Written by foamed

Practical Safety Measures in Medication Administration

On a recent flight my mind had started to wander…..how well are we protecting our patients in the prehospital and transport environment when administering medications?

For my first real blog thought I’d explore basic principles, how they fit into our environment, and finally a few tips and tricks I’ve learned.

Medication Administration Rights

Depending where and when you went to Paramedic or Nursing school, there’s a variety of the rights of medication administration. A cursory goole search reveals the following results:

  1. “The Five Rights of Medication Administration – Institute for Healthcare”
  2. “8 rights of medication administration | NursingCenter”
  3. “Practice the six rights of medication administration – www.hcpro.com”
  4. “10 Rights of Medication Administration”

So how many rights are there, and how do we protect our patients?

Personally, I stick with the 5 fundamental rights of administration. Most, if not all, additional rights of administration are built on these 5 foundational principles.

  1. Right Patient – Lippincott suggests checking the name of the patient against the order, using a special identifier, asking them to confirm their name, and using an electronic system. Personally, this may work well in hospital, especially when the provider ordering the medication is not at the bedside or giving the medication, however in our setting we are often using our clinical gestalt to administer medications.
  2. Right Medication – In the wake of a Vanderbilt nurse mistakenly giving Vecuronium instead of Midazolam (https://www.newschannel5.com/news/vandy-patient-dies-after-nurse-gives-lethal-dose-of-wrong-drug-puts-medicare-at-risk), we need to ensure we’re giving the right medication. In our environment, I use two methods: If able, I’ll hand the medication to my partner and have them confirm the medication and concentration, or we’ll make eye contact, I hold up the vial, and read the name and concentration, then get a verbal confirmation from my partner.
  3. Right Dose – In our practice, we never give a medication without both providers being aware. We utilize a check method: I verbalize the dose and concentration and get agreement with my partner prior to administering anything.
  4. Right Route – We almost always utilize intravenous and intraossous administration routes. In our practice we don’t specifically verbalize this.
  5. Right Time – Like #1, our providers independently give medications and don’t utilize written time specific medications.

Use Syringes, Not Flushes

Recently this question was posed to me: what are my thoughts on using a “saline flush” to dilute and draw up medications. This is a common practice, but is it really safe?

Depends who you ask. The FDA considers a saline flush a medical device – not a drug. The syringes themselves are not designed to measure medication and as such, is not accurate for medication measurement and dilution.

What this really means – use a syringe, not a saline flush. ISMP Canada concludes the issue by saying:

Prefilled saline syringes are indicated for flushing lines and should NOT be used for reconstitution or dilution of medications, for the following 2 reasons: (i) such use may lead the practitioner to withdraw the medication into a syringe that is labelled sodium chloride 0.9%, resulting in an incorrectly labelled container once the medication has been added; and (ii) the volume may not be precise.

Label Your Syringes

I suggest labeling all syringes you draw a medication into. The only time I would say it isn’t necessary when you draw up the medication and immediately administer it with no residual volume.

Labeling syringes is common practice in hospital systems, especially in anesthesia. I keep rolls of labels at base, and keep a few of each label in my reference book for when it’s needed.

If you don’t have labels, don’t sweat it. Use a piece of tape with the generic drug name AND the concentration.

Labels kept in my reference book – long white labels are for infusion lines

Putting It All Together

Recently we flew a 1 year old with new onset seizures to a children’s hospital. We utilize Pedi-Stat for medication dosing, and the dosage for midazolam in seizures is 2.5mg (weight based dosing). However, our rotor crew had been caring for the patient and had been using 0.25mg of midazolam with success, so that is what we were going to use.

Using a 3 way stopcock, I connected a 10mL syringe and a saline flush. Drawing up 8ml of saline into the syringe, I discarded the flush and drew up 2mL (or 10mg) of midazolam from the vial (and discarded the vial). This yielded me 10mg of midazolam in 10mL. Prior to administration, I used a 1mL syringe connected by three way stop-cock to draw up 0.25mL – or 0.25mg.

Both syringes were then labeled and capped. This took less than one extra minute and prevented several potential medication errors, plus any potential infection.

Midazolam drawn up, labeled, and capped until administration

This is my first blog post, so please give me feedback! Comment here or find me on twitter at @_timothy_drake


  • https://www.ismp-canada.org/download/safetyBulletins/2012/ISMPCSB2012-10_ALERT_Errors_with_Prefilled_Saline_Syringes.pd
  • https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/510kClearances/
  • https://www.pharmacypracticenews.com/Clinical/Article/02-18/A-Closer-Look-at-Prefilled-Flush-Syringe-Safety/46801?sub=C63733F385E1FD4090EBC251E2F1174E9B162D4541C3E518622EA66D7AFC67F&enl=true%3Fses%3Dogst
  • https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/detail.cfm?mdrfoi__id=2501052
  • Last modified: January 28, 2019