Failure to Disinfect Medication Vial Septum Prior to IV Administration
Penalty
Summary
A Registered Nurse (RN) failed to follow safe injection practices during the administration of intravenous Ertapenem to a resident. The RN removed the plastic cap from a glass vial containing the medication and attached it to a saline bag without swabbing the rubber septum with alcohol prior to accessing the medication. The RN acknowledged not disinfecting the vial's septum before mixing and administering the medication. The Director of Nursing was unable to confirm whether facility policy specifically required swabbing the septum, and a review of the facility's Parenterals/Intravenous Solutions policy did not include instructions to wipe the septum with alcohol prior to piercing. The CDC Injection Safety Checklist, however, specifies that the rubber septum should be disinfected with alcohol before use.