01Principles and purposeThe professional or clinical skill and the decisions it supports.
Preparation starts with the prescription, current weight where relevant, allergies, organ function, laboratory results, access and monitoring. Read the whole label including salt, concentration and units. Distinguish milligrams from millilitres and units from milligrams. Clarify an incomplete, unusual or out-of-scope prescription before preparing anything.
Use dimensional analysis: required volume equals prescribed dose divided by stock concentration; mL/hour equals total volume divided by hours. Weight-based dose rate must incorporate concentration and weight once, with units cancelling correctly. Estimate plausibility and use an approved calculator or pump library as support. Obtain an independent reconstruction for locally defined high-risk medicines.
Prepare a clean field, PPE, medicine, compatible diluent, correct syringe or bag, transfer device or filter if specified, labels, administration set, pump and sharps bin. Inspect for particles, colour, leakage and expiry. Confirm reconstitution, stability and compatibility from the current SmPC, BNF or pharmacy monograph because these are product-specific.
Disinfect vial stoppers and allow drying; open ampoules away from the body with protection. Use a filter needle only where specified and never as the administration needle. Reconstitute using the instructed diluent and mixing method, withdraw the calculated amount and dispose of the preparation sharp immediately. Maintain key-part protection throughout.
Label a prepared syringe or infusion immediately with patient, drug, total dose, concentration, diluent, volume, route, preparation time, expiry and preparer/checker as policy requires. Never carry an unlabelled syringe, even for immediate use. If interrupted and identity is uncertain, discard safely and start again.
For infusion, confirm peripheral or central access is suitable for pH, osmolarity, vesicant risk, rate and duration. Select the product-specific giving set and filter. Prime completely while disconnected, close clamps, load the pump correctly and program the drug-library concentration, dose or rate and volume to be infused. Any library override needs justification and checking.
At the bedside, use two identifiers and recheck prescription, allergy and line. Trace by sight and touch from container through pump and every port to the insertion site. Scrub and dry the connector, connect aseptically, open intended clamps and start. Observe chamber, pump, line and site for free-flow or occlusion hazards.
Monitor both response and delivery: observations, sedation, ECG, glucose, electrolytes or balance as required. Compare remaining volume with expected delivery. Stop for pain, swelling, leakage, precipitate, unresolved alarm, unexpected physiology or suspected wrong infusion. Preserve container and pump history, assess exposure and obtain medicine-specific urgent help after an error.
Injection equipment includes the labelled syringe, a new administration needle or integrated safety device, antiseptic where required, gauze and sharps bin. Verify the prescribed route, product instructions, skin, anatomy, bleeding risk and previous sites. Never inject through infected, inflamed, oedematous or damaged tissue.
For intradermal injection, stretch the protocol site, insert a fine needle bevel up at a shallow angle into dermis and inject slowly to form the expected small bleb. Do not massage when the diagnostic protocol forbids it. Mark and time as required and arrange competent interpretation; absence of a bleb suggests a deeper dose and needs advice.
For an intradermal procedure such as a Mantoux test, support the forearm and stretch the prepared skin. Following the exact product and test protocol, insert a fine short-bevel needle bevel up at 5–15 degrees, keeping the bevel just beneath the surface, and inject slowly to raise the expected wheal. Do not massage. Record the site and arrange trained reading; absent wheal or suspected deeper delivery needs the named test’s repeat-procedure advice, not an improvised second dose.
For intramuscular injection, expose and landmark the intended muscle rather than guessing through clothing. Choose a needle long enough to reach muscle without deeper injury, considering body habitus and site. Deltoid suits appropriate small-volume products; ventrogluteal or vastus lateralis may suit others under guidance. Insert at 90 degrees and inject at the specified pace.
For an appropriate adult deltoid IM injection, expose the whole upper arm and palpate the acromion. Identify the inverted deltoid triangle below it, extending towards the level of the axilla; select the central thick muscle region within those boundaries, avoiding the shoulder joint above and a low or posterior position. Confirm that this site suits the product and volume. Choose needle length to reach muscle for the patient’s body habitus, insert at 90 degrees and administer at the product-specified pace. If landmarks or tissue depth are uncertain, obtain supervision or select another authorised site.
Activate safety and discard directly, apply pressure and observe for local bleeding, syncope or allergy. Recognise anaphylaxis clinically, call for help and follow Resuscitation Council UK guidance. Document medicine, dose, route, site, time, batch/expiry where required, advice and adverse events.
Direct supervision is required until competency is assessed for each route and device. Cytotoxics, parenteral nutrition, blood components, epidural/intrathecal medicines, concentrated electrolytes, insulin infusions and paediatric preparations require additional governance; competence in routine IV or IM administration does not transfer automatically.
Key points
- Verify patient, medicine, concentration, dose, route, time, allergies, indication, monitoring and access against a valid prescription.
- Calculate with units and independently check high-risk medicines under local policy; a pump cannot legitimise an unchecked calculation.
- Inspect containers, diluent and expiry; use non-touch technique and label every prepared syringe or infusion immediately.
- Trace an infusion line from container to patient before connection and transfer; confirm lumen, compatibility, pump library and clamps.
- Prime tubing, program dose/rate/volume, obtain required checks and start while observing site and patient.
- Intradermal injection creates a superficial bleb; subcutaneous depth depends on tissue/device; intramuscular injection needs a landmarked muscle and suitable needle.
- Stop for mismatch, precipitation, pump error, resistance, infiltration, extravasation, anaphylaxis or instability.
- Document dose, route, exact site, batch when required, checks, response and omissions with escalation.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Any disagreement among prescription, label, calculation, pump, patient or route requires stopping before administration.
Cloudiness, crystals, colour change or unverified co-infusion requires isolation and pharmacy advice.
Pain, swelling, blanching, leakage or resistance requires immediate stop and drug-specific management.
Sudden airway, breathing or circulation compromise with allergic features requires immediate emergency treatment.
Unexpected remaining volume, recurrent alarm or wrong library entry may mean under- or over-infusion.
Severe radiating pain, paraesthesia, bleeding or distal deficit requires stopping and assessment.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Independent calculation and label check - Why
- Detect dose, concentration, unit and patient errors.
- Interpretation and limitations
- The checker reconstructs inputs and calculation rather than confirming the first answer.
- 02
Line trace and compatibility check - Why
- Ensure medicine reaches intended access without interaction.
- Interpretation and limitations
- Trace container to patient and verify each Y-site or lumen against an approved source.
- 03
Pump rate-volume plausibility - Why
- Confirm programmed delivery matches prescription and container.
- Interpretation and limitations
- Expected remaining volume and response should agree; investigate discrepancies and alarms.
- 04
Post-injection observation - Why
- Detect bleeding, injury, syncope and hypersensitivity.
- Interpretation and limitations
- Observation duration depends on product and risk; instability triggers emergency response.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked case: tenfold pump rateInterrupt error before harm continuesAt 10:00 a stable adult with poor oral intake starts a supplied prescription for sodium chloride 0.9%, 500 mL IV over 5 hours, with no additives. At 10:03 the pump shows 1,000 mL/hour and 50 mL delivered.+
- 1Stop the incorrect infusion, preserve usable access and call the supervising clinician. Assess ABCDE, breathing, circulation and fluid status; verify the patient, bag, prescription, line and pump history. This is an existing patient-specific prescription used for calculation, not a universal fluid regimen.
- 2Calculate the intended rate: 500 mL ÷ 5 hours = 100 mL/hour. Three minutes is 0.05 hours, so 1,000 mL/hour × 0.05 hours = 50 mL delivered instead of 5 mL: excess 45 mL. Sodium chloride 0.9% is 9 mg/mL, so delivered sodium chloride is 450 mg versus intended 45 mg; these are salt masses, not elemental sodium.
- 3Reassess for harm and determine a revised fluid plan with the clinician. In this example observations and examination remain stable and the clinician authorises only the remaining 450 mL by the original 15:00 endpoint. Remaining time is 4 hours 57 minutes = 4.95 hours; 450 ÷ 4.95 = 90.9 mL/hour, rounded as authorised for the device, with volume to be infused capped at 450 mL.
- 4An independent checker reconstructs the inputs and reverse-checks 90.9 mL/hour × 4.95 hours ≈ 450 mL, plus the 50 mL already given. Restart only after the revised order and pump settings are checked. Observe delivery and fluid balance, record the exposure and clinical response, explain the incident, preserve evidence and complete reporting.
02Prepare and start infusionCalculate, label, trace and observeA prescribed intravenous infusion is due.+
- 1Verify prescription and factors, calculate with units and obtain required independent check.
- 2Prepare aseptically, label, prime and program the correct pump library.
- 3At bedside recheck and trace line, connect, observe delivery and document monitoring.
03Administer an injectionMatch route and anatomyAn intradermal, subcutaneous or intramuscular injection is prescribed.+
- 1Confirm drug, route, site, device, bleeding and allergy risks.
- 2Landmark and use the route-specific angle, depth and technique without touching key parts.
- 3Discard the sharp, compress or observe as appropriate, document exact site and assess reaction.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Compare infused volume and rate with expected delivery.
- Monitor medicine-specific physiology and laboratory results.
- Inspect access sites throughout delivery and stop for pain, swelling, leakage or suspected extravasation.
- Observe injections for local and systemic reactions.
- Review omitted doses and escalate consequences.
- Investigate pump alerts, overrides and near misses.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Units prevent errors
A dimensional pathway exposes missing weight, time or concentration before the pump is programmed.
Labels are clinical
Prepared medicines become unsafe when not identified immediately and completely.
Trace every line
Tracing prevents wrong-lumen and cross-connection errors hidden by correct pump programming.
Route changes technique
Intradermal bleb, subcutaneous tissue depth and intramuscular landmarking are distinct procedures.
Check means reconstruct
An independent checker derives the dose without being led by the first calculation.
07Common pitfallsFrequent interpretation and management errors.
- 01
Do not prepare from an incomplete prescription.
- 02
Do not omit units during calculation.
- 03
Do not leave any syringe unlabelled.
- 04
Do not force incompatible medicines through one lumen.
- 05
Do not bypass a pump library casually.
- 06
Do not guess an IM site through clothing.
- 07
Do not use one needle length for every patient.
- 08
Do not treat route-specific practices as universal.