Removing Medication From a Vial

Skill 5-4

Removing Medication From a Vial

Skill Variation:Reconstituting Powdered Medication in a Vial

A vial is a glass bottle with a self-sealing stopper through which medication is removed. For safety in transporting and storing, the vial top is usually covered with a metal or plastic cap that can be removed easily. The self-sealing stopper that is then exposed is the means of entrance into the vial. Single-dose vials are used once, and then discarded, regardless of the amount of the drug that is used from the vial. Multidose vials contain several doses of medication and can be used multiple times. The Centers for Disease Control and Prevention (CDC) recommends that medications packaged as multiuse vials be assigned to a single patient whenever possible (CDC, 2019). If the medication enters the patient treatment area, the vial should be designated as a single patient use vial (CDC, 2019). In addition, it is recommended that the top of the vial be cleaned before each entry, and that a new sterile needle and syringe are used for each entry (CDC, 2019).

The medication contained in a vial can be in liquid or powder form. Powdered forms must be dissolved in an appropriate diluent before administration. The following skill reviews removing liquid medication from a vial. Refer to the accompanying Skill Variation for steps to reconstitute powdered medication.

Delegation Considerations

The preparation of medication from a vial is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, the preparation of medication from a vial may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Sterile syringe and needle or blunt cannula (size depends on medication being administered)
Needleless access device (if available)
Vial of medication
Antimicrobial swab
Second needle (optional)
Filter needle (optional)
Electronic Medication Administration Record (eMAR) or Medication Administration Record (MAR)

Assessment

Assess the appropriateness of the drug for the patient. Review the medical history and allergy, assessment, and laboratory data that may influence drug administration. Assess the medication in the vial for any discoloration or particles. Check the expiration date before administering medication. Assess the patient's knowledge of the medication. If the patient has a knowledge deficit about the medication, this may be the appropriate time to begin education about the medication. If the medication may affect the patient's vital signs, assess them before administration. If the medication is for pain relief, assess the patient's pain level before and after administration. Verify patient name, dose, route, and time of administration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Infection risk
Knowledge deficiency
Injury risk

Outcome Identification and Planning

The expected outcomes to achieve when removing medication from a vial are withdrawal of the medication into a syringe in a sterile manner, the medication is free from contamination, and the proper dose is prepared.

Implementation

Action	Rationale
1. Gather equipment. Check each medication prescribed against the original in the health record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies.
2. Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's health status and can also be used to educate the patient about the medication.
3. Perform hand hygiene.	Hand hygiene deters the spread of microorganisms.
4. Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room.	Organization facilitates error-free administration and saves time.
5. Unlock the medication supply system or drawer. Enter the passcode and scan employee identification, if required.	Locking the medication supply system or drawer safeguards each patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use. Entering the passcode and scanning ID allows only authorized users into the system and identifies the user for documentation by the computer.
6. Prepare medications for one patient at a time.	This prevents errors in medication administration.
7. Read the eMAR/MAR and read the label when selecting the proper medication from the medication supply system or the patient's medication drawer.	This is the first check of the label.
8. Read the label and compare the label with the eMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required.	This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary.
9. Remove the metal or plastic cap on the vial that protects the self-sealing stopper.	The cap needs to be removed to access the medication in the vial.
10. Scrub the self-sealing stopper top with the antimicrobial swab and allow to dry.	The antimicrobial swab removes surface microbial contamination. Allowing the antimicrobial solution to dry completely (5 to 20 seconds) ensures complete antimicrobial effectiveness (Gorski et al., 2021; Slater et al., 2018). Drying also prevents antimicrobial solution from entering the vial on the needle.
11. Remove the cap from the needle or blunt cannula by pulling it straight off. If the vial in use is a multidose vial, touch the plunger only at the knob and draw back an amount of air into the syringe that is equal to the specific dose of medication to be withdrawn. If the vial in use is a single-use vial, there is no need to draw air into the syringe.	Pulling the cap off in a straight manner prevents accidental needlestick injury. Handling the plunger only at the knob will keep the shaft of the plunger sterile. Because a vial is a sealed container, injection of an equal amount of air (before fluid is removed) is required to prevent the formation of a partial vacuum. If not enough air is injected, the negative pressure makes it difficult to withdraw the medication after repeated use.
12. Hold the vial on a flat surface. Pierce the self-sealing stopper in the center with the needle tip (Figure 1) or blunt cannula; alternatively, insert a needleless access device (Figure 2) into the stopper on the vial and connect the syringe. Inject the measured air into the space above the solution Do not inject air into the solution. If the vial in use is a single-use vial, there is no need to inject air into the vial.	Air bubbled through the solution could result in withdrawal of an inaccurate amount of medication. Needleless access devices may be used to prevent needlestick injuries based on facility policy (Frandsen & Pennington, 2021).
13. Invert the vial. Keep the tip of the needle or blunt cannula below the fluid level if in use (Figure 3).	This prevents air from being aspirated into the syringe.
14. Hold the vial in one hand and use the other to withdraw the medication. Touch the plunger only at the knob. Draw up the prescribed amount of medication while holding the syringe vertically and at eye level (Figure 4).	Handling the plunger only at the knob will keep the shaft of the plunger sterile. Holding the syringe at eye level facilitates accurate reading, and the vertical position makes removal of air bubbles from the syringe easy.
15. If any air bubbles accumulate in the syringe, tap the barrel of the syringe sharply and move the needle past the fluid into the air space to re-inject the air bubble into the vial. Return the needle tip to the solution and continue withdrawal of the medication.	Removal of air bubbles is necessary to ensure an accurate dose of medication.
16. After the correct dose is withdrawn, remove the needle or needleless access device from the vial; carefully replace the sterile cap over the needle if used. Alternatively, carefully attach a needle or syringe cap. Some facilities require changing the needle, if one was used to withdraw the medication, before administering the medication.	Capping prevents contamination and protects against accidental needlesticks. A one-handed recap method may be used as long as care is taken not to contaminate the needle during the process. Changing the needle may be necessary because passing the needle through the stopper on the vial may dull the needle. In addition, it ensures the tip of the needle is free from medication residue, significantly reducing pain intensity associated with the injection (Ağaç & Günes, 2010).
17. Check the amount of medication in the syringe with the medication dose and discard any surplus.	Careful measurement ensures that the correct dose is withdrawn.
18. Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, read the label and recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient.	This third check ensures accuracy and helps to prevent errors. Note: Many facilities require the third check to occur at the bedside, after identifying the patient and before administration.
19. Label the syringe with the medication's name, dose, and amount (The Joint Commission, 2021).	Unlabeled syringes are unidentifiable and may lead to a medication administration error (The Joint Commission, 2021).
20. If a multidose vial is being used, label the vial with the date and time opened and the beyond-use date (see Special Considerations), and store the vial containing the remaining medication according to facility policy. Limit the use of multiple-dose vials and dedicate them to a single patient whenever possible (CDC, 2019).	Because the vial is sealed, the medication inside remains sterile and can be used for future injections. Labeling the opened vials with a date, time, and beyond-use date limits its use after a specific time period. Limiting use of multiple-dose vials and dedicating their use to a single patient when possible limits risk of contamination and transfer of microorganisms (CDC, 2019; Dolan et al., 2016).
21. Log out of and/or lock the medication supply system before leaving it.	Locking the medication supply system or drawer safeguards the patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use.
22. Perform hand hygiene.	Hand hygiene deters the spread of microorganisms.
23. Proceed with administration, based on prescribed route.	See appropriate skill for prescribed route.

Evaluation

The expected outcomes have been met when the medication was withdrawn into the syringe in a sterile manner, it remained free from contamination, and the proper dose was prepared.

Documentation

Guidelines

It is not necessary to record the removal of the medication from a vial. Prompt recording of administration of the medication is required immediately after it is administered.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

A piece of self-sealing stopper is noticed floating in the medication in the syringe: Discard the syringe, needle, and vial. Obtain a new vial, syringe, and needle and prepare the dose as ordered.
As the needle attached to the syringe filled with air is inserted into vial, the plunger is immediately pulled down: If possible to withdraw medication, continue steps as explained above. If such a vacuum has formed that this is impossible, remove the syringe and inject more air into the vial.
Plunger is contaminated before injecting air into vial: Discard the needle and syringe and start over.
Plunger is contaminated after medication is drawn into syringe: It is not necessary to discard the needle and syringe and start over. The contaminated plunger will enter the barrel of the syringe when pushing the medication out, will not come in contact with the medication, and will not contaminate the medication.

Special Considerations

When mixing medications in one syringe, preparation of medications in one syringe depends on how the medication is supplied. When using a single-dose vial and a multidose vial, inject air into the multidose vial and draw the medication from the multidose vial into the syringe first. This prevents the contents of the multidose vial from being contaminated with the medication in the single-dose vial. The steps to follow when preparing medications from two multidose vials in one syringe are outlined in Skill 5-5.
Vials used to draw two or more medications into a single syringe must be discarded after use (Dolan et al., 2016).
Do not administer medication from a single-dose vial to multiple patients (CDC, 2019).
Limit the use of multiple-dose vials and dedicate them to a single patient whenever possible (CDC, 2019).
Multiple-dose vials must be labeled with a beyond-use date when first opened, as indicated by facility policy (CDC, 2019).

Reconstituting Powdered Medication in a Vial

Drugs that are unstable in liquid form are often provided in a dry powder form. The powder must be mixed with the correct amount of appropriate solution (diluent) to prepare the medication for administration (reconstitution). Verify the correct amount and correct solution type for the specific medication prescribed. This information is found on the vial label, package insert, in a drug reference, an on-line pharmacy source, medication database, or from the pharmacist. To reconstitute powdered medication:

Gather equipment. Check each medication prescribed against the original in the health record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.
Know the actions, special nursing considerations, safe dose ranges, purpose of administration, and adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.
Perform hand hygiene.
Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room.
Unlock the medication supply system or drawer. Enter the passcode and scan employee identification, if required.
Prepare medications for one patient at a time.
Read the eMAR/MAR and read the label when selecting the proper medication and diluent from medication supply system or from the patient's medication drawer. This is the first check of the medication label.
Read the label and compare the labels with the eMAR/MAR. This is the second check of the medication label. Check expiration dates and perform calculations, check medication calculation with another nurse. Scan the bar code on the package, if required.
Remove the metal or plastic cap on the medication vial and diluent vial that protects the self-sealing stoppers.
Scrub the self-sealing tops on both the diluent and powdered medication vials with the antimicrobial swab and allow to dry.
Draw up the appropriate amount of diluent into the syringe.
Insert the needle, needleless access device or blunt cannula through the center of the self-sealing stopper on the powdered medication vial.
Inject the diluent into the powdered medication vial.
Remove the needle, needleless access device or blunt cannula from the vial and replace sterile cap.
Gently agitate the vial to mix the powdered medication and the diluent completely. Do not shake the vial.
Draw up the prescribed amount of medication, as described in Steps 10-15 inSkill 5-4, while holding the syringe vertically and at eye level.
After the correct dose is withdrawn, remove the needle or needleless access device from the vial; carefully replace the sterile cap over the needle if used. Alternatively, carefully attach a needle or syringe cap. Some facilities require changing the needle, if one was used to withdraw the medication, before administering the medication.
Check the amount of medication in the syringe with the medication dose and discard any surplus.
Depending on facility policy, the third check of the label may occur at this point. If so, read the label and recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient.
Label the syringe with the medication's name, dose, and amount (The Joint Commission, 2021).
Log out of and/or lock the medication supply system before leaving it.
Perform hand hygiene.
Proceed with administration, based on prescribed route.

Note: Powdered medications may be supplied in specially designed vials that have the diluent and powder in the same vial, separated by a rubber stopper within the vial (Figure A). When the nurse is ready to administer the medication, the rubber stopper is deployed, and the vial is agitated gently to mix the diluent and powder.

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Skill 5-4