What mistakes should providers be aware of when prescribing and administering long-acting injectables (LAIs)?

Mistakes in preparation:

• Not all injections are given the same way. Aristada (aripiprazole lauroxil) is the most different from the other LAIs in that the pre-filled Aristada syringes must be tapped firmly (10 times), then shaken vigorously for 30 seconds, and then injected rapidly. The shaking ensures well dispersed particles, and the fast speed lowers the viscosity. The procedure is dictated by Aristada’s properties as a non-Newtonian fluid, i.e., its viscosity decreases with a faster speed. A common example of a non-Newtonian fluid is ketchup–it flows more smoothly and quickly after shaking, taping, and once it starts to flow.
• Pay attention to the different preparation requirements of LAIs, i.e., which need to be taken out of the refrigerator to come to room temperature.
• See this tip for more information about LAI administration.

Mistakes in medication administration​​​​​​​:

• Injection errors do occur. Review the five “rights” of medication administration with the patient as safety checks. These include the following principles of safe medication administration: The right medication, the right dose, the right patient, the right route, and the right time (Perry, Potter, & Ostendorf, 2013).
  • Errors of dose — for example, preparing a 1 ml of Haldol Decanoate 50 mg/ 1ml when 100 mg/1 ml was prescribed. Or taking a sample kit of Invega Sustenna 156 mg instead of 117 mg when beginning treatment with a new patient who hasn’t yet had his kit with the prescription label delivered. Organization of supplies, and potentially only having one strength of Haldol Decanoate, are key considerations.
  • Errors of dosing interval — giving an injection sooner or earlier than it is due as ordered by prescriber. All LAIs have windows of time, usually about one week, in which the injection can be administered early or late (per prescribing information); yet, prescriber’s order and clinical judgment should be utilized to make such decisions. Careful attention during transition times (i.e., hospital discharge) is critical.
  • Errors of medication — giving the wrong LAI. It is not inconceivable that a patient on one LAI currently has been on a different one in the past. Careful attention during transition times (i.e., hospital discharge) is critical.
• Parallel documentation can be a helpful safeguard against medication administration errors if this includes a system for double-checking timely documentation of injection administration. Clinics may use electronic health records (EHR) to order and prescribe medication, and document its indication, tolerability, and efficacy. However, the exam room where an injection is administered may be separate and without EHR access.

Mistakes in clinical factors:

• Flexibility around patient preferences.
  • Be respectful of a patient’s strong preference regarding where the LAI is administered. Use clinical judgment regarding manufacturer instructions, risks and benefits of treatment versus non-treatment, and body habitus.
• Safety for patient and clinician.
  • Patient and clinician factors, such as gender, should be considered as often as possible. For example, patients with trauma histories, erotomanic delusions, or paranoia may benefit from a clinician of a preferred gender or accompaniment by a designated safe person in the room.

For more information on specific LAIs, please see individual clinical tips on Abilify Maintena, Aristada Initio, Aristada, Prolixin Decanoate, Haldol Decanoate, Invega Sustenna, Invega Trinza, Risperdal Consta, and Perseris.

REFERENCES

Perry, A.G., Potter, P.A., & Ostendorf, W. (2013). Safe Medication Preparation. Clinical Nursing Skills and Techniques (8^th ed.). St. Louis: Elsevier Mosby.