The December 3 acute care ISMP Med Safety Alert main article discusses small volume intermittent medications (defined as those < 100 mL) and potential medication loss when run as primary infusions in contrast to secondary infusions.

The article recommends giving these "small volume" medications as secondary infusions.

We are a pediatric institution who has recently decided to try to move away completely from secondary infusions due to multiple errors of the medication not infusing due to failure to open the secondary clamp.

In order to prevent loss of medication like the article mentioned we are attaching a 50 mL bag of saline (or other compatible solution as needed) on the same line as the medication once the medication bag is empty and running a 25 mL flush. To further prevent doing this we also standardized that all medications in 50 mL or less would come in a syringe rather than a bag further mitigating medication loss issues.

While I feel the article addresses the important issue of medication loss without a flush being used it does not address the known errors associated with secondary infusions.

I was curious to what others thought about this.