Name: ________________________________________
Date: _________________________________________
POINT VALUE
✦ = 3–6 points
✶ = 7–9 points
GRADED
TRIAL
# 1
GRADED
TRIAL
# 2
NOTES
1. ✦ Check the medication against the
physician’s medication order, as
instructed in the “three befores.”
2. ✦ Do not open the ampule until you
are ready to withdraw the fluid.
3. ✦ Perform hand hygiene and apply
gloves.
4. ✶ Snap your thumb and middle
finger gently against the tip of the
ampule to move all the medication
away from the neck and into the
bottom of the ampule (Figure A).
5. ✦ Clean the neck of the ampule
using an alcohol swab.
6. ✶ Using one hand to hold the
bottom of the vial, snap o the top
with the other hand using a gauze
square to prevent a cut when the
glass neck breaks (Figure B).
7. ✦ If the top of the ampule does not
snap o easily, you may have to
use a file to create a cut or “score”
the ampule at the neck. The glass
ampule should then break easily
at this point (Figure C).
8. ✶ Insert a filter needle (attached
to a syringe) into the ampule
and withdraw the fluid without
touching the sides of the ampule.
9. ✶ Withdraw all the medication from
the ampule. It may be necessary
to tip the ampule slightly to
withdraw all the fluid.
10. ✦ Discard the broken ampule into a
sharps container.
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