of multiple medicines down the same

lumen is a common practice in ICUs.

• There are several potential complications associated with

co-administering incompatible medicines down the same

lumen, and so compatibility must be determined prior to

co-administration.

WHAT THIS PAPER ADDS

• This study indicates that nurses adopt several

workarounds to manage the challenges associated with

co-administration through requesting additional venous

access, prioritising infusions, and spacing out doses

• This study has used the Functional Resonance Analysis

Method (FRAM) to visualise the process of co-

administration which can be adapted to develop a user

friendly decision-making pathway for co-administration

to minimise variability in practice

• This study shows that resources available have limited

compatibility data on commonly used medicines. Future

compatibility studies should focus on providing data

based on current clinical practice.

ODUYALE ET AL. 157

14785153, 2020, 3, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/nicc.12497, W

iley O nline L

ibrary on [17/11/2022]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

3 | DESIGN AND METHODS

This study used a qualitative research design through the use of focus

groups to explore how ICU nurses simultaneously co-administer medi-

cines down the same lumen and the means by which compatibility is

determined in practice. Focus groups were undertaken to allow peo-

ple with similar experiences (ie, nurses) and to identify shared and

common knowledge. Encouraging comments and sharing of views

with each other can provide more in-depth responses and also enable

participants to reflect on their practice.23,24

3.1 | Setting and sample

Three focus groups were conducted with ICU nurses across two hos-

pitals with adult ICUs in the Thames Valley Critical Care Network. An

estimate of 65 ICU nurses were invited to participate in the study.

Within the nursing group, purposeful sampling was employed to

ensure that only qualified ICU nurses with work experience in an ICU

setting were invited because of their experience and knowledge in co-

administration of IV medicines (Table 1). We aimed for four to eight

ICU nurses for each focus group because this is shown to be the most

appropriate size.23 All ICU nurses at each hospital were invited to take

part in the study via email using ICU pharmacists and matrons as con-

tacts at both hospitals. The ICU nurses that indicated interest in par-

ticipating were contacted by the first author—(M.S.O.) directly and

convenient times were arranged for the focus groups.

3.2 | Data collection tools

A focus group schedule consisting of semi-structured questions was

used to guide the discussion, allowing for probing questions and clari-

fication where appropriate.23,25 Focus groups were conducted

between October 2017 and July 2018. Each focus group discussion

took place in a meeting room at the hospital away from the ICU wards

and lasted between 40 and 60 minutes. Each focus group was facili-

tated by M.S.O. The main questions asked were (a) “Can you tell me

about a time where you have had to combine multiple IV drugs down

the same lumen?” and (b) “How do you check for IV compatibility?”

Each focus group was audio recorded with consent from participants,

anonymised, and transcribed verbatim by M.S.O. Field notes were

made after each focus group by M.S.O.

3.3 | Data analysis

3.3.1 | Thematic analysis

The transcribed data were entered into the qualitative data analysis

software NVivo 12 (NVivo qualitative data analysis software; QSR

International Pty Ltd. Version 12, 2018) for data management, and

analysed thematically for codes and themes. Thematic analysis of data

followed six steps as described by Braun and Clarke; familiarizing one-

self with the data, generating initial codes, searching for themes,

reviewing themes, naming, and defining themes.26 Two researchers

(M.S.O. and N.P.) were involved in the thematic analysis of the data.

The initial codes were developed inductively, in that they were driven

from the data and not by any pre-existing theory or coding frame-

work. The initial codes were identified by M.S.O., iteratively refined

within the research team, and collated into potential, and final themes

by both M.S.O. and N.P. Codes were not returned to nurses for

validation.

3.3.2 | FRAM: Building the FRAM model

The FRAM model was built using the FRAM model Visualiser tool.

There are five steps involved in developing a FRAM model. The first

step is to identify the primary purpose of the FRAM analysis and iden-

tify functions that are essential for work to be carried out. In this case,

FRAM was used to demonstrate co-administration practice. The sec-

ond step is to identify the functions that are required for everyday

activities and how each function relates to another. Functions in this

context refer to people's actions to achieve or perform a specific task

either individually or collectively. The functions were identified by

TABLE 1 Participants' demographics

Job role

Years of work experience in ICUs (year) Department of ICU

Staff nurse 3 years Adult and Cardiothoracic

Staff nurse 2 years Adult (general)

Staff nurse 6 years Adult and Cardiothoracic

Staff nurse 2 years Adult

Senior sister 17 years Adult

Staff nurse 1 year Adult and Cardiothoracic

Registered

nurse

4 years Adult

Staff nurse 1 year Adult

Staff nurse 2 years Adult

Staff nurse 1 year Adult and Cardiothoracic

Deputy

sister

18 years Adult

RAF nurse 2 years Adult

Staff nurse 1 week Adult

Staff nurse 8 months Adult

Staff nurse 8 years Neuro, Trauma, Cardio and

General

Deputy

sister

13 years General

Staff nurse 8 months Adult

Staff nurse 2 years and

8 months

Adult

Abbreviations: ICU, intensive care unit; RAF, royal air force.

158 ODUYALE ET AL.

14785153, 2020, 3, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/nicc.12497, W

iley O nline L

ibrary on [17/11/2022]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

M.S.O., by thematically analysing the data and identifying codes that

were integral to the process of co-administration. The codes gener-

ated are represented as functions in the FRAM model. The third step

involves identification of performance variability, the reason for vari-

ability, and potential impact on a work system. The fourth step

involves determining how variability can spread throughout the sys-

tem leading to either an unexpected or expected outcome known as

functional resonance. The final step is to develop recommendations

for monitoring and managing performance variability to diminish the

possible occurrence of unwanted outcomes.

3.3.3 | Respondent validation

Nurses who participated in the focus groups were invited to assess

the accuracy and reliability of the resulting FRAM model (respondent

validation). Participants were requested to review the model, and a

meeting time was arranged. Participants were asked to verify the

model's accuracy and to indicate whether important elements were

missing or insignificant elements had been included.

4 | ETHICAL AND RESEARCH APPROVALS

Ethical approval from University of Reading Ethical Committee was

received on 04/08/2017 (Ref number 17/37). Study participation was

voluntary, no financial incentives were given. Written consent

was obtained from all participants before taking part. Each participant

was allocated a number to ensure anonymity during coding processes,

and all data kept confidential.

5 | RESULTS

A total of 20 ICU nurses participated in the study, 18 of which pro-

vided demographic data. Focus groups consisted of two to eight ICU

nurses. The years of ICU experience ranged from 1 week to 13 years.

Adult ICUs were the most common wards that nurses worked in

(Table 1).

Thematic analysis highlighted two major themes, namely, venous

access and resources.

The FRAM model represents the activities carried out by ICU

nurses from the moment a patient is admitted into the ICU to the

point of IV administration. The model ends when IV administration

has occurred and shows that co-administration is a complex process

with several interdependencies.

A total of 21 functions were identified as important for co-

administration in the FRAM model. A visual representation of the

model can be found in Figure S1, and shows many interrelationships

between several functions.

6 | VENOUS ACCESS

6.1 | Creating venous access

Participants reported that the type of catheter inserted for continuous

IV delivery was dependent on the number of medicines prescribed

and their strength. The use of multi-lumen central venous catheters

was found to be the most advantageous as they consolidate infusions

of more than one medicine independently while limiting the number

of invasive devices on the patient, in turn minimising the risk of

infection.

You want to restrict the amount of invasive devices

you have on the patient - so you don't want to have

4 cannulas in the patient plus a central lumen unless

you have a really good reason - because the more inva-

sive devices, the more risk of infection… (Partici-

pant 9)

6.2 | Availability of venous access

A major concern was the availability of sufficient venous access, espe-

cially in patients who have been prescribed a multitude of medicines

requiring continuous infusions. Participants stated a preference for

the administration of one medicine per lumen. This was not always

possible as the number of prescribed medicines for continuous infu-

sions sometimes exceeded the available lumens.

I would rather have just the one on one lumen and… so

yeah if I have enough lumen… I'll just split everything

up… (Participant 19)

Participants explained that there were certain medicines prescribed

for continuous infusions that can neither be disrupted (eg, vasopres-

sors) nor combined with other medicines (eg, blood products, total

parenteral nutrition). These medicines must be allocated to a desig-

nated lumen in order to prevent accidental bolusing or withdrawal of

the infusion, limiting the number of lumens available for continuous

infusion.

You have your inotropes and vasopressors you have

them specifically on one port….to avoid any accidental

blousing…. So it's kinda like one dedicated lumen…this

is for ionotropes or vasopressants only (Participant 2)

6.3 | Additional venous access

Requesting the insertion of an additional cannula was described by

participants as the easiest and quickest option for administration

when venous access was limited.

ODUYALE ET AL. 159

14785153, 2020, 3, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/nicc.12497, W

iley O nline L

ibrary on [17/11/2022]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

But most of the time when we have that many medi-

cines that you have no entry point on the patient then

it's normally quicker to ask the doctor if they can just

put another cannula for you… (Participant 18)

However, they described that this could become a difficult solution,

especially when doctors were not readily available. One participant

mentioned that sometimes doctors had to be approached multiple

times before the request could be granted. In desperate circum-

stances, some participants mentioned that they had to go higher up

and ask a consultant for assistance, which could take up to a couple of

hours.

Just being persistent with the doctors that I need a

venflon, I haven't given the antibiotics– it was due like

half an hour ago and… I don't want to delay it… or if

that person is not going to do it, you just have to go to

higher up (Participant 20)

Despite strategies to maximise venous access, participants sometimes

ran out of sufficient venous access. They reported that when venous

access was limited or compatibility information was unavailable, some

continuous infusions (insulin, electrolyte fluids, or vitamins) were

stopped to allow for the administration of intermittent medicines per-

ceived to be of higher priority, such as antibiotics and analgesics. Partici-

pants expressed that this can be frustrating and results in disruption in

prescribed administration times, as each medicine had to be adminis-

tered one at a time through a designated lumen after flushing with

saline at every interval because of the uncertainty of compatibility.

If you have medicines which are urgent, say… antibi-

otics. You'd end up having to stop other infusions and

prioritising which ones more important (Partici-

pant 15)

Administering one medicine after the other meant that the partici-

pants had to space out doses, sometimes causing a delay in adminis-

tration of other medicines. One participant reported that making

changes to administration times is one of the reasons administration

errors are made.

Infusions take a long time and we are constantly

supplementing these things…” (Participant 11)… “and

we are delaying medicines as a result, and it ruins it for

the rest of the medicine charts and then errors are

made (Participant 7)

However, the majority of participants were not overly concerned

about delays in administration, and did not think that this would affect

patient care or recovery. This was because of their perception that

delayed administration can be compensated for by adjusting adminis-

tration times to ensure the correct dose is given within the minimum

time frame. Additionally, there was the view that because patients are

constantly monitored, and with their knowledge about medicines,

adverse effects can be identified early and reversed quite quickly.

Well maybe if afternoon dose is like delayed for 2 hours

then we'll delay the evening one with an hour… but we

sort of do makeup in the 24hrs that they do get the

exact same amount (Participant 19)

The majority of participants reported that some medicines can be

administered peripherally instead of centrally. If these medicines were

being administered centrally, they could be swapped to a peripheral

catheter to create space for medicines that can only be administered

centrally.

7 | RESOURCES

Participants highlighted the importance of checking compatibility prior

to co-administering multiple medicines through Y-site connectors. For

familiar medicine combinations, compatibility was largely confirmed

from nurse experience rather than using a compatibility resource. For

example, propofol and fentanyl were described as routine combina-

tions known to be compatible; therefore, participants felt it unneces-

sary to check compatibility using a resource.

I don't use it (compatibility chart) that often if it is a

fairly standard set of drugs that I normally know,

because you get into the experience of which things

go in which things (Participant 9)

However, for unfamiliar medicines, compatibility was checked for

potential medicine combinations using a reference source. Partici-

pants reported a variety of resources for checking compatibility such

as a locally produced compatibility chart, drug monographs, the phar-

macy team, a more experienced nurse, or an in-house medicines man-

agement policy guide as can be seen in the extracted FRAM model in

Figure 1.

The compatibility chart was the preferred reference source

because of availability, and was described as easy to use with the abil-

ity to check compatibility multiple times for a variety of medicine

combinations.

The chart is quicker because you look at it straight

away… (Participant 20)

Participants identified a limitation of the chart being a restricted num-

ber of medicines, with little to no information available for some regu-

larly used medicines. They also mentioned that the resources available

report two medicine combinations but on some occasions may want

to combine three medicines down the same lumen for which they

confirm compatibility by cross-referencing medicine pairs on the com-

patibility chart. However, participants stated that they would not

160 ODUYALE ET AL.

14785153, 2020, 3, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/nicc.12497, W

iley O nline L

ibrary on [17/11/2022]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

combine medicines that resources reported to be incompatible,

unknown, or variable as per advice from the pharmacy team.

I find smaller medicines like the paracetamol, metroni-

dazole and things like that, they are not on our com-

patibility chart (Participant 2)

…Say you have Hartmann's, propofol and fentanyl….

you would have to do Hartmann's against propofol,

Hartmann's against fentanyl and propofol against fen-

tanyl (Participant 8)

The way in which participants made their decisions sometimes varied

and this can be seen in Figure 1. For example, should a participant not

find information on the chart, they might next check the drug mono-

graph followed by a request for additional venous access before

administration and vice versa.

8 | RESPONDENT VALIDATION

Responses were received from six ICU nurses, five of which were

involved in the original focus groups. Respondents thought that

the FRAM model was comprehensive and an accurate representa-

tion of work as performed in everyday practice. However, two

new functions were added to the FRAM model as advised by the

nurses; <to assess number of infusions> and <drug monograph> as

some participants mentioned using the drug monograph to check

compatibility.

9 | DISCUSSION

Our findings suggest that the absence of compatibility data and insuf-

ficient venous access appear to be the main challenges associated

with IV medicine co-administration. Participants managed these

through workarounds such as requesting additional venous access,

prioritising infusions, swapping line of infusion, and changing the form

of medicine. These have also been identified in other studies.14,27

F IGURE 1 Extract from the Functional Resonance Analysis Method model showing the various ways compatibility can be assessed

ODUYALE ET AL. 161

14785153, 2020, 3, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/nicc.12497, W

iley O nline L

ibrary on [17/11/2022]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

Workarounds are alternative work procedures devised to circumvent

a perceived workflow block, which may become necessary for tasks

to be accomplished safely in variable environments such as health

care.28,29 However, there are concerns that workarounds may create

new pathways to error and decrease patient safety by increasing the

likelihood of administration errors.30-33 Koppel et al31 examined medi-

cines administration by nurses using a Barcode Medication Adminis-

tration system, identifying 15 types of workarounds with potential for

administering the wrong medications and at wrong times. A possible

consequence of workarounds in our study is medicine administration

delays, which the National Patient Safety Agency considers to be a

significant patient safety issue.34 Administration delay can have a det-

rimental impact on patient recovery, especially with medicines such as

antibiotics.34 Future work could use the FRAM model to identify areas

of potential safety risks associated with workarounds.35,36

Each workaround involved a clinical decision-making process which

was variable and depended on nurses' experience and organisational

factors. The vast majority of participants used experience to confirm

compatibility, only using other resources with medicines unfamiliar to

them. Pattern recognition could be a possible explanation for this, where

nurses were able to make a clinical decision based on previous knowl-

edge of using similar medicine combinations in patients they had cared

for.37 However, a drawback is that participants may be relying on mem-

ory cues associated with inaccurate information, thereby risking combin-

ing incompatible medicines. Organisational factors such as

institutionalised routines, resource and staff availability can influence

the development of workaround behaviours.38,39 In this study,

workarounds appear to have become embedded into everyday nursing

practice. While it is unclear if these workarounds are without risks, their

constant use can be used to highlight areas within organisations that

require practical interventions to improve work efficiency. For example,

we found that obtaining additional venous access was heavily depen-

dent on doctor availability, which sometimes delayed medicine adminis-

tration. This could be resolved by promoting peripheral cannulation by

senior nurses within organisations.

Given the complexity of co-administration of medicines in the

ICU setting, a clinical decision-making pathway or tool for assessing

compatibility prior to co-administration that includes steps to follow

when compatibility is unknown, variable or incompatible should be

made available. This could be especially useful for new members of

staff unfamiliar with different co-administration practices, and to stan-

dardise the workarounds utilised to reduce the chances of creating

new, more harmful workarounds. The FRAM model can be used to

inform a simplified user-friendly decision-making pathway as it

reflects everyday work as performed in practice. Clay-Williams et al40

used FRAM to develop guidelines compatible with how staff work,

and through this found that the need to create workarounds that

compromised safety and quality of care could be reduced.

Although the compatibility chart was described as useful, there

was a need for more comprehensive compatibility data to be included

in the chart.41 This is supported by findings from a systematic review

investigating the availability of physical and chemical compatibility

data for commonly used medicines in ICU.42 Virtually no data exists

for three medicine combinations, and participants reported reluctantly

co-administering three medicines if they had been previously adminis-

tered without reports of clinical complications. This approach is largely

based on physical compatibility, but there are concerns that not all

incompatibility is physical. It would be worthwhile exploring and con-

firming the chemical compatibility of IV medicines alongside physical

compatibility. Additionally, future compatibility studies should explore

providing compatibility data for potential three medicine combina-

tions to minimise the risk of combining incompatible medicines and

help to improve work efficiency.

Our findings suggest that the compatibility chart in use requires

an update. Because of the possibility of numerous medicine combina-

tions, compiling and producing an updated chart can be arduous.

Nurses’ input in updating the chart would likely be beneficial to

develop a resource that is relevant to current practice. Strategies such

as including physicochemical properties (eg, pH) within the chart with

additional training on the significance of the values included may help

bedside care givers with predicting incompatibilities. However, pH

reactions are not always definitive in measuring compatibility and so

visual monitoring of lines for precipitates is still likely to be required.

A strength of this study is that it directly takes into consideration

the experiences and perspectives of ICU nurses in understanding the

practice surrounding co-administration of multiple medicines down

the same lumen, alongside identifying key challenges associated with

co-administration. The use of FRAM highlights the interrelations

within the process and how variability occurs within the system.

Limitations of the study include being conducted within two hospi-

tals in the same critical care region, and therefore, perspectives and

experiences of the ICU nurses may not reflect practice across all

hospitals. More research to obtain an overall understanding of

co-administration practice across a wider range of hospitals is required.

The presence of senior staff members in the focus groups could have

prevented some junior nurses from expressing their opinions and co-

administration practice freely. A regional compatibility chart was the

main resource used by participants in this study. However, the chart may

not be a standard resource in all hospitals. Further research to investi-

gate resources used in other hospitals, their effectiveness, and potential

limitations, in comparison with the compatibility chart is warranted.

10 | IMPLICATIONS AND RECOMMENDATIONS FOR PRACTICE

The FRAM can be used to inform a user friendly decision-making

pathway to potentially standardise workarounds in practice, promot-

ing safer patient care.

Organisations should consider reviewing and designing compati-

bility charts of commonly used medicines using an interdisciplinary

approach to create a comprehensive tool that is relevant to everyday

practice.

Future compatibility studies should consider compatibility assess-

ment of three medicine combinations.

162 ODUYALE ET AL.

14785153, 2020, 3, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/nicc.12497, W

iley O nline L

ibrary on [17/11/2022]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

ACKNOWLEDGEMENTS

The authors would like to thank all the ICU nursing staff who partici-

pated in the focus groups for sharing their views and experiences.

Funding was received from the University of Reading PhD

studentship.

AUTHOR CONTRIBUTIONS

M.S.O. designed the focus group questions, arranged and conducted

the focus groups, and analysed and interpreted the study data. The

data analysis and interpretation was reviewed by N.P. M.S.O. drafted

the paper and all authors contributed to the subsequent drafts and

final version of the manuscript.

11 | CONCLUSION

The majority of nurses described lack of sufficient venous access and

compatibility data for commonly used medicines as challenges associ-

ated with co-administration of multiple medicines down the same

lumen. The use of FRAM highlighted workarounds used to facilitate

administration of IV medicines that may sometimes lead to delays in

therapy. The FRAM model can be used to develop a user friendly clini-

cal decision-making pathway for co-administration of multiple medi-

cines for use in organisations, which could standardise workaround

behaviours while improving efficiency and safety of patient care.

Future work should consider reviewing and designing compatibility

resources with input from ICU nurses to create robust and compre-

hensive compatibility resources that are relevant to everyday practice.

ORCID

Mosopefoluwa S. Oduyale https://orcid.org/0000-0003-1482-7239

REFERENCES

1. Trissel L. Hanbook of Injectable Drugs. 20th ed. Bethseda, MD: Ameri-

can Society of Health-Systems Pharmacists; 2018.

2. Newton DW. Drug incompatibility chemistry. Am J Health Syst Pharm.

2009;66:348-357. https://doi.org/10.2146/ajhp080059.

3. Collins JL, Lutz RJ. In vitro study of simultaneous infusion of incom-

patible drugs in multilumen catheters. Heart Lung. 1991;20:271-277.

4. Robinson RG, Fawcett CA, van Rij AM. Multiple central venous line

occlusions following an error in parenteral nutrition formulation. Aust

N Z J Surg. 1986;56:347-349.

5. Steadman E, Raisch DW, Bennett CL, et al. Evaluation of a potential

clinical interaction between ceftriaxone and calcium. Antimicrob

Agents Chemother. 2010;54:1534-1540. https://doi.org/10.1128/

AAC.01111-09.

6. Tissot E, Cornette C, Limat S, et al. Observational study of potential

risk factors of medication administration errors. Pharm World Sci.

2003;25:264-268. https://doi.org/10.1023/B:PHAR.0000006519.

44483.a0.

7. Bradley JS, Wassel RT, Lee L, Nambiar S. Intravenous ceftriaxone and

calcium in the neonate: assessing the risk for cardiopulmonary

adverse events. Pediatrics. 2009;123(4):609-613. https://doi.org/10.

1542/peds.2008-3080.

8. Dalton BR, Zuege DJ, Shahpori R, Laupland KB. Concomitant ceftriax-

one and high-concentration intravenous calcium therapy in adult criti-

cal care patients: a matched cohort study. Ann Pharmacother. 2010;

44:1158-1163. https://doi.org/10.1345/aph.1M745.

9. Felton TW, McCormick BA, Finfer SR, Fisher MM. Life-threatening

pulmonary hypertension and right ventricular failure complicating cal-

cium and phosphate replacement in the intensive care unit. Anaesthe-

sia. 2006;61(1):49-53. https://doi.org/10.1111/j.1365-2044.2005.

04381.x.

10. Benlabed M, Perez M, Gaudy R, Genay S, et al. Clinical implications of

intravenous drug incompatibilities in critically ill patients. Anaesth Crit

Care Pain Med. 2018;38:173-180. https://doi.org/10.1016/J.ACCPM.

2018.04.003.

11. Reedy JS, Kuhlman JE, Voytovich M. Microvascular pulmonary emboli

secondary to precipitated crystals in a patient receiving total paren-

teral nutrition: a case report and description of the high-resolution CT

findings. Chest. 1999;115:892-895.

12. Braun Hospital Guidlines (2015) Drug Incompatibility: Prevention of

Risk in Infusion Therapy. Available at: www.safeinfusiontherapy.com.

13. Kupiec TC, Ben M, Trusley C, Trissel LA. Compatibility and stability of

palonosetron hydrochloride with gentamicin, metronidazole, or van-

comycin during simulated y-site administration. Int J Pharm Compd.

2008;12:170-173.

14. Machotka O, Manak J, Kubena A, Vlcek J. Incidence of intravenous

drug incompatibilities in intensive care units. Biomed Pap Med Fac

Univ Palacky Olomouc Czech Republic. 2015;159:652-656. https://doi.

org/10.5507/bp.2014.057.

15. Rothschild JM, Landrigan CP, Cronin JW, et al. The critical care safety

study: the incidence and nature of adverse events and serious medi-

cal errors in intensive care. Crit Care Med. 2005;33:1694-1700.

16. So W, Kim L, Thabit AK, Nicolau DP, Kuti JL. Physical compatibility of

isavuconazonium sulfate with select i.v. drugs during simulated Y-site

administration. Am J Health Syst Pharm. 2017;74:55-63. https://doi.

org/10.2146/ajhp150733.

17. Kanji S, Lam J, Goddard RD, et al. Inappropriate medication adminis-

tration practices in Canadian adult ICUs: a multicenter, cross-

sectional observational study. Ann Pharmacother. 2013;47:637-643.

https://doi.org/10.1345/aph.1R414.

18. Righi AW, Saurin TA. Complex socio-technical systems: characteriza-

tion and management guidelines. Appl Ergon. 2015;50:19-30. https://

doi.org/10.1016/j.apergo.2015.02.003.

19. Hollnagel E, Slater D. (2018). The Functional Resonance Analysis

Method and Manual (Version 2). Available at: http://

functionalresonance.com/onewebmedia/Manual%20ds%201.docx.pdf

20. Raben DC, Viskum B, Mikkelsen KL, Hounsgaard J, Bogh SB,

Hollnagel E. Application of a non-linear model to understand

healthcare processes: using the functional resonance analysis method

on a case study of the early detection of sepsis. Reliab Eng Syst Safe.

2018;177:1-11. https://doi.org/10.1016/J.RESS.2018.04.023.

21. Furniss D, Curzon P, Blandford A. Using FRAM beyond safety: a case

study to explore how sociotechnical systems can flourish or stall.

Theor Issues Ergon Sci. 2016;17:507-532. https://doi.org/10.1080/

1463922X.2016.1155238.

22. Ross A, Sherriff A, Kidd J, et al. A systems approach using the func-

tional resonance analysis method to support fluoride varnish applica-

tion for children attending general dental practice. Appl Ergon. 2018;

68:294-303. https://doi.org/10.1016/j.apergo.2017.12.005.

23. Kitzinger J. Qualitative research. Introducing focus groups. BMJ.

1995;311:299-302. https://doi.org/10.1136/BMJ.311.7000.299.

24. Tausch AP, Menold N. Methodological aspects of focus groups in

health research: results of qualitative interviews with focus group

moderators. Glob Qual Nurs Res. 2016;14:3. https://doi.org/10.1177/

2333393616630466.

25. Breen RL. A practical guide to focus-group research. J Geogr High

Educ. 2006;30(3):463-475. https://doi.org/10.1080/03098260600

927575.

26. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res

Psychol. 2006;3:77-101.

ODUYALE ET AL. 163

14785153, 2020, 3, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/nicc.12497, W

iley O nline L

ibrary on [17/11/2022]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense

27. Maison O, Tardy C, Cabelguenne D, et al. Drug incompatibilities in

intravenous therapy: evaluation and proposition of preventive tools

in intensive care and hematology units. Eur J Clin Pharmacol. 2019;75:

179-187. https://doi.org/10.1007/s00228-018-2602-6.

28. Lalley C, Malloch K. Workarounds: the hidden pathway to excellence.

Nurse Lead. 2010;8:29-32. https://doi.org/10.1016/j.mnl.2010.

05.009.

29. Niazkhani Z, Pirnejad H, van der Sijs H, Aarts J. Evaluating the medi-

cation process in the context of CPOE use: the significance of work-

ing around the system. Int J Med Inform. 2011;80:490-506. https://

doi.org/10.1016/J.IJMEDINF.2011.03.009.

30. Halbesleben JRB, Savage GT, Wakefield DS, Wakefield BJ. Rework

and workarounds in nurse medication administration process. Health

Care Manage Rev. 2010;35:124-133. https://doi.org/10.1097/HMR.

0b013e3181d116c2.

31. Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to

barcode medication administration systems: their occurrences, cau-

ses, and threats to patient safety. J Am Med Inform Assoc. 2008;15:

408-423. https://doi.org/10.1197/jamia.M2616.

32. Tucker AL, Edmondson AC, Spear S. When problem solving prevents

organizational learning. J Organ Change Manage. 2002;15:122-137.

https://doi.org/10.1108/09534810210423008.

33. Westbrook JI, Rob MI, Woods A, Parry D. Errors in the administration

of intravenous medications in hospital and the role of correct proce-

dures and nurse experience. BMJ Qual Saf. 2011;20:1027-1034.

https://doi.org/10.1136/bmjqs-2011-000089.

34. Rapid Response Report NPSA/2010/RRR009: reducing harm from

omitted and delayed medicines in hospital Supporting Information,

2010. Available at: https://www.sps.nhs.uk/wp-content/uploads/

2018/02/NRLS-1183-Omitted-and-del-SI-2010.02.23-FINAL.pdf.

Accessed December 18, 2018.

35. Amorim AG, Pereira CM. Improvisation at workplace and accident

causation – an exploratory study. Procedia Manuf. 2015;3:1804-

1811. https://doi.org/10.1016/J.PROMFG.2015.07.219.

36. Hollnagel E, Wears RL, Braithwaite J. From Safety-I to Safety-II: A

White Paper. The Resilient Health Care Net: Published simultaneously by

the University of Southern Denmark, University of Florida, USA, and

Macquarie University, Australia, 2015. https://www.england.nhs.uk/

signuptosafety/wp-content/uploads/sites/16/2015/10/safety-1-

safety-2-whte-papr.pdf. Accessed December 19, 2018.

37. Banning M. A review of clinical decision making: models and current

research. J Clin Nurs. 2008;2:187-195. https://doi.org/10.1111/j.

1365-2702.2006.01791.x.

38. Fogarty GJ, Mckeon CM. Patient safety during medication adminis-

tration: the influence of organizational and individual variables on

unsafe work practices and medication errors. Ergonomics. 2006;49:

444-456. https://doi.org/10.1080/00140130600568410.

39. Ser G, Robertson A, Sheikh A. A qualitative exploration of

workarounds related to the implementation of national elec-

tronic health records in early adopter mental health hospitals.

PLoS One. 2014;9:e77669. https://doi.org/10.1371/journal.pone.

0077669.

40. Clay-Williams R, Hounsgaard J, Hollnagel E. Where the rubber meets

the road: using FRAM to align work-as-imagined with work-as-done

when implementing clinical guidelines. Implement Sci. 2015;10:1-8.

https://doi.org/10.1186/s13012-015-0317-y.

41. Shakila B, Borthwick M, Cronnolly B, et al. Thames Valley Y-site Intra-

venous Drugs Compatibility Chart, 2011. http://medusa.wales.nhs.uk/

Docs/TVCCNIVCompatibilityChartv2.1.pdf. Accessed May 2, 2017.

42. Kanji S, Lam J, Johanson C, et al. Systematic review of physical and

chemical compatibility of commonly used medications administered

by continuous infusion in intensive care units. Crit Care Med. 2010;

38:1890-1898. https://doi.org/10.1097/CCM.0b013e3181e8adcc.

SUPPORTING INFORMATION

Additional supporting information may be found online in the

Supporting Information section at the end of this article.

How to cite this article: Oduyale MS, Patel N, Borthwick M,

Claus S. Co-administration of multiple intravenous medicines:

Intensive care nurses' views and perspectives. Nurs Crit Care.

2020;25:156–164. https://doi.org/10.1111/nicc.12497

164 ODUYALE ET AL.

14785153, 2020, 3, D ow

nloaded from https://onlinelibrary.w

iley.com /doi/10.1111/nicc.12497, W

iley O nline L

ibrary on [17/11/2022]. See the T erm

s and C onditions (https://onlinelibrary.w

iley.com /term

s-and-conditions) on W iley O

nline L ibrary for rules of use; O

A articles are governed by the applicable C

reative C om

m ons L

icense