Effects of unsafe IM injection administration
Problem: Risk for patient injury related to unsafe IM injection practices
Study question: What is reported as best practice for administering IM medications?
Intramuscular injections – What’s best practice?
Floyd, S., & Meyer, A. (2007). Kai Tiaki Nursing New Zealand, 13(6), 20-22.
The researchers were interested in determining research-based best practices for IM injection and the use of Z-tracking by RNs. Specifically, the study addressed best practices for IM site selection, administration techniques, the use of gloves, and the knowledge gap between what is seen in practice and taught in nursing education. The researchers first conducted a review of the literature and reported that the ventrogluteal site is accepted as the safest IM injection site, although it is not always used in practice. Best-practice guidelines support wearing gloves prior to administering injections. In a survey of 73 RNs from outpatient settings where IM injections are administered, 99% reported using the dorsogluteal site, 97% use the deltoid site; 87% use the vastus lateralis, and 9% use the ventrogluteal site. A total of 885 reported that it was the medication that dictated the IM injection site. Reports of the use of Z-tracking as an injection technique are scarce. Only 14% of nurses in this study reported using this technique consistently. Very few RNs reported wearing gloves consistently when giving IM injections.
Although some complications of IM injections are preventable, RNs do not always follow best practices. The majority neither used gloves nor Z-tracking. Nurses need ongoing education about best practices to ensure safe IM injections and confidence in using the ventrogluteal site. Nurses must wear gloves for IM medication administration. Although there is limited research to support best practice, nurses can maintain competency in performing IM injections through education and support for best practices.
Study question: What factors contribute to unsafe practices during IM administration of medications?
Glass contamination in parenterally administered medication
Preston, S. T., & Hegadoren, K. (2004). Journal of Advanced Nursing, 48(3), 266-270.
The objective of this study was to compare the presence of glass particles in ampules aspirated with syringes with unfiltered needles (18-gauge and 21-gauge) and with a filtered needle (19-gauge). Use of the 19-gauge filtered needle resulted in no glass particles.
Using larger-bore unfiltered needles increased the risk of aspirating more glass and other particles than using smaller-bore or filtered needles did. The findings support using filtered needles to administer IM medications to patients who receive IM injections frequently.
Best practice guidelines for the administration of intramuscular injections in the mental health setting
Wynaden, D., Landsborough, I., McGowan, S., Baigmohamad, Z., Finn, M., & Pennebaker, D. (2006). International Journal of Mental Health Nursing, 15(3), 195-200.
The purpose of this study was to identify best practices for IM injections in the mental-health setting. The researchers conducted a systematic review of the literature, surveyed nurses in current practice, and evaluated nurses who were employing best practices. Best practices for preparing and administering IM medications were synthesized and administration guidelines developed. Of 224 nurses, 93 completed a survey on current practice based on the best-practice guidelines. Nurses reported not using the ventrogluteal site for IM injections and were reluctant to change their practice. In this setting, use of the dorsogluteal site was identified as best practice despite lack of support for this site in the literature. Researchers taught the best-practice technique to nurses and observed how nurses used this technique with 96 consumers. They rated nurse performance and assessed consumers’ perception of pain. Almost 72% of the consumers received injections via the dorsogluteal site. Alternative sites were used for 28% of the consumers based on consumer request. Further education about the long-term effects of injecting large amounts of fluid into the deltoid muscle may be necessary.
A systematic review of the literature and an evaluation of current practice are both important when creating a best-practice technique. Ongoing staff monitoring and staff training in the best-practice techniques are necessary to ensure the long-term success of a change in practice.
Nerve injuries following intramuscular injections: A clinical and neurophysiological study from Northwest India
Pandian, J. D., Bose, S., Daniel, V., Singh, Y., & Abraham, A. P. (2006). Journal of the Peripheral Nervous System, 11(2), 165-171.
This is reportedly the largest single study of nerve injuries following intramuscular injection from a developing country. The researchers investigated clinical features, neurophysiological effects, and outcomes for patients with nerve injuries following IM injections. A second purpose of the study was to identify the factors that affected the prognosis of these patients. Of 4,701 patients referred for neurophysiological assessment, 91 patients were identified with nerve injuries; 66 of them were selected to participate in this study. A retrospective chart review was conducted. The upper arm was the site most often used by uncertified medical practitioners for IM injections because of easy access and cultural practices in the rural villages. The medical practitioners had little formal training in medicine, and administration of the IM injections did not follow standard guidelines.
Nerve injury related to intramuscular injections is “a preventable iatrogenic hazard with poor outcome.” Safe injection practices and public education about the hazards of IM injections are needed. Further follow-up studies are required to understand the outcomes associated with these patients. Factors such as quality of life and functional disability should be studied. The impact of modern nerve and muscle imaging to predict prognosis should be evaluated further.
Preventing sciatic nerve injury from intramuscular injections: Literature review
Small, S. P. (2004). Journal of Advanced Nursing, 47(3), 287-296.
The purpose of this study was to determine the factors associated with sciatic nerve (SN) injury post IM injection and to identify nursing actions for preventing such injury. A review of the literature including legal databases was conducted for current research related to injection procedures and legal issues. Site selection and injection technique are factors resulting in SN injury with IM injections. The dorsogluteal site has been associated with the most SN injuries, but it is unclear whether the cause of injury is related to the site itself or due to inappropriate administration of the medication. The literature supports using the ventrogluteal and the ventrolateral sites for routine IM injections for adults. Nurses must have adequate knowledge of injection sites and the ability to locate anatomical boundaries at each site. Documentation following IM injection is essential for promoting quality of care and ensuring a favorable patient response.
To avoid problems with IM injections, nurses must understand human anatomy, the benefits and disadvantages of each site, and proper administration techniques. Nurses must also administer IM medications carefully. Research-based guidelines for administering IM injections are needed. There is little evidence of nursing research that investigates sciatic nerve injury following IM injections.
A large outbreak of hepatitis B virus infections associated with frequent injections at a physician’s office
Samandari, T., Malakmadze, N., Balter, S., Perz, J. F., Khristova, M., Swetnam, L., Bornschlegel, K., Phillips, M. S., Poshni, I. A., Nautiyal, P., Nainan, O. V., Bell, B. P., & Williams, I. T. (2005). Infection Control & Hospital Epidemiology, 26(9), 745-750.
The objective of this study was to determine whether or not the hepatitis B virus (HBV) was transmitted to patients at a doctor’s office and to identify possible mechanisms of transmission. The researchers gathered data by conducting a retrospective chart review, observed infection-control practices at the clinic, and performed laboratory studies. The cohorts in the study included 91 patients: 73 were considered susceptible and 18 were case patients. Almost 75% of patients had received at least one injection during the period of the study. For the 710 office visits made by these 91 patients, 69% of the visits included the administration of injections. The physician, medical assistant, office assistant, and two medical technicians all administered injections. Most were administered by the medical technicians. Injections were prepared from multidose vials. After injection, the syringe and the needle were returned to the medication room. The researchers reported that HBV was probably transmitted from patient to patient due to contaminated injections from medications taken from multidose vials stored in the same place where used needles and syringes were disposed of after use. Wiping the tops of vials with alcohol before inserting the needle may not have been consistently performed or was not effective in removing HBV. Cross contamination of vials may have occurred.
Healthcare providers must adhere to basic infection-control practices when using multidose vials and in separating clean from contaminated areas when preparing for injections. Continuing education for all healthcare providers is critical. Better methods to ensure safe infection-control practices in outpatient settings are needed. Further research should focus on the frequency and characteristics of transmission of bloodborne diseases in the outpatient setting.