Download GENERAL IV ADMIXTURE POLICY JCI CBAHI Standards Page 1 of 2

HOSPITAL NAME
Department:
INSTITUTIONAL POLICY AND PROCEDURE (IPP)
Manual:
TITLE/DESCRIPTION
Section:
POLICY NUMBER
GENERAL IV ADMIXTURE POLICY
EFFECTIVE DATE
APPROVED BY
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APPLIES TO
PURPOSE
All intravenous admixtures operations or manipulations are performed using aseptic techniques, as to provide sterile,
particulate and pyrogen free products
RESPONSIBILITY
All personnel involved in IV admixtures must be certified. Personnel must be re-certified every two years.
CROSS REFERENCES
POLICY
PROCEDURE
1.The handling of sterile products requires the comprehensive knowledge of aseptic technique. No person shall prepare
such products until they have been properly trained. All personnel working with sterile products must be familiar with the
products, procedures, techniques, equipment and facilities required and available, to prepare the optimal product for the
hospital patient.
2. Standard guidelines for the dilution, stability, preparation, and administration of intravenous admixtures will be
provided and continually updated as information is available
3. The parenteral products prepared shall include: primary intravenous solutions, continuous intravenous medication
solutions, intravenous piggyback medications (IVPB), IV syringe medications for IV, IM, SQ.
4. All primary IV and continuous IV medication infusion orders will be for 24 hours. No bottle/bag shall hang longer than
24 hours
5. Pediatric patients shall not have liter bottle/bags hanging unless the rate is greater than 60ml/hr.
6. Potassium Chloride concentrations should not exceed 80 mMol/liter in a peripheral vein (preferably at 30 to 40
mMol/L for peripheral vein). IVPBs of KCl should not exceed 10 mMol/hr./100ml IVPB unless the patient is on an
ECG monitor.
7. Electrolytes ordered for IVs should be written in mMol per liter. For all 24-hour orders, required IVs should provide
sufficient solution made to cover through 1200 hours to the following day, unless specified by the physician
8. Before preparing IV syringes for the administration of a medication, all personnel must take into consideration the
followings: age of patient, rate of IV, total fluid requirements (if patient is fluid restricted), dilution requirement of
medication, compatibility with IV fluids and stability of medication; after accessing the information, then they can
determine if syringe preparations are indicated.
9. The floor nurse may administer IV push medications listed in the IV push policy.
10 All STAT IV admixtures will be given priority in preparation and handling to provide the product to the patient as
rapidly as possible
11. All preparations will be checked by a second person before administration to the patient for proper labeling,
components, quantity and quality of the product.
12. Neonates and newborn’s IV preparations shall be preservative-free whenever possible.
JCI
Standards
CBAHI
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13. The disposal of IV solution will be according to the medication and volume of the products:
− Antibiotics and antifungals - in “contaminated” trash bags.
− Large volume IV without hazardous medications - bag/bottle opened and fluid emptied into sink, empty
bag/bottle in “contaminated” trash bag.
14. All IV supplies which are sharp or may cause injury in handling, such as IV needle, sharp glass ampules and vial
metal covers will be discarded in special hard plastic containers with the proper labeling affixed for contents inside
contaminated
15. All prepared controlled medications shall be properly logged in the controlled record.
16 Filter needles or PMF filters will be used when withdrawing from glass ampules, when indicated to prevent the
introduction of particulate matter into the IV product.
17. All IVs are to be prepared just prior to the administration.
18 When the volume of the additive exceeds 5% of a continuous infusion, then a volume equal to the volume of the
additive must be removed.
19. The rate of the IV admixture should correlate with the volume of the preparation
20. Minimal volume to be sent in a syringe is 0.2 ml.
FORMS
EQUIPMENT
REFERENCES
APPROVAL:
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Signature
Date
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Approved By
Latest Revision Approved By
JCI
Standards
CBAHI
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