Urgent Message: While giving injections in urgent care may seem like a rote task, the significant safety risks of errors require that providers and staff pay special attention to the “Six Rs” when giving each and every injection.
Unlike other service industries, when you ask people why they go into healthcare, the answer is typically “to help people.” Given your genuine and innate drive to improve the health and wellbeing of your patients, how awful would it be to give an injection incorrectly—causing you or the patient harm? Realizing that patients are counting on you, you attempt to concentrate on the task at hand, but it’s easy to get distracted in the typically hectic, multitasking environment of many urgent care centers. Giving injections is one task that demands your complete focus, from preparing to delivering the injectable properly.
Giving injections starts with understanding the medication order. Except in the case of an emergency, all orders should be in writing; this includes documentation in the electronic health record. If there are any concerns or confusion regarding the order, go directly to the ordering clinician and clear it up. Clinical support staff should never make assumptions regarding a provider’s orders. Ask the patient or guardian about any allergies, in spite of what is documented in the chart. Determine if there are any incompatibility problems or contraindications and, if so, consult the provider before giving the shot.
Once the medication order is understood, the Six Rs provide a framework for delivering injections to urgent care patients safely:
- Right drug: Read drug labels carefully, including verifying the drug name and expiration date on the vial when removing it from the cabinet. Read the vial label again and compare the drug name with the medication order when drawing it into the syringe. Repeat this process a third time upon leaving the medical station. Some clinicians recommend showing the vial to the patient or guardian and drawing it up in the exam room, both to help the patient remember what drug they are being given but also as one final check for you. When giving multiple injections, such as immunizations, either label each in the med room or draw up the medications in the exam room as you are giving them
- Right amount: Correctly draw up the ordered amount. Using a syringe that is closest in size to the amount of medication required improves accuracy. If calculations are necessary, as in cases where the medication is given as units per kilogram of body weight, double check for accuracy and ask for help if it’s at all unclear. It’s a good practice to ask a colleague or supervisor to spot-check the calculations before drawing up the injection.
- Right route: Confirm whether you are to give the injection IM (intramuscular), subQ (subcutaneous), IV (intravenous), or intradermal. All clinical support staff should be sure to have been checked off by a supervisor regarding their knowledge of the correct sites for various injections, and the difference in sites for children and adults. When giving IM injections, aspirate before injecting. This entails pulling back on the syringe plunger after needle insertion but before injection, to assure the needle is not inserted into a blood vessel. Turning an IM into an IV injection can cause life-threatening consequences.
- Right patient: Address the patient by name and let them know what injection is being given after you have verified the medication order again.
- Right time: Timed injections require attention to detail. Setting a timer or using the stopwatch function on your smartphone can be helpful.
- Right record: As the saying goes in medicine, “If it isn’t documented, it wasn’t done.” You must document in the chart or electronic health record immediately after having given the injection(s). The chance of making a mistake increases dramatically once you leave the exam room. Document the medication; use the brand name, if using a branded product, and the generic name if not. Note the company who manufactured the drug, expiration date, lot number (sometimes medication or immunizations have recalls as with any other product), and the exact site of the injection. Note any side effects or therapeutic effects.
When giving the injection, use the aseptic technique, which is designed to prevent contamination from microorganisms. If your center uses latex gloves, check with the patient about any allergies. Latex reactions can be severe. Wash your hands before putting the gloves on. Use an alcohol or antiseptic wipe to first clean the vial, starting from the center of the stopper on the vial and wiping in a spiral pattern. Wiping across the top will only pull contaminants from one place to another. Wait 30 seconds; alcohol only becomes antiseptic as it dries. When preparing the patient for the injection, use the same spiral pattern to cleanse the skin and wait 30 seconds before giving the injection.
Keep personal protection in addition to gloves in mind, if required. Every year healthcare workers experience between 600,000 and 800,000 accidental exposures to blood, with the majority being “needlestick” accidents or inadvertent exposure to sharps. According to the Occupational Safety and Health Administration, syringes that retain an exposed needle after use or that need to be taken apart by healthcare workers pose the greatest risks. To limit blood-borne pathogen exposure, place the syringe and needle into a secure sharps container immediately after use.
Urgent care providers and staff want their patients to get safe, effective, and accurate medical care. Following the Six Rs of injections will help you avoid mistakes that could put a patient at risk or cause harm to yourself, result in malpractice, or provide incomplete or inaccurate documentation.
Alan A. Ayers, MBA, MAcc is Vice President of Strategic Initiatives for Practice Velocity, LLC and is Practice Management Editor of The Journal of Urgent Care Medicine.