INS 2011 part 1 - GAVeCeLTgavecelt.it/nuovo/sites/default/files/uploads/ins_2011_s...1.1 The Infusion Nursing Standards of Practice shall be applied and met in all practice settings

S6 Journal of Infusion Nursing

Copyright © 2011 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.

1. Anatomic characteristics and their effect onphysical assessment, vascular and nonvascularaccess device site selection, insertion procedures,site rotation, and use of specialized infusion-related equipment, including care and mainte-nance practices during infusion therapy.3-5 (V)

2. Physiologic characteristics and their effect on drugand nutrient selection; administration set selection(eg, free of Di[2-ethylhexyl] phthalate); dosage andvolume limitations with reference to age, height,weight, or body surface area; pharmacologicactions, interactions, and side effects; monitoringparameters; and response to infusion therapy.3-11 (V)

3. Growth and developmental stages, includingimplications related to promoting comfort andreducing pain and fears associated with infu-sion therapy procedures.3,4,9,12-14 (V)

4. Interaction with parents, other family members,or legally authorized representative as membersof the patient’s health care team, includingpatient education that is provided with attentionto age, developmental level, health literacy, cul-ture, and language preferences (see Standard 11,Patient Education).2,4,15 (V)

5. Safe and appropriate setting (eg, acute care,ambulatory, school, or home care) for patientsreceiving infusion therapy.2,16 (V)

6. Obtaining assent from the school-age or adoles-cent patient as appropriate (see Standard 12,Informed Consent).2,17-19 (V)

REFERENCES

1. American Nurses Association. Neonatal Nursing: Scope and Standardsof Practice. Silver Spring, MD: ANA; 2004.

2. American Nurses Association. Pediatric Nursing: Scope and Standardsof Practice. Silver Spring, MD: ANA; 2008.

3. Frey AM, Pettit J. Infusion therapy in children. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:550-570.

1. PRACTICE SETTING

Standard

1.1 The Infusion Nursing Standards of Practice shall beapplied and met in all practice settings where infusiontherapy is administered.1.2 Administration of infusion therapy shall be estab-lished in organizational policies, procedures, and/orpractice guidelines.1.3 Administration of infusion therapy shall be in accor-dance with rules and regulations promulgated by thestate’s Board of Nursing and federal and state regulatoryand accrediting agencies in all practice settings.

2. NEONATAL AND PEDIATRICPATIENTS

Standard

2.1 The nurse providing infusion therapy for neonataland pediatric patients shall have clinical knowledge andtechnical expertise with respect to this population.2.2 Clinical management of neonatal and pediatricpatients shall be established in organizational policies,procedures, and/or practice guidelines and in accor-dance with applicable standards of practice.2.3 The nurse shall verify that informed consent fortreatment for neonatal and pediatric patients, as well asthose patients who are deemed emancipated minors ormature minors, is documented.

Practice Criteria

A. The nurse should provide care to neonatal andpediatric patients that is individualized, collabo-rative, and age appropriate.1-4 (V)

B. The nurse providing infusion therapy to neonataland pediatric patients should have knowledge anddemonstrated skill competency in the areas of:

Nursing Practice

The Art and Science of Infusion NursingThe Art and Science of Infusion Nursing

Standards of Practice

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4. Pediatric intravenous therapy. In: Weinstein S, ed. Plumer’s Principles& Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007:613-685.

5. De Jonge R, Polderman K, Gemke R. Central venous catheter usein the pediatric patient: mechanical and infectious complications.Pediatr Crit Care Med. 2005;6(3):329-339.

6. Hughes RG, Edgerton EA. Reducing pediatric mediation errors:children are especially at risk for medication errors. Am J Nurs.2005;105(5):79-84.

7. Mirtallo J, Canada T, Johnson D, et al. Safe practices for parenter-al nutrition. J Parenter Enteral Nutr. 2004;28(suppl):S39-S70.

8. Phillips SK. Pediatric parenteral nutrition: differences in practicefrom adult care. J Infus Nurs. 2004;27(3):166-170.

9. Loff S, Subotic U, Reinick F, et al. Extraction of di-ethylhexyl-phtha-late by home total parenteral nutrition from polyvinyl chloride infu-sion lines commonly used in the home. J Pediatr Gastroenterol Nutr.2008;47(1):81-86.

10. Pak VM, Nailon RE, McCauley LA. Controversy: neonatal expo-sure to plasticizers in the NICU. MCN Am J Matern Child Nurs.2007;32(4):244-249.

11. Kambia K, Gressier B, Bah S, et al. Evaluation of childhood exposure to di(2-ethylhexyl) phthalate from perfusion kits duringlong-term parenteral nutrition. Int J Pharm. 2003;262(1-2):83-91.

12. Zempsky WT. Optimizing the management of peripheral venousaccess pain in children: evidence, impact, and implementation.Pediatrics. 2008;122:S121-S124.

13. Cohen LL. Behavioral approaches to anxiety and pain manage-ment for pediatric venous access. Pediatrics. 2008;122:S134-S139.

14. Sparks LA, Setlik J, Luhman J. Parental holding and positioningto decrease IV distress in young children: a randomized controlledtrial. J Pediatr Nurs. 2007;22(6):440-447.

15. Czaplewski L. Clinician and patient education. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:71-94.

16. Tice AD. Handbook of Outpatient Parenteral Antimicrobial Therapyfor Infectious Diseases. Tarrytown, NY: CRG Publishing; 2006.

17. Unguru Y, Coppes MJ, Kamani N. Rethinking pediatric assent:from requirement to ideal. Pediatr Clin N Am. 2008;55:211-222.

18. Sinclair SJ. Involvement of adolescents in decision making forheart transplants. MCN. 2009;34(5):276-281.

19. Jolly K, Weiss JA, Liehr P. Understanding adolescent voice as a guidefor nursing practice and research. Issues Compr Pediatr Nurs. 2007;30:3-13.

3. OLDER ADULT PATIENTS

Standard

3.1 The nurse providing infusion therapy for older adultpatients shall have clinical knowledge and technicalexpertise with respect to this population.3.2 Clinical management of older adult patients shall beestablished in organizational policies, procedures,and/or practice guidelines and shall be according toapplicable standards of practice.

Practice Criteria

A. The nurse should provide individualized, collabo-rative, and age-appropriate care to older adults—those people who are 65 years and older.1-8 (V)

B. The nurse providing infusion therapy to olderadults should have knowledge and demonstratedskill competency in the areas of:1. Anatomic changes related to older adults and

their effect on physical assessment, vascular andnonvascular access device site selection, inser-tion procedures, and use of specialized infusion-related equipment, including care and mainte-nance practices during infusion therapy.9-11 (V)

2. Physiologic changes related to older adults andtheir effect on drug dosage and volume limita-tions, pharmacologic actions, interactions, sideeffects, monitoring parameters, and responseto infusion therapy.4,9,12-14 (V)

3. Changes in cognitive abilities and dexterity;communication methods, including vision, hear-ing, and verbal changes; as well as psychosocialand socioeconomic considerations.4,9,15 (V)

4. Interaction with family members, caregivers, orlegally authorized representative as members ofthe patient’s health care team, with consent of thepatient or as necessary due to mental status.9,15 (V)

5. Potential for adverse events and drug interac-tions in older adults who may be prescribedmultiple medications.4,9,13,16 (V)

6. Safety and environmental considerations related toolder adults receiving infusion therapy and effectivemanagement of those considerations.9,13,16,17 (V)

REFERENCES

1. American Nurses Association. Nursing: Scope and Standards ofPractice. 2nd ed. Silver Spring, MD: ANA; 2010.

2. American Nurses Association. Scope and Standards of GerontologicalNursing Practice. 2nd ed. Silver Spring, MD: ANA; 2001.

3. Mezey M, Stierle L, Huba GJ, Esterson J. Ensuring competence ofspecialty nurses in care of older adults. Geriatr Nurs. 2007;28(6)(suppl 1):9-14.

4. Zwicker D, Fulmer T. Reducing adverse drug events. In: Capezuti E,Zwicker D, Mezey M, Fulmer T, eds. Evidence-Based Geriatric NursingProtocols for Best Practice. New York, NY: Springer; 2008:257-308.

5. National Gerontological Nursing Association. Definitions ofolder adults and gerontological nursing. https://www.ngna.org/about-items/definitions-of-older-adults-and-gerontological-nursing.html. Published September 2, 2008. Accessed February 23, 2010.

6. Steel K. The old-old-old. J Am Geriatr Soc. 2005;53:S314-S316.7. Woodhouse KW, Wynne H, Baillie S, et al. Who are the frail

elderly? Q J Med. 1988;68(255):505-506.8. World Health Organization. Definition of an older or elderly person.

http://www.who.int/healthinfo/survey/ageingdefnolder/en/. Published2010. Accessed August 10, 2010.

9. Fabian B. Infusion therapy in the older adult. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:

VOLUME 34 | NUMBER 1S | JANUARY/FEBRUARY 2011 S7Copyright © 2011 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.

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An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:571-582.

10. Schelper R. The aging venous system. J Assoc Vasc Access. 2003;8(3):8-10.

11. Walsh G. Hypodermoclysis. J Infus Nurs. 2005;28(2):123-129.12. Aubrun F. Management of postoperative analgesia in elderly

patients. Reg Anesth Pain Med. 2005;30:363-379.13. Francis DC. Iatrogenesis: the nurse’s role in preventing patient harm.

In: Capezuti E, Zwicker D, Mezey M, Fulmer T, eds. Evidence-Based Geriatric Nursing Protocols for Best Practice. New York, NY:Springer; 2008:223-255.

14. Goldstein PC. Assessment and treatment of hypoglycemia in elders:cautions and recommendations. Medsurg Nurs. 2009;18:215-241.

15. Lueckenotte A. Older adult. In: Potter P, Perry A, eds. Fundamentalsof Nursing. 7th ed. St Louis, MO: Mosby Elsevier; 2009:191-214.

16. Thornlow DK. Increased risk for patient safety incidents in hos-pitalized older adults. Medsurg Nurs. 2009;18:291.

17. Toth L. Monitoring infusion therapy in patients residing in long-termcare facilities. J Assoc Vasc Access. 2002;7(1):34-38.

4. ETHICS

Standard

4.1 Ethical principles shall be the foundation for deci-sion making and patient advocacy.4.2 Guidelines and resources for ethical issues shall beoutlined in organizational policies, procedures, and/orpractice guidelines.4.3 The nurse shall act as a patient advocate; maintainpatient confidentiality, safety, and security; and respect,promote, and preserve human autonomy, dignity,rights, and diversity.4.4 Principles of beneficence, nonmaleficence, fidelity,protection of patient autonomy, justice, and veracityshall dictate nursing action.

Practice Criteria

A. Ethical principles should be integrated in all areasof nursing practice.1-4 (V)

B. The nurse should use professional ethical resources,including the Guide to the Code of Ethics for Nurses:Interpretation and Application by the AmericanNurses Association and the Infusion Nursing Code ofEthics.1-4 (V)

C. The nurse should assess for and raise issues relat-ed to potential ethical problems, act as a rolemodel for ethical care, and contribute to resolvingethical issues related to patients, colleagues, or thehealth care system.1-4 (V)

D. The nurse should use organizational ethicsresources, such as ethics committees, and supportnursing participation when dealing with ethicalissues.1-4 (V)

REFERENCES

1. Fowler MDM, ed. Guide to the Code of Ethics for Nurses:Interpretation and Application. Silver Spring, MD: American NursesAssociation; 2008.

2. Infusion Nurses Society. Infusion nursing code of ethics. J InfusNurs. 2001;24(4):242-243.


4. Schroeter K. Ethics. In: Alexander M, Corrigan A, Gorski L,Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-BasedApproach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:60-70.

5. SCOPE OF PRACTICE

Standard

5.1 The scope of practice for each type of personnelinvolved with the delivery of infusion therapy shall beorganized to support patient safety and protection andshall clearly define the roles, responsibilities, tasks,range of services, and accountability for all levels of per-sonnel involved with the delivery of infusion therapy.5.2 All licensed nursing personnel with responsibilityfor infusion therapy shall possess a license in goodstanding with the state’s Board of Nursing.5.3 All personnel involved with the delivery of infusiontherapy shall practice within the legal boundaries of theindividual license or scope of practice.5.4 All personnel involved with the delivery of infusiontherapy shall possess the ability to communicate effec-tively with patients, supervisors, peers, and other mem-bers of the health care team.5.5 The role of nursing assistive personnel (NAP)involved with infusion therapy shall be limited to non-invasive and administrative tasks.5.6 Delegation of infusion therapy tasks shall be inaccordance with rules and regulations promulgated bythe state’s Board of Nursing. The registered nurse (RN)shall be responsible and accountable for all tasks delegated to NAP and licensed practical/vocationalnurses (LPN/LVN).5.7 The RN shall be accountable for patient safety inthe delivery of infusion therapy.

Practice Criteria

A. The legal scope of practice for all licensed healthcare professions is defined in the state statutesgoverning each profession. The changing healthcare system mandates overlap between profes-sional groups, with no single group claimingexclusive ownership of any skill, activity, or task.Interdisciplinary education and collaboration isknown to produce quality patient care.1-3 (IV,Regulatory)

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B. The method for making scope of practice deci-sions is different for each state’s Board of Nursingand includes a decision-tree model, declaratoryrulings, and advisory opinions. The expansion ofinfusion therapies and technologies requires thenurse to be knowledgeable of the method used inthe state(s) where one practices.4,5 (V, Regulatory)

C. Decisions about the scope of practice for eachtype of personnel involved with infusion therapyshould focus on the following:I. Nursing Assistive Personnel (NAP)

a. NAP function in assistive roles to performsupportive patient care tasks that are nonin-vasive. Job titles may include many combi-nations of the terms aides, assistants, ortechnicians. Training is provided in manydifferent settings, and requirements varyamong states. NAP working in some facili-ties and agencies receiving federal fundingare required to have a minimum amount oftraining and pass a state competency evalu-ation. Some states do require a license.6-8 (V)

b. Infusion-related tasks assigned to NAPinclude managing equipment and supplies,gathering statistics, and assisting licensedpersonnel with invasive procedures.6,7 (V)

c. NAP should not have the responsibility toperform invasive infusion therapy proce-dures such as catheter insertion, cathetermaintenance procedures, or the administra-tion of any fluid, nutrition, blood, or med-ication. A practice analysis for NAP identi-fied 119 activity statements; however, therewere no infusion-related tasks, activities, orprocedures identified.6,9 (IV)

d. State Boards of Nursing may have statementsaffirming that initiation, administration, andmonitoring of infusion therapy may not bedelegated to unlicensed personnel.6,7 (V)

e. Personnel (eg, infusion team technicians)performing catheter insertions have beenidentified as a predictor of complicationssuch as phlebitis and infiltration.10 (IV)

II. Medical Assistant (MA)a. MAs function in assistive roles to physicians

and other health care practitioners by per-forming administrative and clinical tasks.Their primary place of employment is themedical office.8,11 (V)

b. Due to the increasing frequency and types ofinfusion therapy provided in non–acute caresettings, MAs should have basic knowledge ofinfusion therapy as it applies to their role.11 (V)

c. MAs should complete a course of infusiontherapy training, including supervised clinicalpractice.11 (V)

III. Licensed Practical/Vocational Nurse (LPN/LVN)a. Successful completion of an organized educa-

tional program, including supervised clinicalpractice on infusion therapy, is required forLPN/LVNs in many states. In states withoutsuch requirements, completion of a similareducational program is recommended priorto performing infusion therapy procedures.These educational programs should apply theInfusion Nursing Standards of Practice.12-14

(V, Regulatory)b. An LPN/LVN practice analysis identified 13

of 159 activity statements as being infusiontasks, activities, and procedures. The frequen-cy of performance of each activity varies bywork practice setting, age and type ofpatients, and years of experience.9 (IV)

c. All infusion-related tasks should be per-formed under the supervision of a registerednurse with appropriate infusion therapyknowledge and skills.13 (V, Regulatory)

IV. Registered Nurse (RN)a. The RN performing infusion therapy should

have the requisite knowledge and skillsderived from application of the InfusionNursing Standards of Practice.15,16 (V)

b. Due to the lack and/or inconsistency of infu-sion therapy in basic nursing curricula, the RNshould successfully complete an organized edu-cational program on infusion therapy.15,17 (V)

c. The RN should participate in the develop-ment of policies and procedures and in qual-ity improvement activities related to infu-sion therapy.18,19 (V)

d. When the RN has received a delegatedassignment from another health care profes-sional and concludes that she or he is inade-quately prepared to perform this function,the RN must refuse this assignment and seekother means for providing the patient carerequired.20 (V)

e. Tasks delegated by the RN to other nurses orassistive personnel are required to be withinthe legal boundaries for those personnel. Tasksdelegated to assistive personnel should notrequire professional judgment, require little orno modification for each patient, and can beperformed with a predictable outcome.20,21 (V)

V. Infusion Nurse Specialist (CRNI®)a. Infusion nurse specialists are RNs who have

attained certification in infusion nursing fromthe Infusion Nurses Certification Corporation(INCC) and use the designation CRNI®

(Certified Registered Nurse Infusion). This credential signifies specialized knowledge and experience in infusion nursing. All RNs


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specializing in infusion nursing should seek toearn this credential.22-24(V)

b. Nurses earning a certification credential from aprofessional organization report benefits of per-sonal and professional growth, career advance-ment, financial rewards, and empowerment.25-27

(IV)c. In addition to the practice criteria for the RN,

the CRNI® serves as direct care provider, carecoordinator, advocate, patient and staff educa-tor, manager, and consultant on all issues relat-ed to infusion therapy.28 (V)

d. The CRNI® is recognized as expert in thisspecialty and should organize and coordi-nate quality improvement activities in infu-sion therapy and be the primary resource toguide policy and procedure developmentderived from best evidence.28 (V)

e. The CRNI® should be involved with imple-mentation of clinical decision support sys-tems (CDSS) to ensure the needs of nursingare addressed. CDSS designed for nursingmay have the potential for guiding clinicaldecisions within the nurse’s scope of practice;however, the available studies have manylimitations. Management of catheter- andinfusion-related complications could benefitfrom such systems.29 (V)

VI. Advanced Practice Nurse (APN)a. Nurse practitioners, clinical nurse specialists,

nurse midwives, and nurse anesthetists com-pose the group of advanced practice nurses.APNs may be licensed independent practi-tioners (LIPs) and function under a facility’sguidelines and procedures for medical staff.APNs may have the legal authority to pre-scribe infusion therapy and perform surgicalprocedures for insertion and removal of vas-cular access devices.30,31 (IV, Regulatory)

b. APNs should be involved with education, con-sulting, and research in infusion therapy.21,30 (IV)

REFERENCES

1. American Nurses Association; National Council of State Boardsof Nursing. Joint statement on delegation. http//www.ncsbn.org/Joint_statement.pdf. Accessed October 15, 2009.

2. McPherson K, Headrick L, Moss F. Working and learning togeth-er: good quality care depends on it, but how can we achieve it?Qual Health Care. 2001;10(suppl 2):ii46-ii53.

3. Lindeke L, Sieckert A. Nurse-physician workplace collaboration.Online J Issues Nurs. 2005;10(1):5. http://www.nursingworld.org/mainmenucategories/anamarketplace/anaperiodicals/ojin/tableofcontents/volume102005/no1jan05/tpc26_416011.aspx. AccessedJanuary 23, 2010.

4. Markovich MB. The expanding role of the infusion nurse in radi-ographic interpretation for peripherally inserted central cathetertip placement. J Infus Nurs. 2008;31(2):96-103.

5. Sutherland BM. Nursing practice: the regulatory arena. J InfusNurs. 1995;18(6):292-296.

6. Infusion Nurses Society [position paper]. The use of nursing assis-tive personnel in the provision of infusion therapy. J Infus Nurs.2009;32(1):21-22.

7. American Academy of Pediatrics [policy statement]. Guidelinesfor care of children in the emergency department. Ann EmergMed. 2009;54(4):543-552.

8. US Department of Labor. Occupational Outlook Handbook,2008-09. Washington, DC:Bureau of Labor Statistics; 2008.

9. Wendt A. Report of Findings From the 2005 LPN/VN Post Entry-Level Practice Analysis. Chicago, IL: National Council of StateBoards of Nursing; 2006.

10. Catney M, Hillis S, Wakefield B, et al. Relationship betweenperipheral intravenous catheter dwell time and the developmentof phlebitis and infiltration. J Infus Nurs. 2001;24(5):332-341.

11. Bonewit-West K. Clinical Procedures for Medical Assistants. 7thed. St Louis, MO: Saunders/Elsevier; 2008.

12. Weinstein S, ed. Plumer’s Principles & Practice of Intravenous Therapy.8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

13. Corrigan A. Infusion nursing as a specialty. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:1-9.

14. Seago J, Spetz J, Chapman S, Dyer W. Can the use of LPNs alle-viate the nursing shortage? Yes, the authors say, but the issues—involving recruitment, education, and scope of practice—arecomplex. Am J Nurs. 2006;106(7):40.

15. Czaplewski L. Clinician and patient education. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:71-94.

16. Diehl-Svrjcek BC, Dawson B, Duncan LL. Infusion nursing:aspects of practice liability. J Infus Nurs. 2007;30(5):274-279.

17. Chippendale M, Gardner H. Review: a model for implementing the“Scope of Professional Practice.” J Child Health Care. 2001;5(3):105-110.

18. ECRI Institute. Failure mode and effects analysis: a hands-on guidefor healthcare facilities. Health Devices. 2004;33(7):233-243.

19. Montalvo I. The National Database of Nursing QualityIndicatorsTM (NDNQI®). Online J Issues Nurs. 2007;12(3).

20. American Nurses Association. Principles of Delegation. SilverSpring, MD: ANA; 2005.

21. Kelly-Heidenthal P, Marthaler M. Delegation of Nursing Care.Clifton Park, NY: Thomson Delmar Learning; 2005.

22. American Board of Nursing Specialties [position statement]. Thevalue of specialty nursing certification. Aurora, OH: ABNS; 2005.

23. Infusion Nurses Certification Corporation. Certification vs certifi-cate: do you know the difference? INCC Chronicle. Norwood, MA:INCC; 2009.

24. Infusion Nurses Society; Infusion Nurses Certification Corporation[joint position paper]. The value of certification in infusion nursing.J Infus Nurs. 2009;32(5):248-250.

25. Piazza I, Donahue M, Dykes P, Griffin M, Fitzpatrick J. Differencesin perceptions of empowerment among nationally certified andnoncertified nurses. J Nurs Admin. 2006;36(5):277.

26. Briggs L, Brown H, Kesten K, Heath J. Certification a benchmarkfor critical care nursing excellence. Crit Care Nurse. 2006;26(6):47.

27. Wade C. Perceived effects of specialty nurse certification: a reviewof the literature. AORN J. 2009;89(1):183-192.

28. Hadaway L. Infusion therapy equipment. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:

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An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:391-436.

29. Staggers N, Weir C, Phansalkar S. Patient safety and health informa-tion technology: role of electronic health record. In: Hughes R, ed.Patient Safety and Quality: An Evidence-Based Handbook for Nurses.Rockville, MD: Agency for Healthcare Research and Quality; 2008.

30. Kleinpell R. Acute care nurse practitioner practice: results of a 5-year longitudinal study. Am J Crit Care. 2005;14(3):211.

31. Klein T. Credentialing the nurse practitioner in your workplace:evaluating scope for safe practice. Nurs Admin Q. 2008;32(4):273.

6. COMPETENCE AND COMPETENCY VALIDATION

Standard

6.1 As a method of public protection, the nurse shall becompetent in the safe delivery of infusion therapy with-in her or his scope of practice.6.2 The nurse shall be responsible and accountable forattaining and maintaining competence with infusiontherapy within her or his scope of practice.6.3 Competency validation shall be performed initiallyand on an ongoing basis.6.4 Competency validation shall be documented in accor-dance with organizational policies, procedures, and/orpractice guidelines.

Practice Criteria

A. The nurse bears responsibility for becoming compe-tent to enter nursing practice and maintaining contin-ued competence throughout her or his career.Competence goes beyond psychomotor skills toinclude application of knowledge, critical thinkingskills, and decision-making abilities. Competencyrequires a commitment to lifelong learning, self-reflec-tion, and professional ethics. Completion of continu-ing education programs is the most common methodfor continuing competence; however, this methoddoes not prove or guarantee competence.1-10 (IV)

B. Employers should use competency validationprocesses to document that the nurse has the knowl-edge, skills, behaviors, and ability to perform theassigned job. Competence should initially be validat-ed at the time of employment, after orientation to theorganization, on an ongoing periodic basis, whenscope of practice changes, and with the introductionof new equipment or technology. Frequency of ongo-ing competence validation and performance evalua-tion is determined by the organization. Frequency forvalidation of specific skills or tasks should be basedon the associated risk and may be considered a com-ponent of the quality improvement process.11,12 (V)

C. Multiple infusion-related tasks are identified as corecompetencies for all registered nurses. Infusion-

related tasks performed by licensed practical/vocational nurses (LPN/LVNs) are determined bythe state’s Board of Nursing and vary greatlyamong states.13,14 (V, Regulatory)

D. Core competencies for the infusion nurse specialistshould be established in the written job descrip-tion and should be based on the infusion nursingcore curriculum, including:1. Technology and clinical application2. Fluid and electrolyte balance3. Pharmacology4. Infection prevention5. Neonate and pediatric patients6. Transfusion therapy7. Antineoplastic and biologic therapy8. Parenteral nutrition9. Quality improvement15,16 (V)

E. Nurses working as contracted staff (eg, peripher-ally inserted central catheter [PICC] insertion) arerequired to document competency with the tasksbeing performed and to comply with the organi-zation’s requirements for staff qualifications andpersonnel practices.11 (V)

F. Competency validation is a dynamic process thatchanges based on organizational needs. Skills ortasks for ongoing competency validation are identi-fied through use of clinical outcome data, problemsdocumented through Unusual Occurrence andSentinel Event Reports, changing patient popula-tions, and patient satisfaction data. Prioritizing thespecific tasks for competency validation is deter-mined by the frequency of performing those tasksand the risks associated with the tasks. Low-fre-quency tasks are performed rarely (eg, less thanweekly). High-risk tasks include invasive procedureswith the potential to be harmful or even life-threat-ening to the patient. Problem-prone tasks includethose that are documented to produce issues for thepatient, staff, or organization.11,12,17 (V)

G. A variety of different methods should be used forcompetency validation including, but not limitedto, written tests for evaluating knowledge, use ofclinical scenarios, and assessment of critical think-ing skills; observation in a skills laboratory; andobserving performance of the skill in the workenvironment, which is the preferred method forinvasive infusion therapy procedures.11,18 (V)

H. A skills laboratory setting involves use of simula-tion with anatomical models and computer-basedvirtual reality. Performance of invasive proce-dures (eg, venipuncture) on peers is discourageddue to health risk for the peer-volunteer.19-21 (V)

I. Documentation of observed performance requiresa well-designed form or checklist that focuses onobjective, measurable assessment of the actualperformance; however, data on the validity and


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reliability of specific forms are not available. Theform includes the competency statement, specificperformance criteria statements, or critical behav-iors; the method of demonstrating performance;the criteria for achieving success; and the signa-ture of the validator.11 (V)

J. Initial competency validation for specialized skillsnot expected of all nurses (eg, PICC insertion,chemotherapy administration) requires attentionto prior clinical experience, educating the nursefor these advanced skills, and completion of aprocedure demonstration and return demonstra-tion. This is followed by performance of an iden-tified number of successful procedures undersupervision in the clinical setting.17,22 (V)

K. The person validating the specific skill should becompetent with the skill. When no one in theorganization has the specific competency,arrangements for a skill validator from outsidethe organization may be necessary.11,18,23 (V)

L. Competency validation should include competen-cy for specific patient populations based on age.Age-based competency will address needs bychronological, functional, or life-stage groups,including physical and psychological developmentneeds and patient educational requirements.11 (V)

M. Competency validation should facilitate culturallycompetent health care by identifying and address-ing the needs of ethnically diverse patient popula-tions. Cultural competence includes health care-related beliefs and values, prevalent diseases in pop-ulations served, religious practices, language andliteracy issues, and family-based needs.11,24,25 (V)

REFERENCES

1. Vanaki Z, Memarian R. Professional ethics: beyond the clinicalcompetency. J Professional Nurs. 2009;25(5):285-291.

2. Tilley D. Competency in nursing: a concept analysis. J ContinuingEduc Nurs. 2008;39(2):58.

3. Burns B. Continuing competency: what’s ahead? J Perinat NeonatalNurs. 2009;23(3):218.

4. Allen P, Lauchner K, Bridges R, Francis-Johnson P, McBride S,Olivarez A. Evaluating continuing competency: a challenge for nurs-ing. J Continuing Educ Nurs. 2008;39(2):81-85.

5. Lazarus J, Lee N. Factoring consumers’ perspectives into policy deci-sions for nursing competence. Policy Polit Nurs Pract. 2006;7(3):195.

6. Milton C. Accountability in nursing: reflecting on ethical codes andprofessional standards of nursing practice from a global perspective.Nurs Sci Q. 2008;21(4):300.

7. Centers for Disease Control and Prevention (CDC). Progress towardstrengthening blood transfusion services: 14 countries, 2003-2007.MMWR Morb Mortal Wkly Rep. 2008;57(47):1273-1277.

8. Minarik P. Issue: competence assessment and competency assuranceof healthcare professionals. Clin Nurse Specialist. 2005;19(4):180.

9. Cowan D, Norman I, Coopamah V. Competence in nursing prac-tice: a controversial concept: a focused review of the literature.Nurse Educ Today. 2005;25(5):355-362.


11. Joint Commission Resources. Assessing Hospital Staff Competence.2nd ed. Oakbrook Terrace, IL: JCR; 2007.

12. McAdams C, Montgomery K. Narrowing the possibilities: usingquality improvement tools to decrease competence assessment over-load. J Nurs Staff Dev. 2003;19(1):40.

13. Wendt A, Alexander M. Toward a standardized and evidence-basedcontinued competence assessment for registered nurses. JONA’sHealthc Law Ethics Regul. 2007;9(3):74.

14. Gorski L, Miller C, Mortlock N. Infusion therapy across the contin-uum. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R,eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. StLouis, MO: Saunders/Elsevier; 2010:109-126.

15. Hadaway L. Infusion therapy equipment. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:391-436.

16. Czaplewski L. Clinician and patient education. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:71-94

17. Rusche J, Besuner P, Partusch S, Berning P. Competency programdevelopment across a merged healthcare network. J Nurs Staff Dev.2001;17(5):234.

18. O’Hearne Rebholz M. A review of methods to assess competen-cy. J Nurs Staff Dev. 2006;22(5):241.

19. Hilton P, Barrett D. An investigation into students’ performanceof invasive and non-invasive procedures on each other in class-room settings. Nurse Educ Pract. 2009;9(1):45-52.

20. Landry M, Oberleitner M, Landry H, Borazjani J. Education andpractice collaboration: using simulation and virtual reality technologyto assess continuing nurse competency in the long-term acute care setting. J Nurs Staff Dev. 2006;22(4):163.

21. Beyea S, von Reyn L, Slattery M. A nurse residency program forcompetency development using human patient simulation. J NursStaff Dev. 2007;23(2):77-82.

22. Andam R, Silva M. A journey to pediatric chemotherapy compe-tence. J Pediatr Nurs. 2008;23(4):257-268.

23. Ringerman E, Flint L, Hughes D. An innovative education pro-gram: the peer competency validator model. J Nurs Staff Dev.2006;22(3):114.

24. Polacek G, Martinez R. Assessing cultural competence at a localhospital system in the United States. Health Care Manager. 2009;28(2):98.

25. Engebretson J, Mahoney J, Carlson E. Cultural competence in the eraof evidence-based practice. J Professional Nurs. 2007;24(3):172-178.

7. QUALITY IMPROVEMENT

Standard

7.1 The nurse shall participate in quality improvementactivities that advance patient care, quality, and safety.

Practice Criteria

A. Quality improvement activities include evaluatingpatient or clinical outcomes; identifying clinical

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indicators, benchmarks, and areas for improvement;providing best evidence; recommending and imple-menting changes in structures or processes; analyzingdata and outcomes against benchmarks; consideringthe use of cost analysis; or minimizing and eliminat-ing barriers to change and improvement.1-13 (V)

B. The quality improvement program should create aculture that fosters the reporting and analysis ofquality and safety indicator outcomes, near-miss-es, errors, and adverse events. The program shouldfocus on systems and processes that promote indi-vidual accountability and a just culture.12,14-22 (V)

C. The knowledge gained through this process shouldbe shared internally and externally with otherhealth care providers and organizations.13,23 (V)

REFERENCES


2. Institute of Medicine. Crossing the Quality Chasm: A NewHealth System for the 21st Century. Washington, DC: NationalAcademy Press; 2001:111-144, 231-308.

3. The Joint Commission. Comprehensive Accreditation Manuals.Edition v2.0.0.0. Oakbrook Terrace, IL: TJC; 2010.

4. Sierchio GP. Quality management. In: Alexander M, Corrigan A,Gorski L, Hankins J, Perucca R. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:22-48.

5. Agency for Healthcare Quality and Research. NQF-EndorsedMeasures. In: National Quality Measures Clearinghouse™. http://www.qualitymeasures.ahrq.gov/browse/endorsed.aspx. AccessedJanuary 30, 2010.

6. Curtis JR, Cook DJ, Wall RJ, et al. Intensive care unit qualityimprovement: a “how-to” guide for the interdisciplinary team.Crit Care Med. 2006;34:211-218.

7. Danello SH, Maddox RR, Schaack GJ. Intravenous infusion safety tech-nology: return on investment. Hosp Pharm. 2009;44:680-687,696.

8. Dunton N, Montalvo I. Sustained Improvement in NursingQuality: Hospital Performance on NDNQI Indicators, 2007-2008. Silver Spring, MD: American Nurses Association; 2009.

9. Farquhar M. AHRQ quality indicators. In: Hughes RG, ed.Patient Safety and Quality: An Evidence-Based Handbook forNurses. AHRQ Publication No. 08-0043. Rockville, MD: Agencyfor Healthcare Research and Quality. http://www.ahrq.gov/qual/nurseshdbk/docs/FarquharM_IS.pdf. Published March 2008.Accessed July 6, 2010.

10. Galloway M. Using benchmarking data to determine vascularaccess device selection. J Infus Nurs. 2002;25(5):320-325.

11. Institute of Medicine. The State of Quality Improvement andImplementation Research: Expert Views. Washington, DC: NationalAcademy Press. 2007;53-56, 29-43.

12. Rudy EB, Lucke JF, Whitman GR, Davidson LJ. Benchmarkingpatient outcomes. J Nurs Scholarship. 2001;33(2):185-189.

13. Sierchio GP. A multidisciplinary approach for improving outcomes.J Infus Nurs. 2003;26(1):34-43.

14. Alexander M, Webster H. Legal issues of infusion nursing. In:Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds.Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis,MO: Elsevier/Saunders; 2010:49-59.

15. Barnhill S. Clinician and patient safety. In: Alexander M, Corrigan A,Gorski L, Hankins J, Perucca R. Infusion Nursing: An Evidence-BasedApproach. 3rd ed. St Louis, MO: Elsevier/Saunders; 2010:95-108.

16. Hughes RG. Tools and strategies for quality improvement andpatient safety. In: Hughes RG, ed. Patient Safety and Quality: AnEvidence-Based Handbook for Nurses. AHRQ Publication No.08-0043. Rockville, MD: Agency for Healthcare Research andQuality. http://www.ahrq.gov/qual/nurseshdbk/docs/HughesR_QMBMP.pdf. Published March 2008. Accessed July 6, 2010.

17. Institute of Medicine. Patient Safety: Achieving a New Standard forCare. Washington, DC: National Academy Press. 2004;226-249,200-225, 279-316.

18. Mitchell PH. Defining patient safety and quality care. In: HughesRG, ed. Patient Safety and Quality: An Evidence-Based Handbookfor Nurses. AHRQ Publication No. 08-0043. Rockville, MD:Agency for Healthcare Research and Quality. http://www.ahrq.gov/qual/nurseshdbk/docs/MitchellP_DPSQ.pdf. Published March2008. Accessed July 6, 2010.

19. Shearburn P, Kratz M. Utilization of error analysis data in chemother-apy order preparation for development of a comprehensive electronicchemotherapy plan of care. Oncol Nurs Forum. 2009;36(3):76.

20. Wachter RM, Pronovost PJ. Balancing “no blame” with account-ability in patient safety. New Engl J Med. 2009;361(14):1401-1406.

21. Minimizing risk and improving performance. In: Weinstein S, ed.Plumer’s Principles & Practice of Intravenous Therapy. 8th ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2007:10-23.

22. Gorski LA. Central venous access device outcomes in a homecareagency: a 7-year study. J Infus Nurs. 2004;27(2):104-111.

23. Stokowski G, Steele D, Wilson D. The use of ultrasound to improvepractice and reduce complication rates in peripherally inserted central catheter insertions. J Infus Nurs. 2009;32(3):145-155.

8. RESEARCH AND EVIDENCE-BASED PRACTICE

Standard

8.1 The nurse shall use research findings and current bestevidence to expand nursing knowledge in infusion therapy,to validate and improve practice, to advance professionalaccountability, and to enhance evidence-based decisionmaking.8.2 The nurse shall obtain approval for research andresearch-related activities in accordance with federalregulations, professional standards, and criteria setforth by accrediting agencies and organizational poli-cies, procedures, and/or practice guidelines.8.3 The nurse shall develop and revise organizationalpolicies, procedures, and/or practice guidelines based onresearch findings and current best evidence.8.4 The nurse shall integrate evidence-based nursingknowledge with clinical expertise and the patient’s pref-erences and values in the current context when provid-ing infusion therapy.

Practice Criteria

A. The nurse should actively participate in infusiontherapy research activities that advance nursing


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knowledge, such as participating on a research teamor journal club, or conducting systematic literaturereviews, in relation to the individual’s education andexperience.1-5 (V)

B. The nurse should actively participate in criticallyevaluating, interpreting, and implementing researchfindings and/or current best evidence into nursingpractice. This includes, but is not limited to, policyand procedure development and review; producttechnology selection; practice guideline implemen-tation; or abstraction of data from publishedpapers, in relation to the individual’s education andexperience.6-10 (V)

C. The nurse should be competent in using evi-dence-based nursing knowledge and identifyingpatients’ preferences and values to provideeffective and safe infusion therapy practice.7,11-14

(V)

REFERENCES


2. Infusion Nurses Society. Mission. http://www.ins1.org. AccessedAugust 2, 2010.

3. Infusion Nurses Society; Infusion Nurses Certification Corporation[position paper]. The value of certification in infusion nursing. JInfus Nurs. 2009;32(5):248-250.

4. Polit DF, Beck CT. Essentials of Nursing Research: AppraisingEvidence for Nursing Practice. 7th ed. New York, NY: LippincottWilliams & Wilkins; 2009.


6. Dos Reis PE, Silveira RC, Vasques CI, Carvalho EC. Pharmacologicalinterventions to treat phlebitis: systematic review. J Infus Nurs. 2009;32:75-79.

7. Hagle ME, Senk P. Evidence-based practice. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R. Infusion Nursing: AnEvidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:10-21.

8. Hertzel C, Sousa VD. The use of smart pumps for preventingmedication errors. J Infus Nurs. 2009;32(5):257-267.

9. Titler MG. The evidence for evidence-based practice implementa-tion. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ Publication No. 08-0043.Rockville, MD: Agency for Healthcare Research and Quality.http://www.ahrq.gov/qual/nurseshdbk/docs/TitlerM_EEBPI.pdf. Published March 2008. Accessed August 2, 2010.

10. Adams J. Utilizing evidence-based practice to support the infusionalliance. J Infus Nurs. 2010; 33(5):273-277.

11. Bays CL, Hermann CP. An evidence-based practice primer forinfusion nurses. J Infus Nurs. 2010;33(4):220-225.

12. Cox JA, Westbrook LJ. Home infusion therapy: essential character-istics of a successful education process—a grounded theory study. J Infus Nurs. 2005;28(2):99-107.

13. Infusion Nurses Society. Infusion nursing code of ethics. J InfusNurs. 2001;24(4):242-243.

14. Evidence-based infusion practice. In: Weinstein S, ed. Plumer’sPrinciples & Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins. 2007;188-200.

9. POLICIES, PROCEDURES,AND/OR PRACTICE GUIDELINES

Standard

9.1 Infusion policies, procedures, and/or practice guide-lines shall describe the acceptable course of action,including performance and accountability, and providea basis for clinical decision making.9.2 Infusion policies, procedures, and/or practice guide-lines shall be compliant with state and federal laws andprofessional standards.9.3 Infusion policies, procedures, and/or practice guide-lines shall be written, reviewed at established intervals,and revised as needed based on best evidence, andapproved within a formal organizational process.9.4 Infusion policies, procedures, and/or practice guide-lines shall be readily available and accessible to health careteam members.

Practice Criteria

A. Infusion policies, procedures, and/or practiceguidelines should encompass all applicable areas ofinfusion therapy and should ensure patient safety,as well as minimize or mitigate patient harm.1-3 (V)

B. Infusion policies, procedures, and/or practice guide-lines should be developed in accordance with criteriaset forth in this document, in collaboration withother health care disciplines, patients, industry rec-ommendations, and in keeping with specific needs ofthe organization and criteria set forth by regulatoryand nonregulatory agencies (see Standard 8,Research and Evidence-Based Practice). 1,2 (V)

C. The organization should have a process to developpolicies, procedures, and/or practice guidelines thatare evidence based, maintains the same standard ofcare throughout the organization, and includes allstakeholders.1,2,4 (V)

D. Procedural checklist(s) should be incorporated intopolicies, procedures, and/or practice guidelines to pro-mote patient safety and desired patient outcomes.5(III)

REFERENCES

1. Sierchio G. Quality management. In: Alexander M, Corrigan A, GorskiL, Hankins J, Perucca R., eds. Infusion Nursing An Evidence-BasedApproach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:22-48.

2. Institute of Medicine. Crossing the Quality Chasm: A New Health Systemfor the 21st Century. Washington, DC: National Academy Press; 2001.


4. Agency for Healthcare Research and Quality: Charting Nursing’sFuture, July 2009, Part II—Addressing the Quality and Safety Gap—Part II: How Nurses Are Shaping, and Being Shaped by, HealthInformation Technologies. http://www.rwjf.org/files/research/20090709chartingissue11.pdf. Accessed February 26, 2010.

5. Pronovost P, Needham D, Berenholtz S, et al. An intervention todecrease catheter-related bloodstream infections in the ICU. N EnglJ Med. 2006;355(26):2725-2732.

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Copyright © 2011 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.VOLUME 34 | NUMBER 1S | JANUARY/FEBRUARY 2011 S15

Introduction of information technology shouldincorporate the principles of patient safety andinvolve all stakeholders in implementing the tech-nology and required processes.2-7 (III)

C. Adherence to prescribing guidelines, such asappropriate dose ranges, population-specificdose reductions, and biochemical and microbio-logical test values, may result from the integra-tion of CDSS with CPOEs, thus facilitating nurs-ing assessment of order appropriateness.5,8 (IV)

D. The nurse should advocate for organizational proto-cols and standard order sets for patient safety.7,9-11

(IV)E. The nurse should accept verbal orders from LIPs

only when medically necessary.11,12 (IV)F. The nurse should adhere to a standard “read-

back” process when accepting verbal or telephoneorders from an LIP.6,12 (V)

REFERENCES

1. Tully MP, Ashcroft DM, Dornan T, Lewis PJ, Taylor D, Wass V.The causes of and factors associated with prescribing errors inhospital inpatients: a systematic review. Drug Saf. 2009;32(10):819-836.

2. Reckmann MH, Westbrook JI, Koh Y, Lo C, Day RO. Does com-puterized provider order entry reduce prescribing errors for hospi-tal inpatients? A systematic review. J Am Med Inform Assoc. 2009;16(5):613-623.

3. Shamliyan T, Duval S, Du J, Kane R. Just what the doctor ordered:review of the evidence of the impact of computerized physicianorder entry system on medication errors. Health Serv Res. 2008;43(1):32-53.

4. van Rosse F, Maat B, Rademaker C, van Vught A, Egberts A, BollenC. The effect of computerized physician order entry on medicationprescription errors and clinical outcome in pediatric and intensivecare: a systematic review. Pediatrics. 2009;123(4):1184-1190.

5. Yu F, Menachemi N, Berner E, Allison J, Weissman N, HoustonT. Full implementation of computerized physician order entryand medication-related quality outcomes: a study of 3364 hospi-tals. Am J Med Qual. 2009;24(4):278-286.

6. National Quality Forum. Safe Practices for Better Healthcare,2009. Update: A Consensus Report. Washington, DC: NQF; 2009.

10. ORDERS FOR THE INITIATIONAND MANAGEMENT OF INFUSION THERAPY

Standard

10.1 Infusion therapy shall be initiated, changed, ordiscontinued upon the order of a licensed independentpractitioner (LIP).10.2 The nurse shall verify that the LIP’s order is com-plete by inclusion of patient identification; fluid type,volume, and a specific infusion rate; specific medica-tion(s), dosage(s), route, and frequency of administra-tion; and any special considerations.10.3 The nurse shall verify that the LIP’s order is clear,concise, legible, and complete prior to initiation,change, or discontinuation of infusion therapy.10.4 Use of verbal and telephone orders shall be estab-lished in organizational policies, procedures, and/orpractice guidelines.10.5 The nurse shall accept only those abbreviationsapproved by the organization.10.6 Appropriateness and accuracy of the prescribed ther-apy shall be assessed and documented using the nursingprocess.10.7 All patient medications shall be reconciled at thetime of admission, transfer within or between healthcare systems, and discharge.

Practice Criteria

A. The nurse should be aware that processes of pre-scribing and transcribing medication orders areresponsible for the greatest number of adversedrug events. The nurse should advocate for a sys-tems approach for improvement.1-3 (III)

B. Technology for enhancing the process of prescrib-ing, changing, and discontinuing infusion ordersincludes computerized provider order entry (CPOE)and clinical decision support systems (CDSS).

Patient Care


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7. Migita D, Postetter L, Heath S, Hagan P, Del Beccaro M.Governing peripherally inserted central venous catheters by com-bining continuous performance improvement and computerizedphysician order entry. Pediatrics. 2009;123(4):1155-1161.

8. Mack E, Wheeler D, Embi P. Clinical decision support systems in thepediatric intensive care unit. Pediatr Crit Care Med. 2009;10(1):23-28.

9. Mickle J, Reinke D. A review of anemia management in theoncology setting: a focus on implementing standing orders. Clin JOncol Nurs. 2007;11(4):534-539.

10. Weber LM, Ghafoor VL, Phelps P. Implementation of standardorder sets for patient-controlled analgesia. Am J Health Syst Pharm.2008;65(12):1184-1191.

11. Wakefield DS, Brokel J, Ward MM, et al. An exploratory studymeasuring verbal order content and context. Qual Saf HealthCare. 2009;18(3):169-173.

12. Wakefield D, Wakefield B. Are verbal orders a threat to patientsafety? Qual Saf Health Care. 2009;18(3):165-168.

11. PATIENT EDUCATION

Standard

11.1 The nurse shall educate the patient, caregiver,and/or legally authorized representative about the pre-scribed infusion therapy and plan of care, including, butnot limited to, purpose and expected outcome(s) and/orgoals of treatment, infusion therapy administration,infusion device-related care, potential complications, oradverse effects associated with treatment or therapy,and risks and benefits, according to organizational poli-cies, procedures, and/or practice guidelines.11.2 The nurse shall document the teaching content pro-vided; to whom it was provided; and the patient, caregiv-er, or legally authorized representative’s response in thepatient’s permanent medical record according to organi-zational policies, procedures, and/or practice guidelines.

Practice Criteria

A. Teaching methods should be developed and basedupon an assessment of age, developmental and cogni-tive level, health literacy, cultural influences, and lan-guage preference; additional factors affecting readi-ness to learn such as current stressors, sensorydeficits, and functional limitations should also beassessed.1-4 (V)

B. Health literacy is a critical component of communi-cation and patient education. Written educationalmaterials and verbal presentation of teachingshould be made as simple as possible for allpatients. Use of materials such as pictures, dia-grams, and audio/video instructional aids should beconsidered for patients with low or limited literacyand/or for those who speak English as a second lan-guage. Medical jargon and abbreviations should beavoided, and simple terminology should be used.1-8

(V)

C. Education should include, but not be limited to:1. Proper care of the access device.2. Precautions for preventing infection and other

complications, including aseptic technique andhand hygiene.

3. Signs and symptoms to report, including thosethat may occur after infusion device removaland after the patient leaves the health care set-ting (eg, signs of postinfusion phlebitis, fever)and how/where to report them.

4. Ensuring that health care providers areemploying proper infection prevention meth-ods, such as hand hygiene, when providingcare.

5. For outpatients and those receiving home infusiontherapy, additional education should include:a. Safe storage, maintenance, and disposal of

solutions, supplies, and equipment.b. Infusion administration as appropriate.c. Information on how to live with an access

device, including activity limitations andprotecting the device while performing activ-ities of daily living.3,8-14 (V)

D. Patient or caregiver comprehension and perfor-mance should be initially evaluated and periodi-cally reevaluated at established intervals.1-4,11,12

(V)E. Effective education is critical to the safe provision

of infusion therapy and in reducing the risk forinfusion-related complications. Goals of infusiontherapy and the patient/caregiver role related toperformance of specific aspects of infusion careshould be mutually developed with the patient orcaregiver. 1,3,4,11,15 (IV)

REFERENCES

1. Czaplewski L. Clinician and patient education. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:71-94.

2. Bass L. Health literacy: implications for teaching the adultpatient. J Infus Nurs. 2005;28(1):15-22.

3. Gorski LA. Pocket Guide to Home Infusion Therapy. Sudbury,MA: Jones & Bartlett; 2005.


5. Walker J, Gerard PS. Assessing the health literacy levels ofpatients using selected hospital services. Clin Nurse Specialist.2010;24(1):31-37.

6. US Department of Health and Human Services. Healthy People2010: Understanding and Improving Health. 2nd ed. Washington,DC: DHHS; 2010.

7. National Network of Libraries of Medicine. Health literacy.http://nnlm.gov/outreach/consumer/hlthlit.html. Accessed December30, 2009.

8. Denham CR. SBAR for patients. J Patient Safety. 2008;4(1):38-48.

Copyright © 2011 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.S16 Journal of Infusion Nursing

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9. National Quality Forum. Safe practice 21: central line associatedbloodstream infection prevention. In: Safe Practices for BetterHealthcare, 2009. Update: A Consensus Report. Washington,DC: NQF; 2009:225-229.

10. Registered Nurses Association of Ontario. Nursing best practiceguideline: care and maintenance to reduce vascular access compli-cations. http://www.rnao.org/Storage/39/3379_Assessment_and_Device_Selection_for_Vascular_Access._with_2008_Supplement.pdf. Revised 2008. Accessed December 30, 2009.

11. Gorski LA, Czaplewski LM. PICC and midline catheters for thehome care nurse. J Infus Nurs. 2004;27(6):399-409.

12. Tice AD. Handbook of Outpatient Parenteral AntimicrobialTherapy. Tarrytown, NY: CRG Publishing; 2006.

13. US Centers for Disease Control and Prevention (CDC). Frequentlyasked questions about “catheter associated bloodstream infec-tions.” http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/BSI_tagged.pdf. Accessed December 30, 2009.

14. Perucca R. Peripheral venous access devices. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:456-479.

15. Moller T, Borregaard N, Tvede M, Adamsen L. Patient education:a strategy for prevention of infections caused by permanent cen-tral venous catheters in patients with hematological malignancies:a randomized clinical trial. J Hosp Infect. 2005;61(4):330-341.

12. INFORMED CONSENT

Standard

12.1 The nurse shall confirm that the patient’sinformed consent was obtained for the defined proce-dure as identified in organizational policies, procedures,and/or practice guidelines and in accordance with local,state, and federal regulations.12.2 Consent shall be obtained by the health careprovider who will perform the procedure and shallinclude full details of the procedure, risks and benefits,alternatives, and complications associated with thetreatment or therapy, in a language that the patient orlegally authorized representative can understand.12.3 The nurse shall advocate for the patient’s or legallyauthorized representative’s right to accept or refuse treat-ment.

Practice Criteria

A. The nurse should be knowledgeable of the proto-col for obtaining informed consent from thepatient or legally authorized representative, bothverbally and written, and ensure that the informa-tion given to the patient or legally authorized rep-resentative has included discussion of risks, bene-fits, alternatives, and complications associatedwith the treatment or therapy. This should bedone in a method such as asking the patient torecount or “teach back” the proposed treatmentor procedure.1-7 (V)

B. The nurse should verify that informed consent wasobtained for the treatment for neonatal, pediatric,and adolescent patients from the patient’s parentor legal guardian, and should document the infor-mation given to the legally authorized representa-tive(s) and the response in the patient’s permanentmedical record.4,8-10 (V)

C. The nurse should obtain and document the child’s(age 7 or older) or teenager’s assent to the proce-dure, tailoring the information with considerationfor knowledge and developmental level.11-13(V)

D. As elements of informed consent, the nurse shouldensure that the patient, parent, or legally authorizedrepresentative, at a minimum, should be able toexplain in everyday words the diagnosis or healthproblem; the name, type, and general nature of thetreatment, service, or procedure; and the primaryrisks, benefits, and alternatives.5,11 (V)

E. The nurse should ensure that informed consentincludes the following elements:1. Documents written at or below the 5th-grade

reading level and provided in the primary lan-guage of the patient.

2. Provision of a qualified medical interpreter orreader to assist patients with limited languageproficiency, limited health literacy, and visual orhearing impairments.

3. Patient-centered information that is adequateand meaningful to the individual.

4. A dialogue with the patient and, as appropriate,the family and other decision makers, about the nature and scope of the procedure.6-8,14

(V)F. The nurse should ensure that if the patient’s con-

dition does not allow for such interaction, appro-priate documentation is provided in the patient’spermanent medical record.11 (V)

REFERENCES

1. Alexander M, Webster HK. Legal issues of infusion nursing. In:Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds.Infusion Nursing: An Evidence-Based Approach. 3rd ed. StLouis, MO: Saunders/Elsevier; 2010:49-59.

2. Nettina SM, ed. The Lippincott Manual of Nursing Practice.8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:16.

3. Smith SF, Duell DJ, Martin BC. Clinical Nursing Skills: Basic toAdvanced Skills. 6th ed. Upper Saddle River, NJ: PearsonEducation; 2004:7-8, 54-55.

4. Cheung, W Pond G, Geslegrave, R, Enright K, Potanina L, Siu L.The contents and readability of informed consent forms for oncolo-gy clinical trials. Am J Clin Oncol. 2010;33(4):387-392.

5. Sims, JM. Your role in informed consent. Dimens Crit Care Nurs.2008;7(3):118-121.

6. Holmes-Rovner M, Wills C. Improving informed consent:insights from behavioral decision research. Med Care. 2002;40(9)(suppl):V30-V38.


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7. National Quality Forum. Safe Practices for Better Healthcare—2009 Update: A Consensus Report. Washington, DC: NQF;2009.

8. Paasche-Orlow MK, Taylor HA, Brancati FL. Readability stan-dards for informed consent forms as compared with actual read-ability. N Engl J Med. 2003;348(8):721-726.

9. Simon CM, Siminoff LA, Kodish ED, Burant C. Comparison ofthe informed consent process for randomized clinical trials inpediatric and adult oncology. J Clin Oncol. 2004;22(13):2708-2729.

10. Committee on Bioethics, American Academy of Pediatrics. AAPpublications retired or reaffirmed, October, 2006. Informed con-sent, parental permission and assent in pediatric practice.Pediatrics. 2007;119:405. doi: 10.1542/peds.2006-3222.

11. Joint Commission on Accreditation of Healthcare Organizations.Comprehensive Accreditation Manual for Hospitals: The OfficialHandbook (CAMH). Oakbrook Terrace, IL: JCAHO; 2009.

12. Rossi WC, Reynolds W, Nelson RM. Child assent and parentalpermission in pediatric research. Theor Med Bioeth. 2003;24(2):131-148.

13. Szalados JE. Legal issues in the practice of critical care medicine: apractical approach. Crit Care Med. 2007;35(suppl 2):S44-S58.

14. Agre P, Rapkin B. Improving informed consent: a comparison offour consent tools. IRB. 2003;25(6):1-7.

13. PLAN OF CARE

Standard

13.1 The nurse shall collect comprehensive data perti-nent to the patient’s health care needs.13.2 The nurse shall analyze assessment data and deter-mine nursing diagnosis (problem).13.3 The nurse shall identify outcome criteria based onnursing diagnoses.13.4 The nurse shall develop a plan of care thatdescribes nursing actions to achieve expected outcomes.13.5 The nurse shall implement nursing actions identi-fied in the plan of care.13.6 The nurse shall evaluate the patient’s progresstoward expected outcomes, revising the plan of care asappropriate and at established intervals.13.7 The use of care plans shall be established in organi-zational policies, procedures, and/or practice guidelines.

Practice Criteria

A. Nursing assessment should be systematic and pri-oritized by patient needs, based on organizationalpolicies, procedures, and/or practice guidelinesusing best evidence and nursing judgment.1,2 (V)

B. The nurse should develop nursing diagnoses (actu-al or potential bio-psychosocial patient problems)based on pertinent and accurate assessments.1-4 (V)

C. The nurse should develop interventions consistentwith the established plan of care, achievable in the cur-rent patient context, and based on best evidence.1,3,5

(V)

D. The nurse should determine the type and frequen-cy of patient monitoring based on the prescribedtherapy, access device, patient’s condition andage, and care setting.1,6-8 (V)

E. The nurse should develop outcome criteria inrelation to the patient’s capabilities, availability,and accessibility to resources, and should includea time frame for achievement.1 (V)

F. The nurse should conduct an ongoing evaluationof the plan of care and revise diagnoses, interven-tions, and outcome criteria as needed.1,2 (V)

G. The nurse should develop a plan of care that isminimally composed of assessment, diagnoses,interventions, and outcome criteria; uses nursingjudgment and critical thinking; is individualized forthe patient, spanning the care continuum as need-ed; and includes, but is not limited to, age, cultur-al and linguistic appropriateness, environmentalsensitivity, and socioeconomic factors.1,3,6-11 (IV)

H. The nurse should involve the patient, caregiver, orlegally authorized representative in the develop-ment, evaluation, and revision of the plan of careto achieve expected outcomes.1,12,13 (V)

I. The nurse should collaborate with other membersof the health care team in the development, eval-uation, and revision of the plan of care and com-municate the plan to the team.1,6,14 (V)

J. The documented plan of care should be in a stan-dardized language or terminology, in a retrievableformat, and contained within the patient’s perma-nent medical record.1,10,11,15-17 (V)

REFERENCES


2. Carpenito-Moyet L. The bifocal clinical practice model. In:Carpenito-Moyet L. Nursing Care Plans & Documentation:Nursing Diagnoses and Collaborative Problems. New York, NY:Wolters Kluwer/Lippincott Williams & Wilkins; 2009:3-8.

3. Duckett K. Creating a POC from the initial assessment: tips foraccurately completing other diagnoses and orders for disciplineand treatments. Home Healthc Nurse. 2005;23(4):210-212.

4. Herdman TH, ed. Nursing Diagnoses: Definitions andClassification, 2009-2011. Ames, IA: Wiley-Blackwell; 2009.

5. Hagle M, Senk P. Evidence-based practice. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:10-21.

6. Adams-Wendling L, Piamjariyakul U, Bott M, Taunton R.Strategies for translating the resident care plan into daily practice.J Gerontol Nurs. 2008:34(8):50-56.


8. American Nurses Association. Nursing’s Social Policy Statement.2nd ed. Silver Spring, MD: ANA; 2003.

9. Cayir G, Beji N, Yalcin O. Effectiveness of nursing care after surgeryfor stress urinary incontinence. Urologic Nurs. 2007:27(1):25-33.

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10. Lang N, Hook M, Akre M, et al. Translating knowledge-basednursing into referential and executable applications in an intelli-gent clinical information system. In: Weaver C, Delaney C,Webber P, Carr R, eds. Nursing and Informatics for the 21stCentury: An International Look at Practice, Trends and theFuture. Chicago, IL: Healthcare Information and ManagementSystems Society; 2006:291-303.

11. Shearburn P, Kratz M. Utilization of error analysis data inchemotherapy order preparation for development of a comprehen-sive electronic chemotherapy plan of care. Oncol Nurs Forum.2009;36(3):76.

12. Penticuff J, Arheart K. Effectiveness of an intervention to improveparent-professional collaboration in neonatal intensive care. JPerinat Neonatal Nurs. 2005;19(2):187-202.

13. Specht J, Taylor R, Bossen, A. Partnering for care: the evidenceand the expert. J Gerontol Nurs. 2009:35(3):16-22.

14. Stewart J, Stansfield K, Tapp K. Clinical nurses’ understanding ofautonomy. J Nurs Adm. 2004;34(10):443-450.

15. Keenan G, Yakel E, Tschannen D, Mandeville M. Documentationand the nurse care planning process. In: Hughes RG, ed. PatientSafety and Quality: An Evidence-Based Handbook for Nurses.Rockville, MD: Agency for Healthcare Research and Quality:1-32. AHRQ Publication No. 08-0043. http://www.ahrq.gov/qual/nurseshdbk/. Published 2008. Accessed November 18, 2009.

16. The Joint Commission. Accreditation Program: Home Care—Standard RC.02.01.01. Oakbrook Terrace, IL: TJC; 2009.

17. The Joint Commission. Accreditation Program: Hospital—Standard RC.02.01.01. Oakbrook Terrace, IL: TJC, 2008.


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and all long-term infusion devices, include themanufacturer and lot number.5,10,11 (V)

4. Date and time of insertion, number and loca-tion of attempts, functionality of device, localanesthetic (if used), and the insertion methodol-ogy, including visualization and guidance tech-nologies.5,11 (V)

5. Identification of the insertion site by anatomi-cal descriptors, laterality, landmarks, orappropriately marked drawings.10,12 (V)

6. For midline (ML) and peripherally insertedcentral catheters (PICCs): external catheterlength and effective length of catheter insert-ed.5,13 (V)

7. Confirmation of the anatomic location of thecatheter tip for all CVADs prior to initial use andas needed for evaluation of catheter dysfunc-tion.5,11 (V)

8. Condition of the site, dressing, type of catheterstabilization, dressing change, site care, patientreport of discomfort or pain on device inser-tion and with each regular assessment of theaccess site, and patient report of changes relat-ed to the VAD or access site.4,14 (V)

9. A standardized assessment, appropriate for age-specific patient populations, for phlebitis, infiltra-tion, or extravasation, that allows for accurateand reliable assessment on initial identificationand with each subsequent site assessment (seeStandards 47, Phlebitis; 48, Infiltration andExtravasation).13,14 (V)

10. Type of therapy, drug, dose, rate, time, routeand method of administration; include condi-tion of venipuncture or access site prior to andafter infusion therapy, as well as patency.3,14-16

(V)11. Pertinent nursing diagnosis (problem), initial

and ongoing assessment, and vital signs asappropriate; patient’s response to insertionand therapy, including symptoms, side effects,or complications; laboratory test results as

14. DOCUMENTATION

Standard

14.1 Documentation shall contain accurate, factual,and complete information in the patient’s permanentmedical record regarding the patient’s infusion therapyand vascular access.14.2 Documentation shall be legible, timely, accessibleto qualified personnel, and readily retrievable.14.3 Documentation shall include factors relating toinitial and ongoing assessment, nursing diagnosis orproblem, intervention, and the patient’s response to thatintervention.14.4 Documentation shall reflect the continuity, quali-ty, and safety of care.14.5 Documentation guidelines and the confidentialityof the patient’s permanent medical record shall beestablished in organizational policies, procedures,and/or practice guidelines, according to the scope ofpractice for personnel, standards of care, accreditingagencies, and state and federal regulations.

Practice Criteria

A. Documentation should be done by appropriateclinical personnel, and identify the person provid-ing the care.1-3 (V)

B. Documentation should include, but not be limitedto, the following:1. Patient, caregiver, or legally authorized represen-

tative’s participation in and understanding of ther-apy, interventions, and patient education.3-6 (V)

2. Specific site preparation, infection prevention,and safety precautions taken, using a stan-dardized tool for documenting adherence torecommended practices.6-9 (IV)

3. For all infusion devices, type, length, and gauge/size of vascular access device (VAD) inserted;for central vascular access devices (CVADs)

Documentation


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appropriate; and barriers to patient educationor care.14,17-21 (V)

12. Daily assessment of the need for continuationof the VAD.22-25 (IV)

13. Upon removal: condition of site, condition ofthe catheter and length, reason for deviceremoval, nursing interventions during removal,dressing applied, patient response, patient edu-cation, date/time of removal.4,5 (V)

14. If cultures are obtained, document source of culture(s).4,5 (V)

15. When multiple access devices or catheterlumens are used, documentation should clearlyindicate what fluids and medications are beinginfused through each pathway.4,5 (V)

REFERENCES

1. Bravery K, Dougherty L, Gabriel J, Kayley J, Malster M, ScaiesK. Audit of peripheral venous cannulae by members of an IVtherapy forum. Br J Nurs. 2006;15(22):1244-1249.

2. Johansson M, Pilhammar E, Khalaf A, Willman A. Registerednurses’ adherence to clinical guidelines regarding peripheral venouscatheters: a structured observational study. Worldviews Evid-Based Nurs. 2008;5(3):148-159.

3. Maxwell B. Documentation and informatics. In: Potter P, Perry A.Fundamentals of Nursing. 7th ed. St Louis, MO: Mosby/Elsevier;2009:384-409.

4. Gorski L, Perucca R, Hunter M. Central venous access devices:care, maintenance, and potential complications. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:495-515.

5. Hagle M, Johnson B, Ladewig N, Montenero D, Pawlak T.Central venous access. In: Weinstein S, ed. Plumer’s Principles &Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007:277-330.

6. Morris W, Tay M. Strategies for preventing peripheral intra-venous cannula infection. Br J Nurs. 2008;17(19)(suppl):S14-S21.

7. Aziz A. Improving peripheral IV cannula care: implementinghigh-impact interventions. Br J Nurs. 2009;18(20):1242-1246.

8. Centers for Disease Control and Prevention (CDC). Reduction incentral line-associated bloodstream infections among patients inintensive care units: Pennsylvania, April 2001-March 2005.MMWR Morb Mortal Wkly Rep. 2005;54(40):1013-1016.

9. Siegel JD, Rhinehart E, Jackson M, Chiarello L; HealthcareInfection Control Practices Advisory Committee. 2007 guideline forisolation precautions: preventing transmission of infectious agentsin healthcare settings. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/isolation2007.pdf. Accessed February 5, 2010.

10. Ahlqvist M, Berglund B, Wiren M, Klang B, Johansson E.Accuracy in documentation: a study of peripheral venouscatheters. J Clin Nurs. 2009;18:1945-1952.

11. Bullock-Corkhill M. Central venous access devices: access andinsertion. In: Alexander M, Corrigan A, Gorski L, Hankins J,Perucca R, eds. Infusion Nursing: An Evidence-Based Approach.3rd ed. St Louis, MO: Saunders/Elsevier; 2010:480-494.

12. Ahlqvist M, Bogren A, Hagman S, et al. Handling of peripheralintravenous cannulae: effects of evidence-based clinical guide-lines. J Clin Nurs. 2006;15:1354-1361.

13. Perucca R. Peripheral venous access devices. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier;2010:456-479.

14. Dugger B. Documentation. In: Alexander M, Corrigan A, GorskiL, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:540-549.

15. Buckner S. Medication administration. In: Potter P, Perry A, eds.Fundamentals of Nursing. 7th ed. St Louis, MO: Mosby/Elsevier;2009:686-770.

16. Burke K, Asimos K. Medication administration. In: Ackley B,Ladwig G, Swan B, Tucker S, eds. Evidence-Based Nursing CareGuidelines: Medical-Surgical Interventions. St Louis, MO:Mosby/Elsevier; 2008:508-512.

17. Alfaro-LeFevre R. Applying Nursing Process: A Tool for CriticalThinking. New York, NY: Wolters Kluwer/Lippincott Williams& Wilkins; 2010:195-208.


19. Keenan G, Yakel E, Tschannen D, Mandeville M. Documentationand the nurse care planning process. In: Hughes RG, ed. PatientSafety and Quality: An Evidence-Based Handbook for Nurses.Rockville, MD: Agency for Healthcare Research and Quality;2008:1-32. AHRQ Publication No. 08-0043. http://www.ahrq.gov/qual/nurseshdbk/. Accessed June 23, 2010.

20. Potter P. Nursing assessment. In: Potter P, Perry A, eds.Fundamentals of Nursing. 7th ed. St Louis, MO: Mosby/Elsevier;2009:230-246.

21. Potter P. Evaluation. In: Potter P, Perry A. Fundamentals ofNursing. 7th ed. St Louis, MO: Mosby/Elsevier; 2009:290-300.

22. Centre for Healthcare-Related Infection Surveillance andPrevention. Peripherally inserted central catheter (PICC): recom-mended practices, version 3. http://www.health.qld.gov.au/chrisp/icare/picc_rec_prac.pdf. Published January 2009. Accessed January17, 2010.

23. Centre for Healthcare-Related Infection Surveillance andPrevention. Percutaneous central venous catheter (CVC): recom-mended practices, version 3. http://www.health.qld.gov.au/chrisp/icare/perc_cvc_rec_prac.pdf. Published January 2009. AccessedJanuary 17, 2010.

24. Joanna Briggs Institute. Management of peripheral intravasculardevices. Aust Nurs J. 2008;16(3):25-28.

25. Powell J, Tarnow K, Perucca R. The relationship between periph-eral intravenous catheter indwell time and the incidence ofphlebitis. J Infus Nurs. 2008;31(1):39-45.

15. UNUSUAL OCCURRENCE ANDSENTINEL EVENT REPORTING

Standard

15.1 The nurse shall report and document unusualoccurrences or sentinel events in practice as a result ofinfusion therapy according to organizational policies,procedures, and/or practice guidelines.15.2 Reporting of unusual occurrences and sentinelevents shall be defined in organizational policies, proce-dures, and/or practice guidelines.


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Practice Criteria

A. The Unusual Occurrence and Sentinel EventReport should be shared with the appropriateorganizational levels and departments, such as riskmanagement (RM), nursing management, andquality improvement (QI) teams.1-7 (V, Regulatory)

B. The event reporting process should incorporateand exhibit a strong culture of safety or “just cul-ture” by creating an environment that encouragesreporting, empowers the nurse to identify andimplement appropriate action to prevent adverseevents, focuses on fixing the system(s) instead ofindividual responsibility, determines cause, is con-sidered a learning opportunity, and promotesquality patient outcomes.1,8-15 (IV)

C. The adverse, significant, preventable complications,Unusual Occurrence, or Sentinel Event Reportshould be written and reviewed, with the reportedevent(s) analyzed, trends identified, and retained ina retrievable form to ensure patient safety.1,2 (V)

D. The organization should have a defined process toinvestigate an unusual occurrence or sentinel event toassess cause and improve safety. This process mayinclude such actions as a root cause analysis (RCA),peer review, or an individual action plan.1,16-18 (V)

E. The RCA, an interdisciplinary approach, shouldfocus on systems issues, procedures, humanresources, products/equipment, processes, andtraining gaps. The RCA should identify cause(s),provide an analysis of the event, and should resultin specific strategies and/or actions for improve-ment that enhance patient safety.6,16-18 (V)

F. The nurse should actively participate in the RCAprocess and in the development and implementa-tion of the action plan derived from the RCA.1(V)

G. The nurse should communicate unanticipated nurs-ing outcomes that are within the control or account-ability of the nurse to the patient, caregiver, or legal-ly authorized representative. The nurse should beinvolved in the predisclosure planning discussion andparticipate as a member of the disclosure team pro-viding information to the patient, caregiver, or legal-ly authorized representative.10,19 (V)

REFERENCES

1. Creating and sustaining a culture of safety. In: Keeping PatientsSafe: Transforming the Work Environment of Nurses.Washington, DC: National Academies Press; 2004. http://books.nap.edu/openbook.php?record_id=10851&page=286. Accessed July8, 2009.

2. Joint Commission on Accreditation of Healthcare Organizations.Sentinel Event Policy and Procedures, 2005. http://www.jcaho.org/accredited!organizations/ambulatory!care/sentinel/events/index.htm. Accessed July 8, 2009.

3. Centers for Medicare & Medicaid Services. Eliminating serious,preventable and costly medical errors—“never events.” http://www.

cms.hhs.gov/apps/media/press/release/asp?counter/1863.Published May 18, 2006. Accessed July 10, 2009.

4. Centers for Medicare & Medicaid Services. Incorporating select-ed national quality forum and never events into Medicare’s list ofhealthcare-acquired conditions. http://www.cms.hhs.gov/apps/media/press/release.asp? Published April 14, 2008. Accessed July10, 2009.

5. National Quality Forum. Serious Reportable Events in PatientSafety: A National Quality Forum Consensus Report, 2002.Washington, DC: NQF; 2002.

6. Sierchio G. Quality management. In: Alexander M, Corrigan A, GorskiL, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-BasedApproach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:22-48.

7. Alexander M, Webster H. Legal issues of infusion nursing. In:Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds.Infusion Nursing: An Evidence-Based Approach. 3rd ed. StLouis, MO: Saunders/Elsevier; 2010: 49-59.

8. Institute of Medicine. To Err Is Human: Building a Safer HealthSystem. Washington, DC: National Academy Press; 2000.

9. Joint Commission on Accreditation of Healthcare Organizations.Sentinel Event Alert: Behaviors That Undermine a Culture ofSafety. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm. Published July 9, 2008. Accessed July 8, 2010.

10. Shannon S, Foglia M, Hardy M, Gallagher T. Disclosing errors topatients: perspectives of registered nurses. The Joint CommissionJ Quality Patient Safety. 2009;35(1):5-12.

11. ECRI Institute. Disclosure of unanticipated outcomes. IncidentReporting and Management. 2008;5(suppl A):1-21. http://www.ecri.org. Published January 2008. Accessed July 29, 2009.

12. Krein S, Holer T, Kowalski C, et al. Use of central venouscatheter-related bloodstream infection prevention practices in UShospitals. Mayo Clin Proc. 2007;82(6):672-678.

13. American Nurses Association [position statement]. Just Culture.http://www.nursingworld.org/psjustculture. Accessed January 23,2010.

14. American Organization of Nurse Executives (AONE). GuidingPrinciples: The Role of the Nurse Executive in Patient Safety.http://www.aone.org/resource/PDF/AONE_GP_Role_Nurse_Exec_Patient_Safety.pdf. Published 2007. Accessed January 22, 2010.

15. American Nurses Association. Nursing Administration: Scopeand Standards of Practice. Silver Spring, MD: ANA; 2009.

16. Institute for Safe Medical Practice. Root causes: a roadmap toaction. ISMP Medication Safety Alert. 2004;9(17):1-3.

17. Dattilo E, Constantino R. Root Cause analysis and nursing man-agement responsibility in wrong-site surgery. Dimens Crit CareNurs. 2006;25(5):221-225.

18. McDonald, A. Leyhans T. Drill down with root cause analysis.Nurs Manage. 2005;36(10):26-31.

19. Weiss P, Miranda F. Transparency, apology and disclosure ofadverse outcomes. Obstet Gynecol Clin North Am. 2008;35:53-62.

16. PRODUCT EVALUATION,INTEGRITY, AND DEFECTREPORTING

Standard

16.1 The nurse shall be involved in the evaluation of infusion-related technologies, including attention to

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clinical application, expected outcomes, performance,infection prevention, safety, efficacy, reliability, and cost.16.2 All infusion equipment and supplies shall beinspected for product integrity before, during, and afteruse. Product integrity shall be determined by verifica-tion of expiration date, if applicable, and visual inspec-tion of the product. If a product’s integrity is compro-mised or the product is expired, it shall not be used.16.3 The nurse shall verify that preventive maintenancehas been performed on infusion equipment being used.16.4 When a defective product is identified, the nurseshall remove it from patient use and report per organi-zational policies, procedures, and/or practice guidelines.16.5 Product evaluation, integrity, defect reporting, andproduct recall shall be in accordance with organization-al policies, procedures, and/or practice guidelines andwith state and federal rules and regulations.

Practice Criteria

A. A multidisciplinary group of direct and indirectend users should be included in the product evalu-ation committee and should be oriented and edu-cated on the new product, as well as data collectiontools for analysis and ongoing monitoring.1 (V)

B. The person responsible for managing productevaluation should receive information aboutadverse outcomes and events.2 (V)

C. Identification of a product defect before, during,or upon completion of therapy requires interven-tion and removal of the product from the clinicallocation.3,4 (Regulatory)

D. Product defect reporting should include suspectedand known intrinsic and extrinsic contamination,product damage, product tampering, improper,unclear, or confusing patient or user instructionsor labeling, similar or confusing names, packag-ing problems, and errors related to reliance oncolor coding (see Standard 17, Verification ofProducts and Medications).1,3-10 (IV, Regulatory)

E. When a product defect is identified before use, thenurse should retain the product, product over-wraps, and other identifying information (modelnumber, lot number, serial number, expirationdate) for further analysis and reporting.1 (V)

F. Serial and lot numbers used in product identifica-tion, tracking, and product recall should beretained to allow for a copy of the report to be kepton file at the health care organization.3 (Regulatory)

G. When a product defect results in an unusualoccurrence or sentinel event, reporting shouldinclude, but not be limited to:1. Identification of occurrence, event, or product

problem.2. Outcomes attributed to the occurrence or event

(eg, death or serious injury).

3. Life-threatening injury or illness.4. Disability resulting in permanent impairment of

a body function or permanent damage to abody structure.

5. Injury or illness that requires intervention toprevent permanent impairment of a body struc-ture or function.

6. Date of event.7. Date of report by the initial reporter.8. Description of event or problem, including a dis-

cussion of how the device was involved, natureof the problem, patient follow-up or requiredtreatment, and any environmental conditionsthat may have influenced the event.

9. Description of relevant tests and laboratorydata, including dates.

10. Description of other relevant patient history, includ-ing preexisting medical conditions.3 (Regulatory)

H. Prevention strategies that focus on facilitatingoptimal care decisions, identifying patients or con-ditions associated with higher risk, and enablingearly detection and intervention to address riskfactors may be more effective in improving safetyand reducing preventable adverse events.4 (V)

REFERENCES

1. Miller C. Product selection and evaluation. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:437-446.

2. Larsen GY. Preventable harm occurring to critically ill children.Pediatr Crit Care Med. 2007;8(4):331-336.

3. US Food and Drug Administration. Medical Devices. 3 CFR Title21. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart"803&showFR"1&subpartNode"21:8.0.1.1.3.3. Revised April 1, 2009. Accessed September 16, 2009.

4. Patient Safety and Quality Improvement Act of 2005, 42 USC.2005. http://www.pso.ahrq.gov/statute/pl109-41.pdf. PublishedJuly 29, 2005. Accessed March 19, 2010.

5. Samore MH, Evans RS, Lassen A, et al. Surveillance of medicaldevice-related hazards and adverse events in hospitalized patients.JAMA. 2004;291(3):325-334.

6. Institute of Medicine. Crossing the Quality Chasm: A NewHealth System for the 21st Century. Washington, DC: NationalAcademy Press. 2001.

7. Radhika V, Assaf RR, Al-Assaf AF. JHQ 197: Making the PatientSafety and Quality Improvement Act of 2005 Work. NationalAssociation for Healthcare Quality. http://www.nahq.org/journal/ce/article.html?article_id"282. Accessed April 1, 2010.

8. US Department of Labor. Occupational Safety and HealthAdministration. Safe Medical Devices Act: Medical DeviceReporting for User Facilities, 21 USC § 360i (1990).

9. Deacon VL. The safe medical device act and its impact on clini-cal practice. J Infus Nurs. 2004;27(1):31-36.

10. American Nurses Association [position statement]. Safety IssuesRelated to Tubing and Catheter Misconnections. Silver Spring,MD: ANA; 2007.



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17. VERIFICATION OF PRODUCTSAND MEDICATIONS

Standard

17.1 The nurse shall identify and verify use of the cor-rect product and/or medication by reviewing the labelfor the name (trade and generic), dosage and concentra-tion, beyond-use date, expiration date, sterility state,route of administration, frequency, flow rate, and anyother special instructions.17.2 The nurse shall trace all catheters/administrationsets/add-on devices from the patient to the point of ori-gin before making additional connections of medicationsor tubing.17.3 The process of medication and product verifica-tion shall be established in organizational policies, pro-cedures, and/or practice guidelines.

Practice Criteria

A. The nurse should not use color coding, color differ-entiation, or color matching for product or medica-tion identification. Color coding can lead users torely on the color coding rather than ensuring a clearunderstanding of which tubing and catheters areconnected.1,2 (V)

B. Confusing labeling should be reported to the appro-priate department within the organization to allowfor process improvements and reporting to themanufacturer and appropriate state and federal reg-ulatory agencies.2 (V)

C. Unit-dose and premixed infusions are preferred toreduce compounding and labeling errors anddecrease medication errors.3 (V)

D. The nurse should recheck administration set/catheterconnections and trace all catheters/administrationsets/add-on devices from the patient to the point oforigin when a patient is transferred to a new settingand as part of the hand-off process.3-10(IV)

E. The nurse should instruct the patient, nonclinicalstaff, and caregivers to obtain assistance from clin-ical staff whenever there is a real or perceived needto connect or disconnect devices or infusions.5 (V)

F. The nurse should route tubing having different pur-poses in different directions (eg, IV catheters routed

toward the head; feeding tubes routed toward thefeet).11 (IV)

G. The nurse should avoid writing directly on the IV bagor use a marking pen to label the IV bag. There is thepossibility that certain chemical components of theinks used in marking pens may permeate the plasticsheeting and compromise the contained solution.Labeling in this manner may also lead to smearing, whichwould cause the labeling to be unrecognizable.1 (V)

REFERENCES

1. Phillips L. Manual of IV Therapeutics: Evidence-BasedApproach. 5th ed. Philadelphia, PA: FA Davis; 2010:237,268.

2. Hadaway L. Infusion therapy equipment. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:424-425.

3. Just S, Schepers G, Piotrowski MM, Saint S, Kauffman CA.Improving the safety of intravenous admixtures: lessons learnedfrom a Pentostam overdose. Jt Comm J Qual Patient Safety. 2006;32(7):366-372.

4. The Joint Commission announces the 2008 National patient safe-ty goals and requirements. Jt Comm Perspect. 2007;27(7):1,9-22.

5. The Joint Commission. Tubing misconnections: a persistent andpotentially deadly occurrence. 2005;36. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_36.htm. Published April3, 2006. Accessed February 11, 2010.

6. Guenter P, Simmons D, Crowley J, et al. Enteral feeding miscon-nections: a consortium position statement. Jt Comm J QualPatient Safety. 2008;34(5):285-292.

7. Gallauresi B, Morrison A. Misconnections between medicaldevices with luer connectors: underrecognized but potentiallyfatal events in clinical practice. Safe Pract Patient Care. 2007;3(2).http://www.safe-practices.org/SafePractice8.pdf. Accessed May 23, 2009.

8. Institute for Safe Medication Practice. Problems persist with life-threatening tubing misconnections. ISMP Medication Safety Alert.2004; http://www.ismp.org/newsletters/acutecare/articles/20040617.asp. Published June 17, 2004. Accessed November 3, 2009.

9. WHO Collaborating Centre for Patient Safety Solutions.Avoiding catheter and tubing misconnections. 2007;1(7). http://www.ccforpatientsafety.org/fpdf/presskit/PSSolution7.pdf. AccessedJanuary 12, 2010.

10. US Food and Drug Administration. More patient deaths from luermisconnections. FDA Patient Safety News. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show"68#5.Published October 2007. Accessed November 3, 2009.

11. American Nurses Association [position statement]. Safety IssuesRelated to Tubing and Catheter Misconnections. Silver Spring,MD: ANA; 2007.

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gluconate as a skin antiseptic, optimal selection ofcatheter site, and daily review of the necessity of aC V A D should be used to reduce risk of CLABSI.1-4

(II)B. The nurse should use a checklist at the time of

C V A D insertion to ensure compliance with steriletechnique and protocol. The nurse should beempowered to stop the insertion procedure if anystep(s) is/are not performed.1-3,5 (III)

C . Nurses should be involved in the organization’sinfusion-related infection prevention program andsurveillance for CLABSI. The goal is 0% infectionrate. A standard formula should be used to measurethe incidence of CLABSI (as shown below).2,4,6-8 (V)

Number of BSIs in patients with central lines ! 1000 " CLABSI Rate

Total number of central line days

D . Infusion-related infection surveillance data shouldbe analyzed to serve as one component of a qual-ity improvement plan of action, and is currently amajor focus of patient safety initiatives relating tohealth care-associated infections.1,4,7,9,10 (V)

E . The nurse should reduce the manipulation of allthe components of the entire infusion system (eg,administration set junctions, catheter hub) to asfew as needed to deliver the infusion therapy.4,7 (V)

F . Infusion nurses should be represented in the organiza-tion’s infection prevention program and should partic-ipate in interdisciplinary collaboration and implemen-tation of infection prevention strategies.11,12 (V)

REFERENCES

1. Institute for H ealthcare Improvement. Implement the central linebundle. http://www .ihi.org/I H I/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheCentralLineBundle.htm. Accessed February16, 2010.

2. M arschall J, M ermel L A , C lassen D , et al. Strategies to preventcentral line-associated bloodstream infections in acute care hospi-tals. Infect Control Hosp Epidemiol. 2008;29(suppl):S22-S30.

18. INFECTION PREVENTION

Standard

18.1 Infection prevention and surveillance protocols shallbe in accordance with organizational policies, procedures,and/or practice guidelines and local, state, and federalrules and regulations.18.2 The nurse shall be competent in procedures to preventinfusion- and vascular/nonvascular access device-relatedinfections.18.3 Standard Precautions shall be used and appropri-ate personal protective equipment (PPE) shall be wornduring all infusion procedures that potentially exposethe nurse to blood and body fluids.18.4 M aximal sterile barrier precautions shall berequired for insertion of central vascular access devices(C V A Ds) and all methods of central vascular catheterexchange and repair.18.5 Appropriate hand hygiene shall be used.18.6 Single-patient-use items shall be used wheneverpossible and disposed of in the appropriate containerupon discontinuation of use.18.7 M orbidity and mortality rates associated with infec-tions shall be collected, reviewed, evaluated, and report-ed in compliance with state regulations as applicable.18.8 Q uality improvement and monitoring programsshall include surveillance of infection prevention prac-tices to minimize health care-associated and community-acquired infections, and infection rates for central line-associated bloodstream infections (C L ABSIs).18.9 The nurse shall educate the patient and caregiverabout procedures and actions to prevent infection andsigns and symptoms of infection to report to the healthcare provider.

Practice Criteria

A . Bundling of evidence-based interventions for C V A Dinsertion, such as hand hygiene, use of maximalsterile barrier precautions, use of chlorhexidine

Infection Prevention and Safety Compliance


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3. Pronovost P, N eedham D , Berenholtz S, et al. An intervention todecrease catheter-related bloodstream infections in the IC U . NewEngl J Med. 2006;355(26):2725-2732.

4. M c Goldrick M . Infection prevention and control. In: A lexanderM , Corrigan A , Gorski L , H ankins J, Perucca R , eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, M O :Saunders/Elsevier; 2010:205-228.

5. Rhinehart E , M c Goldrick M . Infection Control in Home Careand Hospice. 2nd ed. Boston, M A: Jones & Bartlett; 2006.

6. Centers for Disease Control and Prevention. National H ealthcareSafety Network. Central line associated bloodstream (CLABSI) event.http://www.cdc.gov/nhsn/PDFs/psc Manual/4PSC_CLABScurrent.pdf.Accessed M arch 6, 2010.

7. The Joint Commission. Central line associated blood stream infec-tion (C L ABSI). http://www .jointcommission.org/A ccreditationPrograms/ H ome C are/Standards/09_F A Q s/ N PSG / H ealthcare_associated_infections. Accessed M arch 26, 2010.

8. US Department of H ealth and H uman Services. Agency forH ealthcare Research and Q uality. O n the cusp: stop bloodstreaminfections—resources. http://www .innovations.ahrq.gov/content.aspx?id=2685. Accessed M arch 26, 2010.

9. Centers for D isease Control and Prevention (C D C). Guidelines forhand hygiene in health-care settings. MMWR Morb Mort WklyRpt. 2002;51(RR-16):1-45.

10. US Pharmacopeia (USP). Revised General Chapter <797>Pharmaceutical Compounding: Sterile Preparations. USP 31-NF 26(suppl 2). The Pharmacists’ Pharmacopeia. 2nd ed. Rockville, M D;June 1, 2008.

11. Dunton N , Gajewski B, K laus S, Pierson B. The relationship of nurs-ing workforce characteristics to patient outcomes. Online J IssuesNurs. 2007;12(3):7. http://www.nursingworld.org/MainMenuCategories/A N A Marketplace/A N APeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingWorkforceCharacteristics.aspx . Accessed January30, 2010.

12. Institute of Medicine. Keeping Patients Safe: Transforming the WorkEnvironment of Nurses. Washington, D C: National Academies Press;2004.

19. HAND HYGIENE

Standard

19.1 Hand hygiene shall be a routine practice establishedin organizational policies, procedures, and/or practiceguidelines.19.2 Hand hygiene shall be performed before and aftertouching a patient; before handling an invasive device;before moving from a contaminated body site to anothersite; before donning and after removing gloves; and aftercontact with inanimate objects in the immediate vicinity ofthe patient.19.3 The nurse shall not wear artificial nails when per-forming infusion therapy procedures.19.4 In cases in which the nurse’s hands are visibly contaminated with blood or body fluids or hands havebeen exposed to spore-producing pathogens, hand hygienewith either nonantiseptic or antiseptic (preferably antiseptic-containing) liquid soap and water shall be performed.

Practice Criteria

A . Alcohol-based hand rubs are preferred for routinehand hygiene unless hands are visibly soiled.1-4 (II)

B. Chosen hand hygiene products should providehigh efficiency with low potential for skin irrita-tion. Towelettes and non–alcohol-based handrubs should not be used for hand hygiene. H andhygiene products should be used according tomanufacturers’ directions for use.1-4 (V)

C . Proper hand hygiene should be taught to the patientand caregivers involved in care of the patient.1-4 (V)

D . Dispensers of liquid soap or antiseptic solutions arerecommended. Containers should be filled, discarded,and replaced according to organizational policies,procedures, and/or practice guidelines and should beaccessible at the point of care.1 (V)

E . Single-use soap scrub packets or waterless anti-septic products should be used when clean run-ning water is not ensured or is unavailable.1 (V)

F . The nurse should be involved with hand hygieneproduct evaluation to assess for product feel, fra-grance, and skin irritation. Nurses who have sensitiv-ity to a particular product should be provided withan alternative. O ther products for skin care such asgloves, lotions, and moisturizers should be assessedfor compatibility with hand antisepsis products.5 (V)

G . Hand hygiene is a key component of a group of evidence-based interventions to promote better out-comes for patients with intravascular catheters.4,6 (V)

H . Artificial nails have been associated with trans-mission and outbreaks of infection.7-9 (IV)

REFERENCES

1. World H ealth O rganization. WHO Guidelines on Hand Hygienein Health Care. Geneva, Switzerland:W H O; 2009.

2. Boyce J M . N ew insights for improving hand hygiene practices.Infect Control Hosp Epidemiol. 2004;25(3):187-188.

3. Registered N urses’ Association of O ntario. H and hygiene reviewpanel report: nursing best practices guideline program. http://www .rnao.org/Storage/19/1385_ H and_ H ygiene_Review_Panel_Report.pdf. Published M ay 2006. Accessed June 3, 2010.

4. Institute for H ealthcare Improvement. 5 Million Lives CampaignGetting Started Kit: Prevent Central Line Infections: How-toGuide. Cambridge, M A: I H I; 2008.

5. Miller C . Product selection and evaluation. In: Alexander M ,Corrigan A , Gorski L , Hankins J, Perucca R , eds. Infusion Nursing:An Evidence-Based Approach. St Louis, M O: Saunders/Elsevier;2010:437-446.

6. M c Goldrick M . Infection prevention and control. In: A lexanderM , Corrigan A , Gorski L , H ankins J, Perucca R , eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, M O :Saunders/Elsevier; 2010:209-211.

7. Gupta A , Della-Latta P, Todd B, et al. O utbreak of extended-spectrum beta-lactamase Klebsiella pneumoniae in a neonatalintensive care unit linked to artificial nails. Infect Control HospEpidemiol. 2004;25(3):210-215.



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8. Saiman L , Lerner A , Saal L , et al. Banning artificial nails fromhealth care settings. Am J Infect Control. 2002;30(4):252-254.

9. Toles A . A rtificial nails: are they putting patients at risk? A reviewof the research. J Pediatr Oncol Nurs. 2002;19(5):164-171.

20. COMPOUNDING OF PARENTERAL SOLUTIONS AND MEDICATIONS

Standard

20.1 Compounding of parenteral solutions and medica-tions shall be in accordance with state and federal regu-lations and the American Society of H ealth-SystemPharmacists (ASHP) and United States Pharmacopoeia(USP) standards.20.2 The nurse shall perform compounding under thedirection of the pharmacy and shall adhere to com-pounding practices as defined in USP Chapter #797$.20.3 A list of medications that the nurse may compoundshall be developed in collaboration with or under thedirection of the pharmacy and shall be congruent withstandards set forth by regulatory agencies and by rules andregulations promulgated by the state’s Board of Nursing.20.4 Procedures for compounding sterile parenteralsolutions and medications shall be established in organi-zational policies, procedures, and/or practice guidelines.

Practice Criteria

A . Sterile preparations should be compounded in anappropriate environment as defined in USP Chapter#797$, state pharmacy rules and regulations, andASHP guidelines. The compounding environment isdefined by risk category.1-3 (V , Regulatory)

B. Immediate-use medication should be used within 1hour of preparation or discarded.1,2,4 (V , Regulatory)

C . Whenever possible, the nurse should administerpharmacy-prepared or commercially availableproducts.4,5 (V)

D . Access to the sterile compounding area should belimited to staff deemed competent to work in thisarea.1-3 (V , Regulatory)

E . The nurse should use appropriate technique towithdraw any sterile medications from glassampoules using a 5-micron filter needle or filterstraw . The filter needle/straw should be replacedwith a new sterile needle after the medication iswithdrawn from the ampoule, and both the topand bottom of the ampoule should be discardedin the sharps container.4,6 (V)

F . The nurse should label any multidose vials thatare used with the date opened, and the vialsshould be stored according to manufacturers’directions for use. M ultidose vials should be usedfor single patients only; use of commercially pre-

pared sterile product, such as prefilled syringes orpharmacy-filled syringes, is strongly preferredwhen available. The vial must be discarded afterthe beyond-use date (BU D).4,5 (V)

G . The nurse should cleanse the tops of multidosevials and the neck of glass ampoules with 70%alcohol before inserting the needle or breaking theampoule.4-6 (V)

H . Cleaning procedures should be established to dis-infect and remove pyrogenic and endotoxic ingre-dients from work surfaces.1,2 (Regulatory)

I. Q uality-control logs should be maintained to doc-ument all cleaning and calibration proceduresaccording to state and federal regulations, manufactur-ers’ directions for use, and ASHP and USP standardsand practice recommendations.1-3 (V , Regulatory)

J. M aterials placed in the compounding area shouldbe limited to those essential for preparing thesolutions or medications.1-3 (V , Regulatory)

REFERENCES

1. US Pharmacopeia (USP). Revised General Chapter #797$

Pharmaceutical Compounding: Sterile Preparations. USP 31-NF 26(suppl2). The Pharmacists’ Pharmacopeia. 2nd ed. Rockville, M D: June 1, 2008.

2. Pharmaceutical compounding-steri le preparations (G eneralChapter <797>). In: The United States pharmacopeia, 27th rev.and The national formulary. 22nd ed. Rockville, M D: The UnitedStates Pharmacopeial Convention; 2004:2350-70.

3. American Society of H ealth-Systems Pharmacists. The ASHP discus-sion guide on USP chapter #797$: compounding sterile prepara-tions. http://w w w .ashp .org/s_ashp/docs/f i les/discguide797-2008.pdf. Accessed M arch 26, 2010.

4. Association for Professionals in Infection Control and Epidemiology[position paper]. Safe injection, infusion, and medication vial prac-tices in healthcare. http://www.apic.org/Content/NavigationM enu/GovernmentAdvocacy/PublicPolicyLibrary/SafeInjections_final .pdf. Published July 30, 2009. Accessed April 5, 2010.

5. Paparella S. The risks associated with the use of multidose vials.J Emerg Nurs. 2006;32(5):428-430.

6. Stein H G . G lass ampoules and filter needles: an example of imple-menting the sixth “ R ” in medication administration. MedsurgNurs. 2006;15:290-294.

21. SCISSORS

Standard

21.1 The use of scissors in the presence of vascular andnonvascular access devices shall be limited to sutureremoval and during the procedure of catheter repair.21.2 Scissors shall not be used to remove vascular andnonvascular access device dressings, tape, or stabiliza-tion devices due to the potential of severing the catheteror administration set and patient injury.21.3 Use of scissors shall be established in organization-al policies, procedures, and/or practice guidelines.



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Practice Criteria

A . Sterile, disposable scissors should be used forsuture removal and catheter repair; nondisposablescissors have been found to harbor bacteria andmay potentially contribute to transmission ofmicroorganisms.1-3 (IV)

B. Patient injuries and catheter damage related to theuse of scissors in the vicinity of the catheter anddressing have been reported.3,4 (V)

C . The use of scissors to alter the length of peripher-ally inserted central catheters (PIC Cs) was foundto result in rough, irregular surfaces and shouldbe avoided. The manufacturer’s directions for usefor altering the device length should be followedif the device requires trimming.5,6 (IV)

REFERENCES

1. Embil J, Z hanel G , Plourde P, H oban D . Scissors: a potentialsource of nosocomial infection. Infect Control Hosp Epidemiol.2002;23(3):147-151.

2. Cleal B. Scissors: an infection risk? Emerg Nurse. 2006;14(8):22-24.3. Pennsylvania Patient Safety Authority. Snip-it safety. Patient Saf

Advis. 2004;1(4):1-3.4. Weinstein S, ed. Plumer’s Principles & Practice of Intravenous

Therapy. 8th ed. Philadelphia, PA: Lippincott Williams &Wilkins; 2007.

5. Parvez B, Parmar N , Chan A K . T rimming of peripherally insert-ed central venous catheters may increase the risk of thrombosis[letter to the editor]. Thromb Res. 2004;113(2):175-177.

6. Rutledge D N , V iele C . Insertion and care of peripherally insertedcentral catheters (PIC Cs) for intravenous infusions. Online J ClinInnovations. 2006; 9(2):1-73.

22. SAFE HANDLING AND DISPOSAL OF SHARPS, HAZARDOUS MATERIALS,AND HAZARDOUS WASTE

Standard

22.1 A ll blood-contaminated sharp items, including,but not limited to, needles or stylets, surgical blades,and syringes, shall be discarded in a nonpermeable,puncture-resistant, tamper-proof biohazard container.22.2 Sharps shall not be recapped, broken, or bent with-out use of a mechanical device or a one-handed technique.22.3 A ll biohazardous materials, wastes, and drugs shallbe discarded in the appropriate containers and disposedof according to local, state, and federal regulations.22.4 Sharps disposal containers shall be replaced beforethey are full to avoid disposal-related injuries.22.5 Devices that provide built-in safety controls shall beactivated during use and remain protective during disposal.22.6 M anufacturers’ directions for use, standards ofpractice, and state and federal regulations shall be

adhered to when developing organizational policies, pro-cedures, and/or practice guidelines pertaining to the safehandling of hazardous materials and hazardous waste.22.7 Protocols for safe handling of hazardous materialsand hazardous waste shall be established in organiza-tional policies, procedures, and/or practice guidelines.22.8 Exposure to potentially infectious materials or injuryfrom sharps should be identified, tracked, and analyzedfor trends per the organizational exposure control plan andin accordance with the O ccupational Safety and H ealthAdministration (OSH A) bloodborne pathogen standard.

Practice Criteria

A . Device components should be discarded as a singleunit after use.1-4 (V)

B. Primary prevention measures to reduce exposure tohazardous materials should include, but not be lim-ited to, the use of biological safety cabinets and per-sonal protective equipment (PPE—mask , gown,cap, drapes, gloves, and protective eyewear).1,2,5 (V)

C . All sharps should be accounted for before, during, andimmediately upon completion of a procedure.1,3,4,6 (V)

D . N urses should be trained in the use of engineeredsharps safety mechanisms and how to properlyengage the safety mechanism.1-3,7 (V)

E . The nurse should be involved in the multidiscipli-nary team to develop, implement, and evaluate aplan to reduce needlestick injury.7,8 (Regulatory)

F . The nurse should advocate for passive safety-engineered devices for needlestick injury prevention.9(V)

REFERENCES

1. ECRI Institute. Preventing needlesticks and other sharps injuries.http://www.ecri.org/Products_and_Services/Products/Special_Reports/Sharps_Safety_and_Needlestick_Prevention.aspx. Accessed September21, 2005.

2. H adaway L . Infusion therapy equipment. In: A lexander M ,Corrigan A , Gorski L , Hankins J, Perucca R , eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, M O: Saunders/Elsevier; 2010:391-436.

3. Jagger J, Perry J. Exposure safety: safeguarding sharps disposal.Nursing. 2000;30(10):26.

4. US D epartment of Labor. O ccupational Safety and H ealthAdministration. D isposal of contaminated needles and blood tubeholders used for phlebotomy. Washington, D C: OSH A; 2004.http://www .osha.gov/dts/shib/shib101503.html. Accessed August19, 2004.

5. N I OSH workplace solutions: Personal protective equipment forhealth care workers who work with hazardous drugs. C incinnati,O H: D H HS (N I OSH) Publication N o. 1009-106. http://www .cdc.gov/niosh/docs/wp-solutions/2009-106/default .html . A ccessedAugust 6, 2010.

6. O ccupational injury and wel lness recording and reportingrequirements. Fed Regist. 2001;66(121):5319.

7. N I OSH Publication N o. 2010-125: N I OSH H azard Review:O ccupational hazards in home healthcare. http:/www .cdc.gov/



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niosh/docs/2010-125/pdfs/2010-125.pdf. Published January 2010.Accessed M ay 5, 2010.

8. OSH A Bloodborne Pathogen Standard 29 C FR 1910.1030.H ealthcare Wide H azards N eedlestick/Sharps Injuries. http://www .osha.gov/SL T C /etools/hospital/hazards/sharps/sharps.html#resheathingneedle. Published July 21, 2008. Accessed August 3, 2009.

9. Tossini W , C iotti C , Goyer F , et al. N eedlestick injury ratesaccording to different types of safety-engineered devices: resultsof a French multicenter study. Infect Control Hosp Epidemiol.2010;31(4):402-407.

23. DISINFECTION OF DURABLE MEDICAL EQUIPMENT

Standard

23.1 Durable medical equipment (D M E) shall be cleanedto remove foreign material, followed by disinfection toeliminate microorganisms after each patient use.23.2 C leaning and disinfection of D M E shall be estab-lished in organizational policies, procedures, and/orpractice guidelines.23.3 D isinfection solutions shall be used in accordancewith equipment and manufacturers’ directions for useto prevent damage or alteration to the function or per-formance of the equipment.23.4 A ll cleaning solutions shall be cleared by the USFood and Drug Administration (F D A) and registeredwith the Environmental Protection Agency (EPA).

Practice Criteria

A . To prevent cross-contamination and transmission ofinfectious agents, cleaning and disinfection should beperformed prior to new patient use and at establishedintervals during long-term single-patient use.1-3 (I)

B. D M E requiring cleaning and disinfection shouldinclude, but not be limited to, poles, flow-controldevices, ultrasound or infrared devices, and othernondisposable infusion-related equipment.1-3 (II)

C . Primary prevention measures to reduce exposureto disinfection solutions containing glutaralde-hyde, ortho-phthaldehyde, and other hazardouschemicals should include engineering controls,administrative controls, and personal protectiveequipment (PPE).1-3 (II)

D . D M E removed from the home care setting shouldbe cleaned and disinfected before transporting toan appropriate site for terminal cleaning and disinfection.3,4 (V)

REFERENCES

1. Rutala W , Weber D; H ealthcare Infection Control Practice AdvisoryCommittee (H ICPA C). Guideline for disinfection and sterilization inhealthcare facilities. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf. Accessed August 15, 2010.

2. H adaway L . Infusion therapy equipment. In: A lexander M ,Corrigan A , Gorski L , Hankins J, Perucca R , eds. Infusion Nursing:An Evidence Based Approach. 3rd ed. St Louis, M O:Saunders/Elsevier; 2010:391-436.

3. Siegel JD , Rhinehart E , Jackson M , Chiarello L; H ealthcareInfection Control Practices Advisory Committee. 2007 guidelinefor isolation precautions: preventing transmission of infectiousagents in healthcare settings. http://www .cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf. Accessed August 15, 2010.

4. M c Goldrick M , Rhinehart E . M anaging multidrug-resistantorganisms in home care and hospice: surveillance, prevention,and control. Home Healthcare Nurse. 2007;25(9):580-586.

24. TRANSMISSION-BASED PRECAUTIONS

Standard

24.1 Transmission-based precautions shall be used toprevent transmission of infectious agents in health caresettings when the route(s) of transmission is/are notinterrupted using Standard Precautions alone.24.2 The use of transmission-based precautions shall beestablished in organizational polic ies, procedures,and/or practice guidelines.

Practice Criteria

A . Transmission-based precautions are implementedwhen strategies beyond Standard Precautions arerequired to reduce the risk for transmission of infec-tious agents (see Standard 18, Infection Prevention).1

(II)B. Transmission-based precautions are implemented

for patients with suspected or documented infectionor colonization with highly transmissible or epi-demiologically important pathogens for which addi-tional precautions are required to prevent diseasetransmission.1 (II)

C . Contact precautions are implemented to preventtransmission of infectious agents, including mul-tidrug-resistant organisms, which are spread bydirect or indirect contact with the patient or theenvironment, including when there are excessivebodily discharges such as wound drainage.1,2 (II)

D . Droplet precautions are implemented to preventtransmission of pathogens spread through close respi-ratory or mucous membrane contact with respiratorysecretions.1 (II)

E . Airborne precautions are implemented to preventtransmission of infectious agents that remain infectiouswhen suspended in the air over long distances.1 (II)

F . Guidelines for transmission-based precautionsshould be adapted and applied as appropriate fornon–acute care settings, including long-term carefacilities, the home care setting, and other work-places where infusion therapy is provided.1 (V)



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G . In ambulatory and home care settings, StandardPrecautions are followed for patients with multidrug-resistant organisms (M D R O s).1,3 (V)

H . In home care settings for patients with M D R O s,reusable patient care equipment should be limitedand left in the home until discharged, and disin-fected before removing from the home in a con-tainer (eg, plastic bag) or transported to an appro-priate site for cleaning and disinfection.1,3 (V)

REFERENCES

1. Siegel JD , Rhinehart E , Jackson M , Chiarello L; H ealthcareInfection Control Practices Advisory Committee. Guideline forisolation precautions: preventing transmission of infectiousagents in healthcare settings. http://www .cdc.gov/ncidod/dhqp/pdf/guide l ines/Isolation2007 .pdf . Published 2007 . A ccessedFebruary 12, 2010.

2. Siegel JD , Rhinehart E , Jackson M , and the H ealthcare InfectionControl Practices Advisory Committee. M anagement of multi-drug-resistant organisms in healthcare settings. http://www .cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf. Published 2006.Accessed February 12, 2010.

3. M cGoldrick M , Rhinehart E . M anaging multidrug-resistant organ-isms in home care and hospice: surveillance, prevention, and control.Home Healthcare Nurse. 2007;25(9):580-586.

25. LATEX SENSITIVITY ORALLERGY

Standard

25.1 Exposure to latex in the health care environmentshall be minimized.25.2 Latex-free personal protective equipment (PPE) shallbe provided to latex-sensitive or latex-allergic individuals.25.3 Latex-free supplies and equipment shall be usedwith patients at risk for latex sensitization and thosewith known latex allergy.

Practice Criteria

A . The nurse should review the label on medicaldevices for the presence of latex , which is a com-ponent of product labeling required by the USFood and Drug Administration (F D A).1,2 (V)

B. Powdered gloves made of natural rubber latexshould be eliminated from the health care envi-ronment as they are associated with the greatestrisk of sensitization and subsequent allergic reac-tions in individuals. Low-protein, powder-freelatex gloves, or gloves made of nonlatex materi-als, such as neoprene or polyisophrene, willreduce exposure.3-6 (IV)

C . The nurse should assess all patients for history ofasthma, environmental allergens, medications,

and food allergies. A llergies that may create cross-reactions with latex include, but are not limited to,avocados, mangoes, pears, bananas, citrus fruits,chestnuts, and other tropical foods.7,8 (II)

D . The nurse should have knowledge of evolvingguidelines about preventing allergic reactions fromthe Centers for D isease Control and Prevention(C D C) and the O ccupational Safety and H ealthAdministration (OSH A).6,9,10 (Regulatory)

E . Staff and patient education programs should bedeveloped to aid in risk reduction.5,9,11 (IV)

F . Latex allergy in patients should be documented inthe patient’s permanent medical record with ade-quate patient education about avoiding futureexposure and management of an anaphylacticreaction.7-9 (IV)

G . Latex allergy in health care workers and patientsshould be reported to the appropriate depart-ments within the organization per organizationalpolicies, procedures, and/or practice guidelines.Latex allergy in health care workers should berecorded and reported according to O S H Arequirements.5,9,12 (IV , Regulatory)

REFERENCES

1. US Food and Drug Administration. C FR 21: M edical Devices—Labeling. In: Center for Devices and Radiological Health, F , 8thed. Rockville, M D: F D A; 2009.

2. Emergency N urses Assoc iation [posit ion statement]. LatexAllergy. Des Plaines, IL: E N A; 2005.

3. Smith A M , Amin HS, Biagini RE , et al. Percutaneous reactivity tonatural rubber latex proteins persists in health-care workers fol-lowing avoidance of natural rubber latex. Clin Exp Allergy. 2007;37(9):1349-1356.

4. Brown R H , M c Allister M A , Gundlach A M , H amilton R G . Thefinal steps in converting a health care organization to a latex-safeenvironment. Jt Comm J Qual Patient Saf. 2009;35(4):224-228.

5. Ranta PM , O wnby D R . A review of natural-rubber latex allergyin health care workers. Clin Infect Dis. 2004;38(2):252-256.

6. Brown R H , Taenkhum K , Buckley TJ, H amilton R G . D ifferentlatex aeroallergen size distributions between powdered surgicaland examination gloves: significance for environmental avoid-ance. J Allergy Clin Immunol. 2004;114(2):358-363.

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