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HOSPITAL NAME Department: INSTITUTIONAL POLICY AND PROCEDURE (IPP) Manual: TITLE/DESCRIPTION Section: POLICY NUMBER GENERAL IV ADMIXTURE POLICY EFFECTIVE DATE APPROVED BY REVIEW DUE REPLACES NUMBER NO. OF PAGES 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 Page 1 of 2 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: Name Signature Date Prepared by Reviewed by Approved By Approved By Latest Revision Approved By JCI Standards CBAHI Page 2 of 2