Download NUH Intravenous Drug Administration Policy

NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST
NUH Medicines Policy: Code of Practice
NUH Intravenous Drug Administration Policy
Reference
Approving Body
Date Approved
Implementation Date
Version
Summary of
Changes from
Previous Version
Supersedes
Consultation
Undertaken
Date of Completion
of Equality Impact
Assessment
Date of Completion
CL/MM/036
Directors’ Group
5 February 2016
5 February 2016
1
n/a
NUH Guide to Intravenous Therapy (2011) (Part A) Sixth
Edition
 Medicines Management Committee
 Nursing and midwifery board
 Matrons
 Ward Sisters/ Charge Nurses
 Practice Development Matrons
 Nursing Development Department
 Medical prescribers- those on Medicines Safety
Committee.
 Interventional Radiography- vascular access
practitioner
 Specialist Pharmacist for Theatres/anaesthetics, along
with consultation from senior nursing/ ODP team in
theatres
 Infection control Nurse Specialists
 Out Patient Antibiotic Therapy Specialist Nurses
 School of Nursing and Midwifery, University of
Nottingham
 Neonatal senior nurses and consultants.
 Matron clinical procurement
6th September 2015
6th September 2015
NUH Intravenous Drug Administration Policy
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of We Are Here for
You Assessment
Date of
Environmental
Impact Assessment
(if applicable)
Legal and/or
Accreditation
Implications
Target Audience
6th September 2015
MHRA mixing of medicines guidance 2010
CQC standards April 15 (standards 17 and 19)
NMC standards for medicines management 2010
This policy applies to:
Staff Groups
 Registered nurses and midwives (NMC) including
bank and agency staff
 Medical staff (GMC registered) including locum
medical staff
 Radiography staff who undertake diagnostic
procedures (HCPC registered)
 Operating department practitioners (HCPC registered)
 Non-registered healthcare workers competent in
intravenous cannulation
 Other staff groups authorised to administer IV
medicines by the Medicines management Committee
(MMC)
Clinical areas
 All in-patient wards- adult, paediatrics and Neo-natal
areas.
 Operating theatres and recovery rooms (not including
anaesthetists’ practice in theatres)
 All outpatient areas
 Maternity areas
 Assessment areas and emergency departments
 Clinical procedural areas
 NUH staff working at Kings Mill and intermediate care
beds and in the community.
Exclusions
 This policy covers intravenous therapy only and does
not apply to patients undergoing subcutaneous or
epidural infusions/therapy.
 This policy does not apply to administration of IV
NUH Intravenous Drug Administration Policy
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Review Date
Lead Executive
Author/Lead
Manager
Further Guidance/
Information
medicines or fluids in the Circle Treatment Centre
 This policy does not include the use of specialist
infusion equipment used in anaesthesia delivery or
radiology contrast media. In these areas the therapy
and use of medical devices falls under the remit of the
department specialist infusion equipment
 This policy does not apply to anaesthetic practice in
the operating theatre department.
February 2017
Chief Nurse for Nursing and Midwifery at NUH
Medical Director
Mohamed Rahman
Head of Pharmacy, Clinical Director Medicines
Management, Chair of Medicines Management
Committee
Ext 62984
Sonia Gilmore
Professional secretary to Medicines Management
Committee
Ext 59374
Lynn Fullerton Practice Development Matron (Corporate)
Ext 57236
NUH Intravenous Drug Administration Policy
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CONTENTS
Paragraph
Title
Page
1.
2.
3.
4.
5.
6.
6.1
6.2
6.3
6.4
6.5
Introduction
Executive Summary
Policy Statement
Definitions (Glossary and Abbreviations)
Roles and Responsibilities
Policy and/or Procedural Requirements
Prescription
Authorisation to administer
Two-person checking (also called second checking)
Timing of medicine preparation
Preparing the medicines or fluid for
administration
Calculations
Compatibility and mixing of medicine and suitability
of venous access device
Preparing the intravenous medicine
Administration of the IV medicine
Administration of medicines requiring double
pumping
Administration of medicines to be given by titration
After administration
Non-administration
Interruptions to infusions
Disposal
Administration set changes
Identifying and managing possible complications of
IV administration
Administration via a verbal order
Administration by NUH staff working in the
community
Administration of an OPAT medicine
Removal of access devices
Training, Implementation and Resources
Impact Assessments
Monitoring Matrix
Relevant Legislation, National Guidance and
7
7
7
7-11
11-13
6.6
6.7
6.8
6.9
6.10
6.11
6.12
6.13
6.14
6.15
6.16
6.17
6.18
6.19
6.20
6.21
7.
8.
9.
10.
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15-18
18
18-19
19-20
20
21
21-24
24-26
26
26
26-27
27
27-28
28
29-30
30
30
30
31
31-32
32-33
33-34
35
36-37
4
Associated NUH Documents
Appendix 1 The Procedure for administering intravenous Drugs
using Aseptic Non-Touch Technique (ANTT) (NUH
(2015) Aseptic Non-Touch Technique Policy)
Appendix 2 Best Practice for the administration of medication via
intravenous route.
Appendix 3 Summary Steps for medication intravenous drug
administration.
Appendix 4 Procedure for withdrawing a solution from an
ampoule (glass or plastic) into a syringe
Appendix 5
Appendix 6
Appendix 7
Appendix 8
Appendix 9
Appendix
10
Appendix
11
Appendix
12
Appendix
13
Appendix
14
Appendix
15
Appendix
16
Appendix
38-39
40
41-42
43-44
Procedure for withdrawing solution or suspension
from a vial into a syringe
Procedure for reconstituting powder in a vial and
drawing the resulting solution or suspension into a
syringe.
Procedure for using multiple dose vials to withdraw a
solution or suspension into a syringe.
Procedure for adding a medicine to an infusion fluid
in a bag.
Procedure for diluting a medicine in a syringe for use
in a syringe pump
Information on Administration an infusion (with or
without an additional medication)
Preparing an administration set (‘giving set’ or
‘intravenous infusion set’)
Procedure for administering Intermittent or
continuous infusion of intravenous medicines (with or
without additional medicines)
Procedure for the intravenous medication
administration via a bolus/ push. Including
medication that may need to be administered over
several minutes
Summary of Flushing and Locking in Adults
45-46
Summary of Flushing and Locking in Children
69-70
Summary of flushing and locking in Neo-natal
71
Table of possible complications of intravenous
72-74
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48-49
50-51
52-53
54-55
56-57
58-61
62-65
66-68
5
17
Appendix
18
Appendix
19
Appendix
20
Appendix
21
Appendix
22
medication administration
Guidance for the management of extravasation
following administration of cytotoxic medication
Double pumping
Appendix
23
Appendix
24
75
76
What involvement students can have in medicines
administration?
Equality Impact Assessment
77-78
Environmental Impact Assessment
81-82
Here For You Assessment
83-84
Certification Of Employee Awareness
85
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1.0
1.1
Introduction
This policy is to inform staff working at Nottingham University
Hospitals NHS Trust (NUH) of the correct practice and procedures
when administering intravenous (IV) therapy to patients.
2.0
Executive Summary
2.1
This policy outlines the responsibilities of all staff groups involved in
the administration of IV therapy in all areas at NUH (adults and
paediatrics). It ensures that there is a safe, consistent level of
practice in the care of these patients.
IV therapy in this policy includes all medication via: direct/ bolus
injection or infusion, flushes, IV parental nutrition, line locks, infusion
fluids.
3.0
Policy Statement
3.1
The Trust supports the safe administration of IV therapy by all NUH
staff
Practitioners involved in the prescribing or administration of IV
medicines should act within their sphere of competence at all times.
This includes having the relevant training and competency to use the
medical devices in their area to administer IV drugs.
Practitioners are accountable for their practice in accordance with the
standards of their professional body and with the requirements of the
NUH medicines policy.
4.0
Definitions and Glossary of abbreviations
4.1
4.1.1 Healthcare professional: A registered member of staff,
including nurses, operating department practitioners, doctors,
dentists and radiographers. This also includes individuals employed
by a third party to work within NUH.
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4.1.2 Healthcare support workers: Non-registered staff employed
as band 2, 3 or 4. This group will include phlebotomists.
4.1.3 Scrubbed Practitioner: Authorised professional who assists
the Operating Surgeon, handing the surgical instruments or other
items.
4.1.4 Operator: These are registered medical practitioners e.g. the
surgeon, endoscopist, cardiologist, obstetrician, radiologist or other
healthcare professional or practitioner performing the invasive
procedure.
4.1.5 Competence: Is defined as demonstrating the knowledge and
skills to perform the task to NUH standards, consistently and without
supervision.
4.1.6 IV trained practitioner: A practitioner who has satisfactorily
completed the NUH training for IV administration or has had their
training and competency from another organisation verified, has
undergone a competency check in their area of practice and has
reviewed associated NUH policies and procedures to align their
practice.
4.1.7 Direct Intravenous injection: Introduction of a small volume of
medicine solution into the cannula or the injection site of an
administration set. A direct intravenous injection should be
administered slowly over 3-5 minutes unless otherwise specified.
Sometimes referred to as intravenous bolus.
4.1.8 Intermittent infusion: Administration of an infusion over a set
time period, either as a one-off dose or repeated at specific time
intervals. This will involve repeated use of a single cannula. This may
be a central venous access device for example PICC lines/Port-acatheter devices/Hickman lines.
4.1.9 Continuous infusion: Intravenous administration of a volume
of fluid with or without medicines added over a number of hours to
achieve a clinical end point. The infusion may be repeated over a
period of days. Large volume i.e. 25-1000mL or small volume
infusions may be delivered continuously.
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4.1.10 Infiltration: the deposition of a solution (e.g. local anaesthetic)
directly into tissue often during surgical procedures. Due to the
associated risks the same procedure as for IV preparation and
administration should apply.
4.1.11 Irrigation: washing or filling of an organ, body cavity or wound
by a stream of fluid. Due to the associated risks the same procedure
as for IV preparation and administration should apply.
4.1.12 Two person check procedure (also known as second
checking): At NUH the accepted standard is to have two registered
health care practitioners both check the medicine for administration.
This is usually two registered nurses/ midwives. All steps of the
process are checked from drug selection and preparation to
administration. Where a calculation is involved, both practitioners
must perform an independent calculation and then share their
individual calculation result to confirm accuracy.
4.1.13 Extravasation: The inadvertent administration of vesicant
medication or solution into the surrounding tissue instead of into the
intended vascular pathway (also sometimes called tissued).
4.1.14 ANTT: Aseptic Non Touch Technique
4.1.15 VIPS: Visual Infusion Phlebitis Score
4.1.16 IV administration monographs: Detailed guidance on the
preparation, reconstitution and administration of specific intravenous
injections and infusions are available on every ward/ unit. The most
up to date version of the guidance available in that area must be
used. Trust wide versions currently in use include NUH Part B (“blue
pages”- adults), and Medusa IV drug guide. In the Neonatal unit this
includes the Neonatal Pharmacopeia.
4.1.17 TPN: Total Parenteral Nutrition
4.1.18 Peripheral cannula: a cannula that is less than or equal to
7.5cm in length. Ideally for short term therapy of 3-5 days. Often
referred to as venflons.
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4.1.19 Midline catheter for adults: a cannula that is 7.5-20cm in
length. Are used where the patient has poor peripheral venous
access and the use of a central venous catheter is contraindicated.
Drugs that require central access are NOT suitable to be
administered via a Midline. Ensure that the drug prescribed is
suitable for midline administration.
4.1.20 PICC: Peripherally Inserted Central Catheter in neonatal,
referred to as ‘long lines’. These are suitable for all drugs as per
Central venous catheter/ Hickman line/ Portacath.
4.1.21 Central Venous Catheter (CVC) ‘Central line’, ‘central
venous line’ is placed into a large vein in the neck (internal jugular),
chest (subclavian vein) or groin (femoral line). In neonates, this also
includes umbilical artery & venous catheters. Some medication are
best delivered via a central line e.g. inotropes; chemotherapy; TPN.
Additional evidence of competency to use this type of access is
required before administering medication via this device.
4.1.22 Skin tunnelled catheter is a long-term catheter that lies in a
subcutaneous tunnel before entering a central line. Examples
include: Hickman line; Broviac line. Additional evidence of
competency to use this type of access is required before
administering medication via this device.
4.1.23 Implantable ports such as Portacath are used for long term
intermittent venous access. Additional evidence of competency to
use this type of access is required before administering
medication via this device.
4.1.24 Preceptorship nurse: A newly qualified nurse who upon
commencing post undergoes a programme of supported learning in
their practice environment. Supported learning programmes are
available for other newly appointed nurses to the Trust, where this is
deemed essential to their role.
4.1.25 Y site connector- This is a connector device that is used to
deliver IV medicines from different sources into one vein.
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4.1.26 Mixing of medicines- This is the combining of two or more
medicinal products together for the purpose of administering them to
meet the needs of an individual patient. This technically produces an
‘unlicensed’ product. The Medicines Healthcare products Regulatory
Agency (MHRA) has put into place changes to medicines regulations
to enable the mixing of IV medicines prior to administration in clinical
practice. See 6.1.4
4.1.27 OPAT: Out Patient Antibiotic Therapy
4.1.28 Double Pumping: Use of two pumps simultaneously. Used
when changing infusions of very short acting drugs where a break in
therapy could be detrimental to the patient.
5.0
Roles and Responsibilities
5.1
Committees
5.1.1 Nursing and Midwifery Board
Responsible for ensuring that this policy reflects best practice for
nursing.
5.1.2 Medicines Management Committee (MMC)
Responsible for approving the policy, managing the monitoring
arrangements for the policy and to address barriers to
implementation of the policy.
5.2
Individual Officers
5.2.1 The Chief Nurse is responsible for implementation of this
policy by nurses at NUH.
5.2.2 The Head of Pharmacy is responsible for ensuring the content
of this policy aligns with the necessary legislation and accreditation
standards through the Medicines Management Committee.
5.2.3 Divisional Nurses and Heads of department are responsible
for ensuring that necessary measures are in place to support the safe
implementation and monitoring of the use of the policy in practice.
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They will need to take measures where practice has been deemed
potentially unsafe.
5.2.4 Matrons and department managers are responsible for
ensuring that all staff accountable to them are aware of and adhere
to this policy. It is the manager in practice. They will investigate and
rectify any discrepancies identified.
5.2.5 Ward sister/ charge nurse/ department leader will act as
excellent role models and are responsible and accountable for the
policy implementation among staff in practice, and the monitoring of
standards and best practice associated with it. They will ensure that
all staff in the sphere of their responsibility have access to training to
develop the skills and competence. This includes the completion of
the associated work books, medical equipment competency
documents and study sessions in a timely manner.
5.2.6 All registered healthcare professionals have a duty of care
to their patients. This is a legal and professional requirement of state
registration that cannot be delegated. All registered healthcare
professionals are personally responsible and professionally
accountable in ensuring that they receive training in the safe use and
observation of any medical device used in the delivery of intravenous
therapy (MHRA, 2010). It is the responsibility of the healthcare
professional to ensure that any IV access or IV therapy is
appropriately prescribed for the patient and that the patient and
therapy delivery are monitored accordingly according to associated
policies and procedures.
5.2.7 Pharmacists are responsible for monitoring both the
prescribing and overseeing the administration of medicinal therapies
and alerting prescribers and other health care professionals to
potential or actual problems in line with NUH pharmacy procedures
and Royal Pharmaceutical Society standards.
5.2.8 All staff are required to prevent and manage healthcare
acquired infection as part of The Health Act 2008: Code of Practice
on the control of infections and related guidance (Department of
Health, 2015).
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5.2.9 Allied health professionals not required to take part in IV
therapy administration
This group of staff should not be involved in, or action any part of the
delivery of IV therapy including use of medical devices. This includes
disconnection of lines and starting infusion devices or pumps
between the point of delivery and the patient. In the event of the need
to access a patient where therapy may need to be discontinued for
any reason, the advice of a registered person should be sought.
6.0
Policy and/or Procedural Requirements
6.1
Prescribing
6.1.1 Prescription requirement
All medicines to be administered must be prescribed on a NUHapproved prescription chart- see Prescribing policy CLMM006.
If the medicine is not suitable for peripheral line administration this
must be stated on the prescription, e.g. ‘for central line only’. It is
good practice for IV medicines to state details of any diluting fluid and
duration of the injection or infusion, which vascular access should be
used, the date, rate or duration of infusion and signature.
6.1.2 Prescribing of IV loading doses
For IV loading doses only:
 Direct injections should be prescribed on the ‘once-only’ section of
the drug chart.
 Infusions (which must be administered via a rate controlling
device) should be prescribed on the infusion therapy prescription
section of the drug chart.
6.1.3 Prescription of other IV drugs
For IV maintenance doses and other infusions:
 Maintenance doses of medicines administered intermittently by
direct injection or infusion should be prescribed on the ‘regular’ or
‘as required’ sections of the drug chart
 Insulin infusions either as a continuous or variable rate should be
prescribed on an Insulin Chart
 Opioids being administered via Patient Control Analgesic Pump
(PCA) should be on PCA chart
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 Chemotherapy should be prescribed via a Chemocare® (where
Chemocare in place)
 Maintenance doses of antibiotics should be prescribed on the
antibiotics section of the drug chart.
 All other infusions (large volume infusion bag, or small volume
syringe or bag) which must be administered continuously via a
rate controlling device should be prescribed on the infusion
therapy prescription section of the drug chart. The prescription
must be rewritten in full at least every 24 hours. Prescribers
changing the rate must document; new rate, date, time and initials.
Includes:
o Crystalloids, plasma expanders, or fluids
o Drugs added to a large volume infusion bag, or in a small
volume syringe, or ready to administer from the
manufacturer for continuous infusion
6.1.4 Prescribing of IV drugs which require mixing prior to
administration
 By definition ‘mixing’ is ‘the combination of two or medicinal
products together for the purpose of administering them to meet
the needs of a particular patient’. This does not include
reconstitution or dilution with the infusion fluid which is permitted.
 The prescriber must state ‘mixed’ or ‘mixing in line’ on the
prescription. This may be pre-printed on the prescription, e.g. in
critical care areas.
Under MHRA regulations, prescribers are legally authorised to mix
medicines to administer to a patient themselves. Other practitioners
may mix medicines on the authorisation of a prescriber prior to
administration. This also applies to concurrent administration of
multiple drugs via a Y site connector.
6.1.5 Prescribing of Infiltration or irrigation for intraoperative use
 Administration via these routes requires that the practitioner has
completed their NUH approved Intravenous Drug administration
Training, as well as practice based assessment. The practitioner
must also be able to provide evidence of training in the use of any
medical device required to administer the medication they are
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




administering.
Medication for administration via infiltration or irrigation in theatres
is prescribed an electronic Kardex system; this is an approved
medicine order which is validated by the operator.
The electronic Kardex system, gives details of the medicines
which the operator will expect to administer during a specific
operative procedure. The system allows a practical way for the
theatre practitioner to plan and safely prepare for operative
procedures.
All medicines which are selected for intra-operative administration
must be checked against the operator’s medicine order as detailed
in the electronic theatre Kardex.
Irrigation and infiltration preparations should prepared and
administered using a two person check for all stages.
If a verbal order is made from the operator that differs from the
Kardex, the registered practitioner will instruct the circulating
practitioner to select the medicine. The selected medicine will be
checked against the verbal order by the registered practitioner
before the medicine enters the sterile field. The registered
practitioner is responsible for second checking this with the
operator prior to administration.
For local anaesthetics the scrub practitioners must check that the
operator and anaesthetist have communicated and agreed on the
concentration and volume of local anaesthetics which are ordered by
the operator before preparing the infiltration. This is to safeguard
against local anaesthetic toxicity.
6.2
Authorisation to administer IV medicines
All registered healthcare professionals MUST be competent to be
involved in the administration process of IV medicines. If they are
unfamiliar with the advised administration method, e.g. using a
central line, then this MUST be highlighted and an alternative
appropriate staff competent in administering the drug should be
sought.
The following practitioners are permitted to administer medicines
intravenously, providing they have the relevant underpinning
knowledge and competencies to do so (also see 7.0 Training) :
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6.2.1 Registered Nurse or midwife:
Must have evidence of successful completion of the NUH approved
Intravenous Drug administration Training and competency package,
as well as practice based assessment. Must also be able to provide
evidence of training in the use of any medical device required to
administer the medication they are administering.
6.2.2 Newly appointed nurse or midwife who have completed an
IV package/training at another organisation:
Having previously worked at another organisation, practitioners are
required to supply evidence of training, along with proof of supervised
practice and verification of competence in order to continue to
administer IV medication. Without this evidence, staff will be required
to complete the current NUH Intravenous administration competency
package.
6.2.3 Newly Qualified nurse or midwife PLUS registered nurses
that have NOT worked within an acute care hospital in the last 6
months PLUS registered nurses from overseas:
Must successfully complete the NUH approved Intravenous Drug
administration Training and competency package, as well as practice
based assessment prior to administering IV medication.
However, once they have successfully completed the IV medication
calculations section of the NUH approved Intravenous Drug
administration Training and competency package they may participate
in the preparation (including separate calculations if required),
checking and recording of the administration as part of the 2-person
check. They cannot administer the drug to the patient or connect an
infusion.
NB The only exception where IV medication maybe administered by
this staff group prior to successfully completing the NUH approved
Intravenous Drug administration Training and competency package, is
in in a time critical emergency situation, taking into consideration both
the patient’s critical condition and the practitioner’s knowledge and
skills.
6.2.4 Agency nursing staff (including NHS Professionals and
other external Agency organisations) must not administer
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intravenous medication unless they have received additional training
and have a documented competence assessment. Where staff are
working outside of their usual area of work, their competence must be
assessed in that area prior to administering intravenous medication.
They must have the knowledge and skills for safe and effective
practice when working without direct supervision (NMC, current
version). Agency staff cannot check IV drugs for administration with
another flexible worker; these must be checked with a permanent
member of staff within the clinical area. In addition, agency staff must
also be able to provide robust evidence of Trust specific medical
device training for any device they are using.
6.2.5 Health care assistants may administer a single 0.9% sodium
chloride flush immediately after peripheral cannulation to adults
(completion of venepuncture and cannulation education package
required). Also refer to NUH medicines administration policy
CL/MM/008.
6.2.6 Medical students under the direct supervision of a doctor who is
then responsible for the correct administration and recording of the
medicines prescribed.
6.2.7 Other practitioners approved by the Trust as Designated by
the Trust e.g. radiographers, physiotherapists, Operating
department practitioners Must have the relevant underpinning
knowledge, AND following successful completion of the NUH IV
training and assessment of competence AND must have a list of
medicines/local agreement in place ratified by Medicines Management
Committee. Also refer to NUH medicines administration policy
CL/MM/008.
6.2.8 Other practitioners: If any other named individual or staff group
need to administer IV medicines, there must be a local agreement in
place which has been ratified by the Medicines Management
Committee.
6.2.9 Patients or carers: This group will not normally self-administer
IV medicines. In some circumstances, patients or carers are taught to
self-administer OPAT antibiotics in hospital for further administration
after discharge where they may prepare and administer IV medicines
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and flushes under the supervision.
6.2.10 Student nurses or student midwives who are not registered,
can assist in the preparation and recording of intravenous infusions
and direct injections under the direct supervision of 2 registered
nurses but CANNOT administer the medication. The supervising
registered nurses are responsible for the correct process throughout.
6.3
Two-person checking (also called second-checking)
The following groups of practitioners are authorised to second check
injectable medications:
 A doctor
 A registered nurse or Midwife that has completed the calculation
section of the NUH approved Intravenous Drug administration
Training and competency package.
 A Pharmacist that has completed the theory section of expansion
to practice IV administration of medicines (an exception is that a
pharmacist working within their sphere of competence may second
check a calculation without completion of this pack, but should not
check other steps in the process).
All injectable medicines (except prophylactic doses of enoxaparin)
including IV fluids and irrigation and infiltration fluids must have a two
–person check before administration.
All rate changes of IV infusions must also have a two-person check,
and must be within the rates specified on the prescription.
Refer to NUH medicines administration policy CL/MM/008 for other
drugs requiring a two person check. Both practitioners:
 MUST check all stages of any intravenous drug/medication/fluid
preparation (include undertaking separate drug calculations if
required), up until the injection or infusion is commenced.
 MUST observe the preparation.
 Take equal responsibility for the correct administration of the drug/
medication/ fluid to the correct patient.
 Should sign the prescription chart.
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6.4
Timing of medicine preparation
 A venous access device must be in place before an injectable is
prepared. Intravenous medicines must not be prepared in advance
of their use.
 Administration must be commenced as soon as possible after
preparation, and must be within one hour of preparation
(considered to be the time when the sterile seal of the primary
packaging is breached). Any medicine prepared in advance must
be discarded if the clinical need ceases, and in any case after
24hours (or less if physically unstable- refer to IV administration
monographs in use in your area).
 Exceptions to this must be made for the benefit of the patient, not
the convenience of the staff. An exception to this is when IV
medication is prepared within the pharmacy department, e.g. Total
parenteral nutrition (TPN) and cytotoxic medicines.
 Areas that have a clinical need to routinely prepare medicines in
advance (e.g. paediatric retrieval team, procedural areas such as
cardiac catheter lab) must:
o Have a current local agreement in place (ratified by MMC)
o Complete a full risk assessment
o Use tamper proof packaging
o Discard any prepared products if clinical need ceases, and
within 24hours (or sooner if product unstable)
6.5
Preparing the medicines or fluid for administration
Refer to Procedures on Appendix 1-19+ for details.
All steps of preparing medication must occur, and involve 2 persons.
However they may occur in a different order, ensuring patient safety
at all times.
6.5.1 Check the patient’s prescription for:
 The right patient
 The right drug chart
 The right date/ day/ time
 Right Route
 Right drug, preparation, dose and indication
 Check patient allergies
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See Appendix 3 ‘Summary of steps of administration’ for more details
6.5.2 Patient consent
All patients should give valid consent to receiving healthcare,
including receiving medicines. Consent should happen at all stages
of the process. Refer to NUH Consent policy CL/CGP/020 for more
information.
6.5.3. Prepare for one patient at a time
Prepare and administer IV medicines for each patient individually.
Preparing medicines for multiple patients simultaneously is a high risk
practice and must be avoided.
If a patient requires more than one parenteral medicine at a given
time, it is good practice to fully prepare, check and administer the first
medicine before preparing the second.
6.5.4 Single use vial policy
Sterile fluids intended for injection, including infusion fluids, water and
medicines (other than approved Multiple Dose Vials) must be for
single use only. If only part of the container is used, the remainder
must be discarded. It must not be kept for multiple uses on separate
occasions, even for the same patient. Other equipment used to
prepare or administer intravenous medicines that has been
designated as ‘single use’ must not be re-processed or re-used under
any circumstances including needles, syringes, lines, catheters and
tubing.
Refer to CL/MM/028 Medicines Policy: Code of Practice: Use of
Single and Multiple dose vials.
6.6
Calculations
You may need to calculate:
 concentration or total quantity of medicine in the final infusion
container or syringe;
 volume of diluent and/or infusion fluid;
 rate and duration of administration;
All calculations MUST be 2-person checked. Calculations must be
done independently and any discrepancies must be re-calculated. If
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necessary seek advice from a pharmacist. Confirm that your answers
are consistent with the IV administration monographs in use in your
area. Dose calculation tools are available in some areas.
6.7
Compatibility, mixing of medicines, and suitability of venous
access device.
Confirm that the medication is suitable for the venous access the
patient has in place.
Ensure compatibility or incompatibility of the IV medication by
referring to the IV administration monographs in use in your area.
Where multiple drugs are being administered through the same
lumen through a Y-site connector or multiway adaptor fixed to a
patient’s cannula, confirm that they are both compatible with other
medicines and fluids and suitable for the route of administration i.e.
peripherally/ centrally. This is particularly important for medicines
administered via the same lumen of a CVC. If necessary seek advice
from a pharmacist.
Ensure that the prescriber has stated “mixing in line’ on the
prescription as above, or that a specific approved local policy is in
place.
Patient Controlled Analgesia (PCA) style lines containing an antireflux valve must be used when potent drugs are running together or
when a potent drug and an intravenous fluid are running into the
same cannula and the fluid is running under gravity rather than being
pumped.
6.8
Preparing the intravenous medicine
6.8.1 Also Refer to Appendices:
Appendix 2: Best Practice for the administration of medication via
intravenous route
Appendix 3: Summary Steps for medication intravenous drug
administration.
 Use a ready-made product, e.g. a pre-filled syringe, where
available
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 Right diluent or infusion fluid. If in powder form identify correct
diluent and volume required. If medication needs to be given in an
infusion, select correct infusion fluid.
 Right expiry. Check the expiry date of ALL medication, diluents
and fluids to be administered.
 Ensure area in which medicine is prepared is as clean, uncluttered
and free from interruption as possible.
 Medication intended for injection should not be put into gallipots.
 Some areas may choose to wear red tabards for medicines
administration e.g. the neo-natal areas.
 Assemble all medicines in line with the NUH (2015) Aseptic Nontouch Technique (ANTT) Policy (see Appendix 1). The key
principles of ANTT are:
o Always decontaminate hands effectively
o Never contaminate ‘key parts of the equipment or the
patients’ susceptible site.
o Touch non ‘key parts’ of the equipment with confidence
o Take appropriate infection prevention and control
precautions.
 Procedures for the preparation of the following can be found in the
appendices and must be followed by all practitioners:
o Appendix 1: The Procedure for administering intravenous
Drugs using Aseptic Non-Touch Technique
o Appendix 4: Procedure for withdrawing a solution from an
ampoule (glass or plastic) into a syringe
o Appendix 5: Procedure for withdrawing solution or
suspension from a vial into a syringe
o Appendix 6: Procedure for reconstituting powder in a vial
and drawing the resulting solution or suspension into a
syringe.
o Appendix 7: Procedure for using multiple dose vials to
withdraw a solution or suspension into a syringe.
o Appendix 8: Procedure for adding a medicine to an infusion
fluid in a bag.
o Appendix 9: Procedure for diluting a medicine in a syringe
for use in a syringe pump
o Appendix 10: Information on Administration of an infusion
(with or without an additional medication)
o Appendix 11: Preparing an administration set (‘giving set’ or
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intravenous infusion set’)
o Appendix 12: Procedure guideline: Intermittent or continuous
infusion of intravenous medicines (with or without additional
medicine)
o Appendix 13: Procedure for the intravenous medication
administration via direct injection. Including medication that
may need to be administered over several minutes.
 Refer to the pharmacist or individual drug monographs for up to
date technical information on preparation and administration/ or
current information available in your area
6.8.2 Labelling injections, infusions and giving sets
 Unless in a hand-held syringe for immediate direct injection,
administered by the person who prepared the medicine, ALL
intravenous medication should be labelled immediately after
preparation with a fully completed NUH IV additive label.
 An operator should not be in possession of more than one
unlabelled syringe at a time.
 An unlabelled syringe must not be fitted to a syringe driver or
similar device, e.g. when preparing multiple medicines for one
patient.
For medication being administered via continuous infusion the givingset must also be labelled with the date on which it is due to be
changed.
6.8.3 Infusion devices
See Appendix 10: Information on Devices to Administer an infusion
(with or without an additional medication) for further information.
Key points:
 Select and prepare an appropriate infusion device, e.g. a gravity
flow device or a rate controlled device.
 The staff member must be competent to use device selected.
 Select an appropriate administration set for the pump and the drug
to be infused, i.e. it may be necessary to use a giving set that
incorporates a filter, an anti-reflux valve and/or flow-control line.
A rate controlled infusion device must be used for administering:
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 Infusions to neonates and children
 Medicines where the rate of infusion is important, e.g. when
treating hypokalaemia, you must use a rate controlled infusion
device where administering an infusion containing a concentration
of 40mmol of potassium per litre, or greater.
Staff using infusion pumps operating Drug Error Reduction Software
(DERS) must ensure they have the necessary competence to
operate the device. They must ensure that they select the appropriate
infusion programme, and that the medicines they are administering
match the prescription and DERS and fall within the upper and lower
parameters for that regime.
6.9
Administration of the IV medicine
6.9.1 Responsibility for administration
 Practitioners must only administer IV medication that has been
prepared in their presence (unless the medication is provided in a
pre-prepared syringe or bag from Pharmacy). If both practitioners
involved in the preparation have to leave the room before
administration the medicines must be kept securely.
 In cases of transfer with a continuous infusion, the practitioner
may delegate the ongoing administration to another practitioner.
 In exceptional circumstances e.g. when a patient is transferred
between units, the practitioner may delegate administration of an
IV medicines to another practitioner, where not doing so would be
a disadvantage to the patient. There should be a formal
documentation of a handover in the patient’s notes.
6.9.2 Positive patient identification
 Positive patient identification MUST occur by both
practitioners prior to IV medication administration. This includes
full confirmation of the wrist band details with the drug chart; and
positive patient identification by the patient to confirm their
identification verbally, where possible.
 Where possible explain to the patient and/or family and carers
what is about to happen, the likely benefit and possible side-effect,
and obtain patient’s verbal consent to treatment and answer any
concerns the patient has.
Refer to NUH positive patient identification policy CL/CGP/037
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6.9.3 Check allergy status of patient- two person check
This needs to be done at the bedside, confirming the red wrist band,
checking the drug chart and where possible asking the patient to
state any known allergies and / or sensitivities.
6.9.4 Confirm route/cannula
 The details of what specific intravenous device(s) a patient has are
located in the patient’s medical notes on the ‘IV Device Insertion
Sticker’. If the patient has multiple IV devices, confirm with the
prescriber if in doubt as to which route should be used. This
can be of particular importance for some medication
 Ensure central or peripheral route appropriate for the medication
and concentration which you are administering.
6.9.5 Check patency of cannula
 The practitioner must check the patency of the device prior to
administration of medicines and/or solutions
 Lines should be flushed initially to check patency and between
incompatible drugs and infusions. All flushes must be prescribed,
unless a Patient Group Direction is being followed. See Appendix
14 for Summary of Flushing and Locking guidelines in Adult
and Appendix 15 for Flushing and Locking guidance in
Children.
With PICC catheters check that external length has not increased by
>2cm- indicates that may not be correctly positioned. Seek medical
advice.
6.9.6 Set rate on pump if applicable (must be two person
checked)
6.9.7 Prepare giving set/administration set
The practitioner must prepare the administration set as per Appendix
11: Procedure for preparing an administration set (‘giving set’ or
‘intravenous infusion set’)
6.9.8 Connect administration set as per Appendix 12: Procedure
for administering intermittent or continuous infusion or
intravenous medicines (with or without additional medicines)
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6.9.9 Commence administration
Connect the syringe or infusion to access device, and deliver the
medication over the correct time period.
6.9.10 To ensure minimal medication being left in giving sets. If
giving a medication in a volume of less than 50mL, do not use a
giving set through a volumetric pump, due to the risk of the drug
being left in the line and incomplete administration of the drug.
If less than 50mL, this should be administered by a syringe driver or a
non-volumetric pump. Ensure the line is flushed after administration.
6.10
Administration of drugs requiring double pumping
Best practice is that only one drug should be double pumped at any
one time, in areas where more than one drug requires double
pumping local guidance must be followed.
Inform the nurse co-ordinating the shift prior to commencing
procedure.
Refer to Appendix 19 for procedure on Double Pumping
6.11
Administration of medicines to be given by titration (e.g.
procedural areas)
Where the medicine is available in a multi-dose vial, draw up each
dose increment and administer as it is required. The vial should be
appropriately labelled and kept in the designated place when not in
use, and discarded when no longer needed, e.g. at the end of the
procedure.
Where the medicine is only available in an ampoule, the contents of
the ampoule(s) should be drawn up, ideally to a standard amount or
concentration, as used in that area. After each dose the syringe
should be disconnected if cannula is required for other drug
administration. The syringe should be labelled, and kept securely in a
designated place when not in use (which must be the CD cupboard if
a CD).
The total amount of drug given must be documented.
6.12
After administration
6.12.1 Locking and flushing
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Flushing of the access device is required after administration of ALL
medication, and between medications being administered
consecutively. See the following appendices for further information:
Appendix 14: Summary of Flushing and Locking in Adults
Appendix 15: Summary of Flushing and Locking in Children
Appendix 16: Summary of Flushing and Locking in Neonates
All flushes must be either prescribed or administered via a Patient
Group Direction.
When flushing/locking an intravenous device note the device
condition, patient comfort, ease of use. For peripheral cannula
complete a Visual Infusion Phlebitis (VIPS) chart.
6.12.2 Rate changes
Rate changes of IV medicines or fluids must have a two person
check. Both practitioners should sign in the appropriate location (e.g.
drug chart or observation chart) details of the new rate, date and
time of the change.
In areas where rate changes are changing rapidly e.g. critical care;
labour suite, the patient may be stabilised with several rate changes
over a short period of time. In these cases it is acceptable to have the
new rate checked and documented hourly with a second practitioner
once the patient is stable.
6.12.3 Recording administration of intravenous medication
Both practitioners involved in the preparation and administration of
the medicine must sign their initials on the drug chart, with the date
and time of administration if appropriate
6.13
Non-administration
It is important to communicate with the medical staff / prescriber any
medication that is unable to be administered so that appropriate
action can be taken i.e. route change; new cannula; ordering of drug.
Document on the medication chart why medication not administered
and actions taken.
Contact On-call pharmacist out of hours to obtain drugs / ward
pharmacist in normal hours.
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6.14
Interruptions to infusion
Best practice is to discard interrupted infusions and to record volume
administered and remaining dose required.
The maximum time an infusion can be paused is an hour as it should
be clear whether the infusion would need to be restarted within this
time. Exceptions to this are time critical medication where the patient
would be at clinical risk if there was a delay in restarting the
medication i.e. critical care areas; neo-natal.
If disconnection is unavoidable use ANTT for both disconnection and
reconnection; and ensure any administration sets or extension lines
are clamped before disconnection and a sterile ‘bung’ is placed at the
patient end of the administration set. The administration set must
be replaced if the reconnection is not immediate.
If it is not necessary to disconnect between infusions leave the
administration set in situ, but clamped off.
If the dose of an infusion containing a medicine has been delivered
by volumetric infusion pump and more remains in the bag, this can be
used for the next dose provided that the infusion is not disconnected
from the venous access device (and the infusion fluid is still in date
for the next infusion. The administration set should be clamped
between infusions. If the prescribed dose is taken from a bag into a
syringe pump for administration, then the remainder of the bag has to
be discarded and cannot be used for subsequent infusions.
6.15
Disposal
6.15.1 Disposal of equipment
Dispose of all equipment (including but not limited to syringes,
needles, stylets and surgical blades) from the patient’s bedside and
area used for preparation. Follow the NUH Waste Handling and
management policy (HS/EI/017)
For disposal of equipment used to administer cytotoxic or cytostatic
medication use a yellow body purple lidded sharps bin. Refer to NUH
Medicines Policy: cytotoxic policy CL/MM/013
6.15.2 Disposal of used and unwanted medication
Discard empty ampoules and vials from which the injection was
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prepared. Recheck the identity of empty ampoules and vials as they
are discarded after the infusion or injection has commenced.
In procedural areas (i.e. those areas performing procedures to
multiple patients e.g. cardiac catheter lab) all medicines prepared
must be discarded at the end of each individual procedure. Systems
should be in place to ensure that the area is cleared after each
procedure; ensuring medicines drawn up for one patient are not
administered to another patient.
In procedural areas it is best practice to keep all vials, ampoules and
syringes used until the end of the procedure in the designated
location, and perform a reconciliation of these against medicines
administered during the procedure. A designated tray as used in
theatres may be used for this purpose.
Also refer to:
 CLMM013 for disposal of cytotoxic medicines
 CLMM012 for disposal of Controlled Drugs
 CLMM011 Return and disposal of non-controlled medicines
6.16
6.15.3 Disposal of IV therapy infusions that have not completed
Any medicine infusion that is still in progress and has not yet been
administered must be disposed of after the following times:
 <24hours- where pharmaceutical stability is a concern
 At 24 hours- any infusion that has been prepared on a ward or
department (i.e. a drug added into an infusion fluid or a dilution
into a syringe for insertion into a syringe pump). Exceptions for
Nottingham Children’s Hospital as per local guidelines.
 At 48 hours for an infusion drawn into a syringe from a single
vial or ampoule already in solution and without further dilution
on the ward (e.g. ISOKET 0.05% solution, morphine 50mg in
50mL, heparin 20,000 units in 20mL)
At 72 hours for an infusion that has been prepared in Pharmacy
aseptic unit, theatre recovery or prepared ready made by the
manufacturer. After 72 hours both the infusion and the administration
set will need to be replaced if further administration of the drug
required.
Administration set changes
Administration sets must be changed:
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 Following a blood transfusion or every 12 hours during transfusion
(whichever is sooner)
 When the administration set becomes disconnected and has not
been immediately reconnected using ANTT
 When a central venous access device is replaced
 After 24 hours of administration of IV parenteral nutrition (unless
the solution contains only glucose and amino acids or Vamin
infusion in neo-natal areas that lasts for 48 hours).
 After 72 hours in all other circumstances
 When it has not been possible to replace the peripheral cannula
immediately (consider putting a white cap/bung onto the line whilst
waiting for another peripheral cannula to be inserted).
NB: If used, add- on devices used as part of the administration set
should be changed with the administration set.
6.17
Identifying and managing possible complications of IV
administration Refer to:
Appendix 17: Table of possible complications of intravenous
medication administration
Appendix 18: Guidance for the management of extravasation
following administration of cytotoxic medication
6.18
Administration via a verbal instruction
During drug administration in procedural areas it is common practice
for the doctor to issue verbal instructions on the drug and dose to be
administered at that time to a patient. In these areas there is a local
agreement covering how to do this.
6.19
Administration by NUH staff working in the community
Where possible the right drug, dose, indication checked in advance at
NUH. Calculations should be performed and checked in advance at
NUH.
IV medication administered in the community by NUH staff should be
checked by one registered nurse and by another competent person
who knows the patient. This could be a parent, carer or the patient
themselves. The patient or carer is acting as a second checker to
confirm a: positive patient identification, that they are expecting the
drug intended; that they are not allergic to the drug being
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administered.
6.20
6.21
In the event of emergency, call an ambulance.
Administration of OPAT medicines
May be administered on the ward, and patient may self-administer
following proper assessment/under supervision of nurse. The patient
can act as the second checker providing they have the necessary
competence at that time.
Removal of access devices
The removal of any vascular access device must only be undertaken
by an appropriately trained practitioner. Those commonly removed by
nurses include cannulas, midline catheters, PICCs and non-tunnelled
CVCs.
Exit sites must be inspected for signs of infection at every
manipulation and at least twice a day.
Assessment of the site must be documented on the patients Visual
Infusion Phlebitis (VIPs) chart. Use the VIPS score to determine
whether the access device needs to be removed or changed
immediately.
 Access devices must be kept in place for the minimum time
necessary. However, consideration to patient’s clinical
requirements for further infusion must be considered prior to
removal, particularly with regards to central lines; PICC lines etc.
 Best practice is to remove a peripheral cannula must be changed
at least every 72 hours unless. However in some areas it maybe in
the patients best interest to leave in situ. The rationale for this
decision must be documented in the patient’s records.
 A peripheral cannula inserted in an emergency situation, where
aseptic technique has been compromised, should be replaced
within 24 hours.
 The optimal dwell time for removal of midline catheters, PICCs,
tunnelled catheters or implanted ports is unknown. Ongoing and
frequent monitoring of the access site must therefore be
performed.
 A midline catheter should be removed if the tip location is no longer
appropriate for the prescribed therapy.
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Caution should be used in the removal of central venous catheters,
including precautions to prevent air embolism (patient should be flat
with head down if tolerated). Digital pressure should be applied until
haemostasis is achieved, then a sterile occlusive dressing should be
applied to the access site upon catheter removal, and checked
regularly to ensure it is intact. It should remain in situ for 72 hours
after removal.
If a Luer lock needle free injection access device is removed for any
reason, it must be discarded and a new sterile needle free device
attached: the previous bung must never be re-attached .
7.0
Training and Implementation
7.1
Training
Prior to commencing IV administration, all staff must have read this
document (NUH IV drug administration policy) and be able to
demonstrate this as part of their training.
All staff must have successfully completed:
 The Medicines Management Assessment test on appointment to
the Trust (and every 2 years if moving post), and have completed
any additional part(s) of the Medicines Assessment that are
required in addition (depending on score on test).
 Completed NUH approved Intravenous Drug administration Training
and competency package, as well as practice based assessment.
 The NUH Anaphylaxis package located on:
http://learningatnuh.co.uk (excluding staff working in the neonatal
units)
 Accountability self-assessment package.
 Accessed training and completed the competency forms for the
Trust infusion pumps/medical devices relevant to role and practice.
They will also need to be aware of the associated content of a number
of Trust Policies- Refer to section 10
It is expected that staff completed the above packages as soon as
they feel they are able, ideally within 6 months
7.1.1 Training updates for IV administration
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 All practitioners have a professional obligation to maintain their
knowledge and skills, including taking part in regular educational
activities which maintain and further develop competence and
performance. Practitioners must be able to evidence an update in
their knowledge 3 yearly. Evidence of this update can be used for
revalidation and as part of staff appraisals.
All staff giving IV drugs must complete the following at a minimum
every 3 years:
 Accountability Self- Assessment Package
 Evidence that the maths section of the IV section on the IV
competency package has been repeated.
 Evidence that the practitioner has identified any individual learning
needs i.e. up-to-date knowledge and understanding of medication
they are currently administering (i.e. staff member may have
moved speciality since previous assessment)
 Evidence that they have been assessed safely performing 3 IV
drug administrations, a direct injection (bolus); an infusion and one
of the most regularly administered drugs in their area.
7.1.2 Parental cytotoxic medications: must not be administered
unless staff have completed additional training, demonstrated
competency and working in a location where administration of
cytotoxic medication is allowed.
7.1.3 Total Parental Nutrition: see local procedures
7.2
Implementation
7.2.1 Incident Reporting: Incidents related to intravenous drug
administration are reported locally via the hospital patient safety
incident reporting tool, DATIX. Incidents are collated by the Hospital
Medicines Safety Officer. Themes and actions are then shared with
the Medicines Safety Committee, which has representatives from all
of the directorates/ diversions.
7.2.2 Monitoring: See 9.0 Policy / Procedure Monitoring Matrix
7.3
Resources
No additional resources are required.
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8.0
Trust Impact Assessments
8.1
Equality Impact Assessment
An equality impact assessment has been undertaken on this
document and has not indicated that any additional considerations are
necessary.
8.2
Environmental Impact Assessment
An environmental impact assessment has been undertaken on this
document and has not indicated that any additional considerations are
necessary.
8.3
Here For You Assessment
A Here For You assessment has been undertaken on this document
and has not indicated that any additional considerations are
necessary.
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9.0
Policy / Procedure Monitoring Matrix
Minimum
requirement
to be
monitored
Responsible
individual/
group/
committee
Process
for
monitoring
e.g. audit
Trust wide risk
assessment
on intravenous
drug
preparation
and
administration
Medicines
Safety
Committee
(MSG)
Risk
assessment of
current risk
plus Essence
of care
benchmark to
audit current
practice
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Frequency
of
monitoring
Annually
and
reported to
MSG
Responsibl
e
individual/
group/
committee
for review
of
results
Responsible
individual/
group/
committee
for development
of action plan
Responsible
individual/
group/
committee
for
monitoring
of action plan
Results from the
Essence of care
benchmark are
reported to the Trust
Board. Individual
clinical areas are
required to develop
locally agreed action
plans to improve
practice.
MSG and
Essence of
Care Steering
group
35
10.0
Relevant Legislation, National Guidance and Associated NUH
Documents
10.1
List all of the following which are relevant:
1. Legislation
MHRA medicines regulations
2. National Guidance
British National Formulary- current version
NMC code (2015)
NMC standards for medicines management
RCN standards for infusion therapy
National Patient Safety Agency (2006) Safer Use of Injectable
Medicines in Near-Patient Areas Consultation Document London:
NPSA
3. Associated NUH Documents (with NUH referencing)
All policies referred to are the current versions.
NUH Medicines Policy: Code of Practice including CL/MM/008 NUH
administration policy and CL/MM/006 Prescribing policies
CL/MM/013 for disposal of cytotoxic medicines
CL/MM/012 for disposal of CDs, and
CL/MM/011 Return and disposal of non-controlled medicines
CL/MM/028 Medicines Policy: Code of Practice: Use of Single and
Multiple dose vials.
CL/MM/014 Medicines in the Operating theatre
HS/EI/017NUH Waste Handling and management policy
HS/SP/011 Blood borne virus policy
HS/SP/003 Management of Latex Policy & Procedures
CL/CGP/008 Transfusion policy
CL/CGP/072 Aseptic Non Touch Technique (ANTT) Policy
CLCGP039 Hand Hygiene Policy
CLCGP031 NUH Infection Prevention and Control Manual
CL/CG/001 Cardiopulmonary Resuscitation Policy (Adult and
Paediatric)
NUH current approved Intravenous Drug administration Training and
competency package
NUH Current Self-Assessment Accountability package
NUH Current Anaphylaxis package http://www.learningatnuh.co.uk/
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Medical device(s) competencies
Peripheral venous cannulation guidelines
Central venous catheterisation – Nursing Practice Guidelines
10.2
References
Department of Health Gateway ref:14330
Mixing of medicines prior to administration in clinical practice:
medical and non-medical prescribing
Pratt RJ, Pellowe CM, Wilson JA, et al. epic2: National EvidenceBased Guidelines for Preventing Healthcare-Associated Infections in
NHS Hospitals in England. Journal of Hospital Infection.65S: S1-S64.
Available from:
http://www.maryseacole.com/richardwells/pdfs%20and%20document
s/epic2-final%20glines.pdf [Accessed 27 September 2010].
Department of Health (2003) Winning Ways - Working together to
reduce healthcare associated infections in England London: HMSO
Infection Control Nurses Association (2000) Guidelines for
Preventing Intravascular Catheter-related Infection. London: ICNA
McCulloch, J. (2000) Infection Control: Science, management and
practice London: Whurr
NHS England (2015) Stage One Working ‘Risk of death or severe
harm due to inadvertent injection of skin preparation solution.
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Appendix 1: The Procedure for administering intravenous Drugs
using Aseptic Non-Touch Technique (ANTT) (NUH (2015) Aseptic
Non-Touch Technique Policy)




The ideal environment for ANTT procedures at ward level is a designated clinic
room. Where this is impractical, clinical procedures performed at the patients’
bedside must not occur directly after activities such as bed making which may
contribute to airborne contamination. Windows must also be kept closed and fans
turned off during the clinical procedure.
Use ANTT for ALL IV therapy procedures including: insertion, administration,
manipulation and removal.
Ensure the patient is informed, has given consent and is prepared for the
procedure.
Never put down a syringe attached to an unsheathed needle.
1. Clean hands with soap & water followed by alcohol hand rub
Action
Rationale
Clean hands as per Trust
Effective hand hygiene is vital to
Hand Hygiene policy with
reduce the risk of contaminating key
soap & water and alcohol
parts/sites
hand rub
2. Clean aseptic surface (plastic tray). Whilst drying, gather equipment, drugs etc.
Clean plastic tray with
To establish a clean working surface
sanitising wipe. Allow 30
seconds to dry before use
To eliminate bacteria/micro-organisms
Collect equipment and place
next to tray while it is drying
3.Clean hands with alcohol gel
Decontaminate hands with
alcohol hand rub
Hands may have become
contaminated by handling equipment
4. Prepare drugs and equipment and protect key parts at all times using a non-touch
technique
Identify key parts and
Prevents contamination of key parts
remove equipment from
during removal from packaging
packaging carefully
An orderly aseptic field decreases
Assemble equipment and
chance of contaminating key parts
arrange in an orderly
Exposed key parts increase risk of
manner in aseptic field
contamination
Ensure key parts are
A non-touch technique protects key
protected at all times
parts/sites
(syringe tips etc.)
Handle non key parts with
confidence
5. Decontaminate hands with alcohol gel. Put on non-sterile gloves and clean the port
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with 2% chlorhexidine/70% alcohol
Put on non-sterile gloves
Using a non-touch technique Drying of cleaning solution is vital for
clean the port with 2%
disinfection to be completed
chlorhexidine/ 70% alcohol
then wipe away from the tip
for 30 seconds then allow to
dry for 30 seconds
6. Administer drugs and dispose of sharps
Administer drugs using a
non touch technique
To avoid risk of sharps injury
Dispose of sharps in sharps
bin at bedside. Dispose of all
other equipment as per
Trust policy
Adjust patient clothing or resecure bandage
7. Remove gloves. Decontaminate hands with alcohol hand rub or soap and water
Remove gloves
Gloves must only be used for one
Decontaminate hands with
procedure
alcohol hand rub or soap
Hands must be cleaned after glove
and water
removal as organisms thrive in the
warm moist environment beneath
gloves
Clean plastic tray after use
with sanitising wipe
To prevent cross-infection when next
used
Sign drug chart/ complete
VIPS chart
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Appendix 2: Best Practice for the administration of medication via
intravenous route.
In development; available from Medicines Management Committee
secretary
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Appendix 3: Summary Steps for medication intravenous drug
administration.
1. RIGHT PATIENT, RIGHT MEDICATION CHART
Check the patient name and unique identifying number (i.e. NHS number, N number, S
number, K number) on the drug chart matches the patient’s name and unique identifying
number on their wristband.
2.RIGHT DAY & TIME
Check all the pages of the drug chart including ‘once only’ and ‘as required’ sections
plus any additional charts in use to identify which drugs are due on this drug round.
Check when the last dose was administered. Prioritise which drugs should be given
first. Check the prescription is legible, unambiguous and is signed by an authorised
prescriber.
3. CONTRAINDICATIONS
Check the ALLERGY box on the front of the drug chart. This must be completed and
signed before any drugs can be administered.
4. RIGHT DRUG RIGHT INDICATION
Look up any unfamiliar medicines in the BNF, BNF for Children or other appropriate
reference. Check that you know the usual reason for giving the medicine, the reason for
giving it to this patient and important side effects. Refer to the medical notes or the
prescriber if there is any doubt.
5. RIGHT ROUTE
Check that the medicine can be administered via the intravenous route. Determine
whether the medicine will be administered by direct injection (injection from a hand held
syringe), or by infusion (in an infusion container and administered over a period of
time). The rate of infusion may be controlled by an infusion device such as a volumetric
pump or syringe pump. (Refer to Part B of the Nottingham Guide to Intravenous Therapy
“Essential Technical Information for Intravenous Medicines” to identify the most
appropriate method.
6. RIGHT DOSE & RATE
Check the dose is reasonable. Check the patient’s weight if applicable. Refer to the BNF,
BNF for Children, other appropriate reference, pharmacist or the Medicines Information
Service (extension 61200 / 64185) if there is any doubt. If applicable, determine the rate
that will be required. Complete any calculations.
7. RIGHT DILUENT FOR THE INJECTION (if applicable)
If the injection is in powder form, refer to Part B of the Nottingham Guide to Intravenous
Therapy “Essential Technical Information for Intravenous Medicines” to identify the
diluent and volume required for reconstitution of the injection.
8. RIGHT INFUSION FLUID (if applicable)
If the injection requires further dilution for infusion, refer to Part B of the Nottingham
Guide to Intravenous Therapy “Essential Technical Information for Intravenous
Medicines” to identify a suitable concentration and infusion fluid.
9. RIGHT LINE (if applicable)
Check whether the medicine will be administered peripherally or centrally. Peripheral IV
access should be used for IV medicines wherever possible. Central access is essential
for administration of some medicines. Refer to Part B of the Nottingham Guide to
Intravenous Therapy “Essential Technical Information for Intravenous Medicines” as
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necessary.
10. RIGHT DILUTION (if applicable)
Complete calculations to establish the volume of injection and volume of infusion fluid
required for the correct dilution.
11. RIGHT PREPARATION
Select the correct form and strength of the right medicine. Select the correct diluent &
infusion fluid if required.
12. RIGHT EXPIRY
Check the expiry date of the medicine and diluent has not passed, and for an infusion,
that it is suitable for the prescribed duration of the infusion.
13. SECOND CHECK
A second check is required for all parenteral medications. The only exception is
subcutaneous injection of a prophylactic dose of low molecular weight heparin e.g.
enoxaparin.
The second checker is responsible for checking all the steps 1-12 and 16. For an
infusion they must also:
observe the preparation of the infusion including additions to bag/syringe , step 14
check the pump and the starting rate that has been set are correct, step 15
check the patient’s identity at the patient’s bedside, step 16
subsequent changes in rate, step 19
sign the prescription for administration, step 20
14. PREPARE THE DOSE OR INFUSION
If necessary, prepare the dose required as described in Part A of the Nottingham Guide
to Intravenous Therapy “Procedure for preparing and administering intravenous
medicines”. For infusions, refer to information in Part B of Nottingham Guide to
Intravenous Therapy “Essential Technical Information for Intravenous Medicines”.
Follow the manufacturer’s instructions e.g. gently swirl the vial for injections which are
in suspension form.
The vials of any unused medicines should be kept until the administration to the patient
has commenced and the identity of these should be rechecked as they are discarded.
15. SET THE RATE ON THE PUMP (if applicable)
16. RIGHT PATIENT
Recheck the patient’s identification with the second checker at the patient’s bedside
17. START THE INFUSION OR ADMINISTER THE DOSE
18. RIGHT FLUSH (if applicable)
Identify the type of flush that is required after administration and repeat all relevant
steps. Heparin flushes are not required for peripheral cannulae. Saline flushes have to
be identified by a second checker but the administration does not have to be observed
by the checker.
19. RIGHT RATE CHANGE (if applicable)
Step 6 must be completed for any rate changes and all rate changes must be second
checked. Both checkers must sign either on the prescription or a monitoring chart. For
inotropes in critical care and uterine stimulants in obstetrics where doses are being
titrated to response constantly, the rate must be second checked and documented at
least hourly.
20. SIGN THE DRUG CHART IMMEDIATELY TO RECORD ADMINISTRATION
Both practitioners must sign the prescription. For infusions, this also indicates that the
initial rate has been second checked
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Appendix 4: Procedure for withdrawing a solution from an ampoule
(glass or plastic) into a syringe
Essential equipment







Medication ampoule
Needle
Syringe
Syringe
Sterile swab
Sharps container
Ampoule opening aid (optional)
Action
Rationale
Preparation is undertaken using an ANTT procedure as described in Appendix 1.
This procedure is underpinned by the Steps for administration as described in Appendix
3.
1. Inspect the solution for cloudiness or
To prevent the patient form receiving an
particulate matter. If this is present,
unstable or contaminated drug.
discard and return to pharmacy
2. Tap the neck of the ampoule gently
To ensure that all the solution is in the bottom
of the ampoule
3. Cover the neck of the ampoule with a
sterile swab and snap open. If there is any
difficulty, a file or ampoule opening aid
maybe required
To minimize the risk of contamination.
To prevent aerosol formation or contact with
the drug that could lead to a sensitivity
reaction.
To reduce the risk of injury to the nurse
4. Inspect the solution for glass fragments; if
present, discard.
To minimize the risk if injection of foreign
matter into the patient
5. Open packaging and attach the needle
onto the syringe.
To assemble equipment
If the ampoule is made of glass a blue (23
gauge) needle or a filter needle should be
used
To avoid the pickup of microscopic particles.
When drawing from a plastic ampoule, a
blunt needle should be used. In all other
circumstances use a green (21 gauge)
needle.
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NB: The neck of some plastic ampoules is
designed to connect directly to a syringe
without the use of a needle, after the top
of the ampoule has been twisted off (this
applies only to slip syringes and NOT Luer
lock)
6. Withdraw the required amount of solution,
tilting the ampoule if necessary to
aggregate the air bubbles.
7. Expel air carefully
To avoid drawing in any air
To prevent aerosol formation
8. Attach new needle if required and discard
used needle in sharps container
To reduce the risk of contamination of syringe
tip
9. Keep all ampoules/ vials and diluents in
the tray with the syringe until
administration to the patient is complete.
To enable further checking at the bedside. The
identity of these should be rechecked as they
are discarded.
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Appendix 5: Procedure for withdrawing solution or suspension
from a vial into a syringe
Essential equipment
 Medication vial
 Needle x 2 (sterile blind hub-optional)
 Syringe
 Sterile swab
 Sharps container
Action
Rationale
Preparation is undertaking using an ANTT procedure as described in Appendix 1.
This procedure is underpinned by the Steps for administration as described in
Appendix 3.
1. Open packaging and attach needle to
To assemble equipment
the syringe
2. Remove the tamper-evident seal from
To minimise the risk of contamination
the vial and wipe the rubber septum
with a 2% chlorhexidine and 70%
alcohol wipe. Allow to air dry for 30
seconds
3. With the needle sheathed, draw into the To reduce the risk of injury to the nurse
syringe a volume of air equivalent to the
required volume of solution to be drawn
up
To allow for removal of solution from
vacuumed vial
4. Remove the needle cover and insert the
needle into the vial through the rubber
septum
5. Invert the vial. Keep the needle in the
solution and slowly depress the plunger
to push air into the vial.
Release the plunger
So that the solution flows back into the syringe.
If a large volume of solution is to be
withdrawn, use a push-pull technique
6. Repeatedly inject small volumes of air
This ‘equilibrium method’ helps to minimise the
and draw up an equal volume of
build-up of pressure in the vial.
solution until the required total is
reached.
7. Alternatively, the rubber septum may be To let air into the vial as solution is withdrawn.
pieced with a second needle.
The tip of vent needle must always be
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8.
9.
10
11
kept above the solution to prevent
leakage.
Withdraw the needle and syringe
containing the solution from the vial.
Tap the syringe lightly and expel excess
air from the syringe.
Remove and dispose of needle and
replace with new needle or a sterile
blind hub
.Keep all vial(s) in the tray with the
syringe until administration to the
patient is complete.
If the vial(s) contain a suspension rather
than a solution, it should be gentle
swirled before they are drawn into the
syringe.
To aggregate the air bubbles at the needle end
and prevent aerosol formation
To reduce the risk of contamination of syringe
tip
To enable checking at the bedside
To mix the contents
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Appendix 6: Procedure for reconstituting powder in a vial and
drawing the resulting solution or suspension into a syringe.
Essential equipment
 Medication vial
 Diluent
 Needle x 2 (sterile blind hub-optional)
 Syringe
 Sterile swab
 Sharps container
Action
Rationale
Preparation is undertaking using an ANTT procedure as described in Appendix 1.
This procedure is underpinned by the Steps for administration as described in
Appendix 2.
1. Remove the tamper-evident seal from
To minimise the risk of contamination
the vial and wipe the rubber septum
with a 2% chlorhexidine and 70%
alcohol wipe. Allow to air dry for 30
seconds
2. Follow ‘Procedure for withdrawing a
solution from an ampoule (glass or
plastic) into a syringe as described in
Appendix 4 to withdraw the required
volume of diluent into the syringe (e.g.
water for injection, sodium chloride
0.9%)
3. Inject the diluent into the vial. Keeping
The syringe will fill with the air which has been
the tip of the needle above the level of
displaced by the solution (if the vial was
the solution in the vial, release the
packed under a vacuum).
plunger. If a large volume of diluent is to
be added, use a push-pull technique.
4. Consider the displacement value of the When a solid/powder is dissolved in a fluid, the
solution, particularly in paediatrics and
total volume of the fluid often increased. This is
check this in the manufactures details.
termed the displacement value.
5. Follow the relevant steps from
‘Procedure for withdrawing a solution
from a vial into a syringe (Appendix 5)
6. Alternatively, the rubber septum may be To let air into the vial as solution is withdrawn.
pieced with a second needle.
The tip of vent needle must always be
kept above the solution to prevent
leakage.
7. If a purpose-designed reconstitution
device is used, the manufacturer’s
instruction show be read and followed
carefully
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Appendix 7: Procedure for using multiple dose vials to withdraw a
solution or suspension into a syringe.
Essential equipment
 Medication vials
 Diluent
 Needle x 2 (sterile blind hub-optional)
 Syringe
 Sterile swab
 Sharps container
 Labels
Action
Rationale
Preparation is undertaking using an ANTT procedure as described in Appendix 1.
This procedure is underpinned by the Steps for administration as described in
Appendix 3.
1. Determine whether use of the
A multiple dose vial contains sufficient
prescribed multiple dose vial is
medicines for two or more doses and contains
approved for use at NUH. Check this
a preservative. It is for SINGLE PATIENT USE
with pharmacy
2. Where possible use a single dose vial
For patient safety
in preference to multiple dose vials
3. Multi dose vials are for SINGLE
To minimise the risk of contamination.
PATIENT USE ONLY
Preservatives do not protect against
contamination with blood borne infections.
4. Label each vial with the patient’s
To ensure the vial is not used for another
details.
patient
To prevent out of date medication being
The maximum expiry date is 14 days
administered.
from the date of opening (28 days for
insulin).
The date of opening and expiring must
be included on the label
5. If the vial is already in use, check that it
has not exceeded the expiry date.
Check it is for the correct patient.
6. If the medicine is in a powder form,
follow the ‘Procedure for reconstituting
powder in a vial and drawing the
resulting solution or suspension into a
syringe’ (Appendix 6).
7. Note that on every occasion that the
To minimise the risk of contamination
vial is used, the top of the vial must be
cleaned with 2% chlorhexidine and 70%
alcohol wipe and allowed to dry for 30
seconds.
8. Store the remaining contents of the
To ensure the integrity of the medication for
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multi-dose vial according to the
subsequent administrations.
manufacturer’s instructions or as
advised by pharmacy
NB: Injections vials with a re-sealable rubber top are often thought of as multiple dose vials.
However, this is not true, as many do not contain a preservative
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Appendix 8: Procedure for adding a medicine to an infusion fluid in
a bag.
Action
Rationale
Preparation is undertaking using an ANTT procedure as described in Appendix
1.
This procedure is underpinned by the Steps for administration as described in
Appendix 3.
1. Prepare the medicine into a syringe
using one of the procedures in
Appendix 4-7
2. Check the outer wrapper of the
infusion container is undamaged
3. Remove the wrapper and check the
To confirm it is intact and free of cracks,
infusion container in good light.
puncture/ leaks.
To check the solution for any
discoloration, particles.
4. Where necessary, remove the
tamper-evident seal on the additive
port according to the manufacturer’s
instruction or wipe with 2%
chlorhexidine and 70% alcohol wipe
and allow to dry for at least 30
seconds.
5. If the volume of medicine solution to
be added is more than 10% of the
initial contents of the infusion
container (more than 50mL to a
500mL or 100mL to a 1litre infusion),
an equivalent volume must first be
removed with a syringe and needle.
6. Inject the medicine into the infusion
container through the centre of the
injection port, taking care to keep the
tip of the needle away from the side
of the infusion container
7. Withdraw the needle and invert the
container at least five times to ensure
thorough mixing before starting the
infusion.
8. Never add a medicine to an infusion
fluid once an administration set has
been inserted into the bag.
9. Do not add anything to any infusion
container when it is hanging on the
infusion stand since this makes
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adequate mixing impossible.
10. Check the appearance of the final
infusion
For absence of particles, cloudiness or
discolouration.
11. Label the infusion with the following
information (clinical areas should
have labels available):
 Name of medicine
 Diluent;
 Total volume;
 Strength or concentration;
 Date and time preparation made up;
route of administration;
 Patients name;
 Name of practitioner preparing the
medicine;
 Name of second checker.
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Appendix 9: Procedure for diluting a medicine in a syringe for use
in a syringe pump
Action
Rationale
Preparation is undertaking using an ANTT procedure as described in Appendix
1.
This procedure is underpinned by the Steps for administration as described in
Appendix 3.
1. Prepare the medicine into a syringe
To ensure that there are no cracks in the
using one of the procedures in
syringe.
Appendix 4-7.
2. Draw the diluent into the syringe to be
used for administration by the pump
or syringe-driver. Draw in some air
(slightly more than the volume of
medicine needed) and remove the
needle.
3. Stand the diluent syringe upright.
Insert the needle of the syringe
containing the medicine into the tip of
the diluent (administration) syringe
and add the medicine to it.
4. Alternatively, a disposable sterile
connector may be used to connect
two syringes together directly.
5. Check the following:
 the total volume of injection solution  So that the infusion can be delivered
in the syringe is as specified in the
at the prescribed rate by the
prescription
administration device chosen;
 To ensure safe administration

The rate of administration is set
correctly on the administration device
and according to the manufacturer’s
instructions.
6. Fit a blind hub to the administration To mix the contents.
syringe and invert several times.
7. Remove the blind hub. Tap the
syringe lightly to aggregate the air
bubbles at the needle end. Expel the
air and refit the blind hub.
8. Label the syringe especially noting
the requirements specific to syringe
drivers. with the following information
(clinical areas should have labels
available):
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




Name of medicine
Diluent;
Total volume;
Strength or concentration;
Date and time preparation made up;
route of administration;
 Patients name;
 Name of practitioner preparing the
medicine;
 Name of second checker.
9. Check that the rate of administration
is set correctly on the device before
fitting the syringe, priming the
administration set and starting the
infusion device. Where present the
pressure disk should also be primed.
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Appendix 10: Information on Devices to administer an infusion (with
or without an additional medication)
Infusions can be administered and their dose regulated to the patient either:
 Manually by gravity flow; (e.g. roller clamp) or
 electronically (e.g. volumetric infusion and syringe pumps,)
When selecting an infusion device consideration should be given to the patient’s age
and condition, prescribed therapy and the care setting in which the therapy is
delivered.
Administration by gravity flow
Gravity flow with rate control by roller clamp may be used to regulate simple low-risk
infusions. Regular monitoring and documentation of the infusion rate of the prescribed
therapy is necessary. The frequency of flow rate monitoring depends on the patient’s
clinical requirements
The practitioner should demonstrate knowledge and competency related to gravity
flow, including indications for use and ability to calculate flow rate.
Electronic infusion device
The health care professional MUST be able to demonstrate knowledge and
competency which has been assessed relative to electronic infusion device(s) being
used.
The healthcare professional is responsible for monitoring the patient and is
accountable for the use of electronic flow control infusion devices.
Manufacturers’ guidelines should be adhered to in the use of electronic infusion
devices.
A separate infusion device should be used for each infusion running simultaneously
e.g. do not use a pump you have been using for maintenance fluid even if it is to be
stopped for the administration of a paracetamol infusion, have a second pump at the
bedside for use.
An infusion device must be used in the following situations:
•
When administering infusions to neonates and children
•
When administering a high risk medicine
High risk medicines are either
•
Irritant or hyperosmolar as sensitive occlusion alarms are required to prevent
extravasation
•
Medicines with a narrow therapeutic range, short duration of action or toxicity
when administered too rapidly
•
Medicines where safe infusion demands that minimal bolus is delivered on
release of an occlusion
An appropriate electronic infusion device should be selected, taking into account the
volume being infused and the access device. The volume to be infused should be set
on the electronic device.
Use of a pump which requires a calculation is a known risk factor that increases risks
associated with intravenous therapy. Extra caution is advised.
When using a syringe pump, select the smallest Luer lock syringe that can
accommodate the volume being delivered.
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Electronic infusion devices should be considered an adjunct to patient care and are
not intended to alleviate the practitioner’s responsibility for regularly monitoring and
documenting the infusion rate of the prescribed therapy.
Patients receiving infusion therapy via electronic pumps must continue to receive all
prescribed therapies, even when the patient is off the ward to undergo diagnostic tests
in a clinical department. Only when there is written authority from a medical
practitioner may registered practitioners temporarily discontinue infusion therapy when
the patient (or specific group of patients) is off the ward. If a patient needs/wants to
leave the clinical area unaccompanied by a registered practitioner, the suitability to do
so must be assessed and documented and an end used form is completed.
Reconnection of the same infusion is not allowed. For intermittent infusions, every
effort must be made to complete the infusion before the patient leaves the ward or
leaves the ward with the infusion in progress. An escort may then be required.
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Appendix 11: Procedure for preparing an administration set (‘giving
set’ or ‘intravenous infusion set’)
Action
Rationale
Preparation is undertaking using an ANTT procedure as described in Appendix
1.
This procedure is underpinned by the Steps for administration as described in
Appendix 3.
1. Either prepare the infusion as described in Appendix 8: Procedure for adding a
medicine to an infusion fluid in a bag OR
Check the outer wrapper of the infusion container for damage, remove the wrapper
and check the infusion container in good light. It should be intact and free of
cracks, punctures/leaks. Check the solution for any discolouration, particles.
2. Open
the
administration
set
packaging.
3. Check
the
integrity
of
the
administration set.
4. Close the roller clamp. If the roller
clamp is already closed, then discard
the administration set.
5. Using aseptic non touch technique,
remove the protective covers from the
insertion port of the infusion fluid and
from the ‘spike’ of the administration
set.
6. Holding the intravenous medicine
container with one hand, insert the
‘spike’ of the administration set into
the insertion point, twisting it fully into
position.
7. Prime the drip chamber, by gently
squeezing it until half full according to
manufacturer’s
instructions.
This
prevents air entering the tubing of the
administration set.
8. Prime the tubing by holding the Luer
end (with cap still in place), above the
level of the fluid container and slowly
open the roller clamp.
9. As the tubing fills, lower the Luer end
until the tubing is full.
10. Close the roller clamp and place the
Luer end of the tubing into the ‘notch’
on the roller clamp.
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11. Label the administration set or
extension set with the set change
label. Attach the drug identification
label to the administration set if
multiple infusions are in progress.
12. Follow Procedure guideline for
intermittent or continuous infusion of
intravenous medicines in Appendix 12
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Appendix 12: Procedure for administering Intermittent or
continuous infusion of intravenous medicines (with or without
additional medicine)
Essential equipment
















Patient’s prescription and chart
Personal protective equipment as required per trust policy for infection
control/the policy for administration of cytotoxic medicines
Container of appropriate intravenous infusion fluid/ diluent
’Drug Additive’ label
IV line label (if new or change of line)
IV infusion pump
IV administration set
IV infusion stand
Clean dressing trolley (depending on amount of equipment) or clinically clean
blue plastic procedure tray containing the prepared medication to be
administered
Sterile needles (safety devices where available) and syringes
10 mL for injection of a compatible flush solution – e.g. 0.9% sodium chloride
2% chlorhexidine/70% alcohol swab
Alcohol-based hand wash solution or rub
Sterile dressing pack if the procedure requires e.g. TPN
Hypo-allergenic tape
Sharps bin/or sharps bin to be adjacent
NOTE: This is a 2–registered person check procedure from start to
finish
Action
1. Explain and discuss the procedure with the
patient. Establish verbal consent, where
the patient lacks capacity; ensure that a 2stage test and a best-interests checklist
are in place to support the procedure in the
patient’s best interest.
For children ensure that consent for
care has been obtained.
Rationale
To ensure that the patient understands the
procedure and gives their valid consent
where it is possible.
To ensure that care is given for the patient’s
best interests.
2. Before administering any prescribed
medication, check that it is due and has
not been given already. Check that the
information contained in the prescription
chart is complete, correct and legible.
To protect the patient from harm.
3. Before administering any prescribed
medication, consult the patient’s
prescription sheet and ascertain the
To ensure that the patient is given the correct
medication in the prescribed dose using the
appropriate diluent via the correct route.
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following using the 5 R’s approach:
• Right patient
• Right medication
• Right dose
• Right time
• Right route
Check the patient’s allergy status.
CHECK THAT COMPATIBLE SOLUTION
HAS BEEN PRESCRIBED CORRECTLY ON
THE FLUID PRESCRIPTION CHART
4. Select the required medication and check
the expiry date. Check the packaging for
any signs of damage that may affect the
contents.
5. Wash hands with soap and water and
assemble necessary equipment and apply
personal protective equipment.
6. Prepare a 10 mL syringe of 0.9% sodium
chloride (or compatible solution) for
injection, using aseptic non-touch
technique and place into a clinically clean
receiver.
7. Prepare the medication for administration
using aseptic non- touch technique
(Appendix 1).
Introduce into the compatible IV fluid agitate
gently to mix.
Complete and apply ‘Drug Additive’ label to the
solution.
Perform a visual check to ensure that no
particulate formation has taken place or that no
compromise to the IV fluid bag has occurred.
Ensure compliance with 2 registered
persons checking procedure.
Discard all used sharps and equipment safely
into appropriate waste containers.
8. Prime the intravenous administrations set
with infusion fluid and suspend it from the
infusion stand, or place into the
appropriate infusion pump. Appendix 11:
Preparing an administration set (‘giving
set’ or ‘intravenous infusion set’)
9. Approach the patient with the second
To protect the patient from harm.
To comply with NUH Medicines Policy.
Treatment with medication that is outside the
expiry date is dangerous outside the
manufactures licence. Medicines deteriorate
with storage. The expiry date indicates when
a particular medication is no longer
pharmacologically efficacious or may have
dangerous effect on the patient.
To minimize the risk of infection.
To use for flushing before, during (if more
than one medication) and after administration
of medication. To clear the patient’s existing
or new line and prevent possible interaction
of solutions.
Correct preparation of the medication to be
used, minimising the risk of infection to the
patient
To enable others to identify and be informed
of the medication infusion in process.
To ensure that no reaction between additive
and solution has occurred, or that no
accidental compromise of the IV fluid bag
has occurred during the mixing process.
Safe checking following the 5 R’s principles
to prevent patient harm.
To ensure removal of air from set and check
that tubing is patent. To prepare for
administration.
To ensure that the patient is given the correct
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registered person to check and complete
the 5 R’s checking procedure immediately
prior to administration (see point 3).
10. Clean hands, and apply appropriate PPE.
Clean the end of the needle free
connection device with a 2%
chlorhexidine/70% alcohol swab and allow
drying.
If a single port needle-free access device
is currently in use with an infusion
attached, it is acceptable to replace this
with a multi-port needle-free access device
using ANTT. It is not acceptable to
disconnect any infusion line and leave it
without reconnecting immediately.
Check compatibility of solution in use with
the medication to be administered.
Blood transfusions must never be stopped:
a second cannula will be needed.
11. Inspect the patient’s cannula site and
surrounding tissue. Record the site on the
Visual Phlebitis score (VIPS chart)
12. Administer gently 5 mL of 0.9% sodium
chloride for injection check that no
resistance is met, no pain or discomfort is
felt by the patient, no swelling is evident,
no leakage occurs around the device.
medication in the prescribed dose using the
appropriate diluent via the correct route.
To protect the patient from harm.
To comply with NUH Medicines Policy
To reduce the number of pathogens
introduced at the time of the insertion. To
ensure complete disinfection has occurred.
To prevent interactions between solutions
and irritation, discomfort and possible harm
to the patient.
To detect any signs of inflammation,
infiltration, and so on. If present, take
appropriate action.
To confirm the patency of the device and
vein.
Administer 1-2mL of 0.9% sodium chloride
to infants and younger children.
13. Connect the infusion to the needle-free
access device port using ANTT and begin
infusion.
If using an infusion pump double check of rate
and volume to be infused. On an hourly basis
check and record volume infused and cannula
site
14. Check the insertion site and ask the
patient if they are comfortable.
15. Secure the administration set in a way that
places no strain on the device, which could in
turn damage the vein.
To connect and commence treatment and
monitor administration.
To confirm that the vein can accommodate
the extra fluid flow and that the patient
experiences no pain
To reduce the risk of mechanical phlebitis or
infiltration.
To prevent inadvertently dislodging the
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For children if it is felt the cannula may
become dislodged re-bandage over the
cannula
16. Record the administration on the medicine
administration chart ensuring that the two
registered persons sign.
17. Stop the infusion when the prescribed
volume to be infused has been administered.
(A ‘minibag’ may be used to flush the
medication through the tubing but the cost
implications of this as well as the risk to
patients on restricted intake should be
considered before this is adopted routinely).
For children, flush the infusion line with
30mL of 0.9% sodium chloride or other
compatible solution.
18. Clean hands, and apply appropriate PPE.
Disconnect the infusion set and clean the end
of the needle free connection device with a 2%
chlorhexidine/70% alcohol swab and allow
drying.
Flush the device with 5 mL of 0.9% sodium
chloride or other compatible solution for
injection.
19. Check patient is comfortable, answer any
queries or questions they may have.
cannula
To maintain accurate records, provide a point
of reference in the event of any queries and
prevent any duplication of treatment.
To ensure that all the prescribed mixture has
been delivered and prevent air infusing into
the patient.
To ensure correct medication dosage is
administered.
To prevent contamination of the device to the
patient/to protect the wearer from any
hazardous substances.
To flush any remaining solution away from
the cannula and to prevent any possible
interaction with subsequent fluids
administered.
To ensure the patient is comfortable and any
anxieties have been addressed.
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Appendix 13: Procedure for the intravenous medication
administration via a direct injection (also called bolus/ push)
Including medication that may need to be administered over several
minutes.
Essential equipment







Clinically clean receiver or tray containing the prepared medication to be
administered
Patient’s prescription chart
Protective clothing as required by hospital policy and (for specific medicines)
Sterile needles (safety where available) and Luer lock® syringes (where
available)
10 mL for injection of a compatible flush solution – e.g. 0.9% sodium chloride
2% chlorhexidine/70% alcohol swab
Sharps container
NOTE: This is a 2–registered person check procedure from start to finish
Action
Preparation is undertaking using an ANTT procedure as described in Appendix 1.
This procedure is underpinned by the Steps for administration as described in
Appendix 3.
Action
Rationale
To ensure that the patient understands the
1. Explain and discuss the procedure
procedure and gives their valid consent where it
with the patient. Establish verbal
is possible.
consent, where the patient lacks
capacity; ensure that a 2-stage test
To ensure that care is given for the patient’s best
and a best-interests checklist are in
interests.
place to support the procedure in the
patient’s best interest. For children
ensure that consent for care has
been obtained.
2. Before administering any prescribed
medication, check that it is due and
has not been given already. Check
that the information contained in the
prescription chart is complete, correct
and legible.
To protect the patient from harm.
3. Before administering any prescribed
medication, consult the patient’s
prescription sheet and ascertain the
To ensure that the patient is given the correct
medication in the prescribed dose using the
appropriate diluent via the correct route.
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following using the 5 R’s approach:
•
Right patient
•
Right medication
•
Right dose
•
Right time
•
Right route
Also check the patient’s allergy status.
4. Select the required medication and
check the expiry date. Check the
packaging for any signs of damage
that may affect the contents.
5. Wash hands with soap and water and
assemble necessary equipment and
apply personal protective equipment.
6. Prepare the medication for injection
referring to procedures in the
following procedures:
 Appendix 4: Procedure for
withdrawing a solution from an
ampoule (glass or plastic) into a
syringe
 Appendix 5: Procedure for
withdrawing solution or suspension
from a vial into a syringe
 Appendix 6: Procedure for
reconstituting powder in a vial and
drawing the resulting solution or
suspension into a syringe.
 Appendix 7: Procedure for using
Multiple dose vials to withdraw a
solution or suspension into a syringe.
Ensure compliance with 2 person
checking procedure
7. Prepare a 10 mL syringe of 0.9%
sodium chloride (or compatible
solution) for injection, as described,
using aseptic non- touch technique.
8. Place medication/s to be
administered and flushing solution
To protect the patient from harm.
To comply with NUH Medicines Policy.
Treatment with medication that is outside the
expiry date is dangerous outside the
manufactures licence. Medicines deteriorate with
storage. The expiry date indicates when a
particular medication is no longer
pharmacologically efficacious or may have
dangerous effect on the patient.
To minimize the risk of infection.
To prepare the medication correctly using
correct dilution solution if required.
To use for flushing before, during (if more than
one medication) and after administration of
medication. To clear the line and prevent
possible interaction of solutions.
To maintain clinically clean area and the sterility
of equipment that will come into contact with
patient’s cannula port during administration.
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into the clinically clean tray along with
2% chlorhexidine/70% alcohol swab.
Remove gloves.
9. Collect any additional equipment
necessary to complete the procedure.
10. Approach the patient with the second
registered person to check and
complete the 5 R’s checking
procedure immediately prior to
administration
To ensure all equipment is available to
commence procedure. To prevent delays and
interruption of the procedure.
To ensure that the patient is given the correct
medication in the prescribed dose using the
appropriate diluent via the correct route.
To protect the patient from harm.
To comply with NUH Medicines policy.
11. Wash hands thoroughly and apply
gloves and any other necessary PPE.
To minimize the risk of infection.
12. Clean the end of the needle free
connection device with a 2%
chlorhexidine/70% alcohol swab and
allow drying.
To reduce the number of pathogens introduced
at the time of the insertion. To ensure complete
disinfection has occurred.
If a single port needle-free access device
is currently in use with an infusion
attached, it is acceptable to replace this
with a multi-port needle-free access
device using ANTT. It is not acceptable
to disconnect any infusion line and leave
it without reconnecting immediately.
Check compatibility of solution in use
with the medication to be administered.
13. Inspect cannula site prior to
administering any flush preadministration of the medicine.
For children remove the bandage over
the cannula and inspect the entry site
throughout the procedure.
14. When both registered persons are
satisfied with all parts of the checking
procedure open the clamp on the
needle free connector and administer
a 5 mL 0.9% sodium chloride flush, if
the line is deemed patent then the
medication should be administered
To prevent interactions between solutions and
irritation, discomfort and possible harm to the
patient.
To exclude any obvious signs of phlebitis
infection/irritation to the vein.
To ensure vein and cannula patency, aiding safe
and comfortable administration of the medicine,
to prevent discomfort to the patient and to
prevent thrombophlebitis reactions at the
cannula site.
(refer to relevant Trust policies if central line
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according to the recommended
appropriate bolus rate.
Only administer 1-2mL of 0.9%
sodium chloride flush to infants and
younger children.
Administer 0.9% sodium chloride.
Close the clamp on the needle free
connection device after flushing to create
positive pressure.
15. Consult the patient during the
administration about any discomfort.
devices are used).
To clear the cannula following injection.
To prevent backflow of solution and occlusion.
To flush any remaining irritant solution away
from the device site.
To detect any complications at an early stage,
and ensure patient comfort.
16. Inspect the insertion site of the
device.
To detect any signs of inflammation, infiltration,
and so on. If present, take appropriate action
(see Appendix 17 for Extravasation procedure).
17. Repeat for any further IV bolus
administrations ending with 0.9%
sodium chloride or compatible
solution.
For children assess the need to rebandage over the cannula.
18. Check patient is comfortable, answer
any queries or questions they may
have.
To clear line and prevent any interactions with
any medicines administered in subsequent
doses.
19. Ensure used equipment and any
ampoules are disposed of in
appropriate waste containers.
To reduce the risk of injury, safe disposal of
equipment that may cause injury.
20. Record the administration on the
medicine administration chart
ensuring that the two registered
persons sign
To maintain accurate records, provide a point of
reference in the event of any queries and
prevent any duplication of treatment.
To prevent inadvertently dislodging the
cannula
To ensure the patient is comfortable.
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Appendix 14: Summary of Flushing and Locking in Adults
 Lines should be flushed initially to check patency and after each drug,
infusion or blood sampling episode
 For central lines the syringe size should be not less than 10mL.
 Flush each unused lumen of lines when aspiration of another lumen
has taken place.
 When flushing a line do so using a ‘pulsating’/ push-pause technique.
 When locking a line do so under positive pressure.
Before
flushing
Peripheral
Lines
Midlines
inserted on
the ward
Midlines
inserted in
interventional
radiology
Peripherally
Inserted
Central Line
Catheters
Percutaneous
Central Lines,
PICC lines,
Check VIPS
(Visual
Infusion
Phlebitis
Score)
Check line is
the correct
one for
administration
and that it is in
the correct
position.
Observe for
signs of
infection
Check line as
above.
Sticker will
indicate is was
inserted in
Radiology)
Check line
Prescribed solution when in
active use
0.9%
Saline or
sodium
Heparinised
chloride
saline lock
(Note strength
varies)
5 -10mL
per flush
Frequency of
flushing
if not in active
use
(minimum
volumes
suggested)
12 hourly with 5
-10mL 0.9%
sodium chloride
5 -10mL
(NB Do
not take
blood
from
midlines)
The line is flushed
with 5mL 0.9%
sodium chloride
and locked with 25mL Heparin
10units/mL every
time the line is
accessed.
Daily with 510mL 0.9%
sodium chloride.
Lock with 5mL
heparinised
saline 10
units/mL
5-10mL
per flush
10mL 0.9% sodium
chloride after each
antibiotic
administration.
5 -10 mL
per flush
Daily with 510mL 0.9%
sodium chloride.
Lock with 5mL
heparinised
Locked with 5mL of saline 10
10units/mL
units/mL
Heparin after the
last infusion/ direct
injection of the day
10mL of 0.9%
Flush unused
sodium chloride
with 10mL 0.9%
solution if to be
sodium chloride
accessed again
solution then
within 24hours.
lock with 5mL
heparinised
saline
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Before
flushing
Prescribed solution when in
active use
0.9%
Saline or
sodium
Heparinised
chloride
saline lock
(Note strength
varies)
For patients under
the care of the
OPAT team to lock
with 5mL Heparin
10units/ mL
Non-tunnelled
Central
Venous
Catheters
Withdraw at
least 5mL
from the line
prior to
flushing to
avoid
inadvertent
administration
of any
medications
that may still
be in the
lumen of the
line
5 -10mL
per flush
Lock with 10mL of
0.9% sodium
chloride solution if
the CVC is to be
accessed again
within 48hours
Skintunnelled
Catheters
Broviac lines,
Hickman lines
Attempt to
5 -10mL
aspirate from
per flush
line before
use, unless
clear
documentation
that this is not
possible
Lock with 10mL of
0.9% sodium
chloride solution if
the CVC is to be
accessed again
within 48hours
Implantable
Ports
Accessing
ports is only
For CF patients
AND patients
Longlines
5 -10mL
per flush
Frequency of
flushing
if not in active
use
(minimum
volumes
suggested)
10units/mL).
Flush and lock
at least once a
week. Increase
to twice weekly
if there are
patency
problems.
Lock with 5mL
heparinised
saline 10
units/mL if
catheter not to
be used again
within 48hours.
Flush at least
once a week
(10mL 0.9%
sodium chloride
solution then
lock with 5mL
heparinised
saline
10units/mL).
Lock with 5mL
heparinised
saline 10
units/mL if
catheter not to
be used again
within 48hours
Flush unused
lumens once or
twice a week
(10mL 0.9%
sodium chloride
solution then
lock with 5mL
heparinised
saline
10units/mL).
Lock with 4-5mL
heparinised
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Before
flushing
Portacaths
CVCs used for
Haemodialysis,
Apheresis,
Haemofiltration
and Haemodiafiltration
Prescribed solution when in
active use
0.9%
Saline or
sodium
Heparinised
chloride
saline lock
(Note strength
varies)
done with nonunder the
coring needle
management of the
and port
OPAT team lock
extension to
with 4mL
which hub of
heparinised saline
syringe is
100units/mL three
attached
times daily.
For ALL other
patients lock with
heparinised saline
5mL 10units/mL
Withdraw
indwelling
heparin / lock
and discard
volume of
lumen before
accessing the
catheter
Flush
See local
both
guidelines and
lumens
practices.
with 10mL
0.9%
sodium
chloride in
10mL
syringes
using
push
pause
technique.
Frequency of
flushing
if not in active
use
(minimum
volumes
suggested)
saline
100units/mL if
catheter not to
be used again
within 48hours
Flush the port
once every 4-6
weeks with
10mL 0.9%
sodium chloride
then lock with 4
-5mL
heparinised
saline
100units/mL
Flush unused
lumens at least
weekly:
withdraw and
discard if
necessary, then
flush with 510mL 0.9%
sodium chloride
solution and
lock according
to local
guidelines and
practices.
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Appendix 15: Summary of Flushing and Locking in Children
 Lines should be flushed initially to check patency and after each drug,
infusion or blood sampling episode
 For central lines the syringe size should be not less than 10mL.
 Flush each unused lumen of lines when aspiration of another lumen
has taken place.
 When flushing a line do so using a ‘pulsating’ technique.
 When locking a line do so under positive pressure
Before
flushing
Peripheral
Lines
Peripherally
Inserted
Central Line
Catheters
Percutaneous
Central Lines,
PICC lines,
Longlines
Neonatal
Long Lines
Not
exclusive to
NNU - e.g.
24G (2Fr)
Skintunnelled
Catheters
Broviac lines,
Hickman
lines
Implantable
Ports
Portacaths
Check VIPS
(Visual
Infusion
Phlebitis
Score)
Check line
Attempt to
aspirate from
line before
use, unless
clear
documentation
that this is not
possible
Accessing
ports is only
done with noncoring needle
and port
extension to
which hub of
Prescribed solution when
in active use
0.9%
Heparinised
sodium saline lock
chloride (Note strength
varies)
2-5mL
per flush
Frequency of
flushing
if not in active use
(minimum
volumes
suggested)
12 hourly with 25mL
0.9% sodium
chloride
2-5mL
1.5 mL
per flush heparinised saline
10units/mL if not
to be used within 8
hours
Flush lumens once
a week with
2-5mL 0.9% sodium
chloride then lock
with 1.5 mL
heparinised saline
10units/mL
2-5mL
per flush
Continuous infusion
at 1-3mL/hr of
0.9% sodium
chloride
5mL per
flush
2.5 mL
heparinised saline
10units/mL if not
to be used within 8
hours
5mL per
flush
Lock with 4mL
heparinised saline
100units/mL
Flush unused
lumens at least
once a week with
5mL 0.9% sodium
chloride then lock
with 1.5 mL
heparinised saline
10units/mL
Flush the port once
a month with 10mL
0.9% sodium
chloride then lock
with 4 mL
heparinised saline
100units/mL
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syringe is
attached
See NUH Children and Young Persons Cystic Fibrosis Unit Management
Guidelines for more information
Non-tunnelled
Withdraw
5mL
Lock using
Aspirate line then
Temporary
indwelling
per
volume of
flush once a week
Haemodialysis Line
heparin / lock
flush
the line plus with 5mL 0.9%
Acute dialysis central
and discard
0.2mL
sodium chloride
lines
volume of
heparinised
then lock using
lumen before
saline
volume of the line
accessing the
100units/mL plus 0.2mL
catheter
heparinised
saline
100units/mL
Permanent/Tunnelled Withdraw
5mL
Lock new
Unused lumens:
Dialysis line
indwelling
per
lines with
flush at least
heparin / lock
flush
100units/mL weekly: withdraw
and discard
(volume of
and discard, then
volume of
deadspace
flush with 5mL
lumen before
plus 0.2mL)
0.9% sodium
accessing the
for first 24
chloride solution
catheter prior
hours. If line and locking
to flushing to
inserted for
solution as stated
avoid
> 24 hours:
above.
inadvertent
lock line with
administration
Alteplase
of any locking
2mg/2mL
solution in the
(volume of
line.
deadspace
plus 0.2mL).
Whilst this guide refers to 0.9% sodium chloride flushes it must be noted that
not all drugs are compatible with 0.9% sodium chloride, for example
Ambisome® must be flushed with 5% Glucose. (The process therefore would
be a flush with 0.9% sodium chloride, a flush with 5% glucose, administration
of Ambisome®, a flush with 5% glucose followed by a flush with 0.9% sodium
chloride.)
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Appendix 16: Summary of Flushing and Locking in Neonates
 Lines should be flushed initially to check patency and after each drug,
infusion or blood sampling episode
 For central lines the syringe size should be not less than 10mL5mL.
 Flush each unused lumen of lines when aspiration of another lumen
has taken place.
 When flushing a line do so using a ‘pulsating’ / push-pause technique.
 When locking a line do so under positive pressure
Before
flushing
Peripheral
Lines
Neonatal Long
Lines
Vygon Long
Line 24G
Check VIPS
(Visual
Infusion
Phlebitis
Score)
Check VIPS
(Visual
Infusion
Phlebitis
Score)
Prescribed solution when in active use
0.9% sodium
Heparinised saline
chloride or 0.45%
lock
in smaller babies
(Note strength varies)
to reduce sodium
and chloride load
0.5mL per flush
Frequency of
flushing
if not in active use
(minimum volumes
suggested)
2-5mL per flush
0.12mL heparinised
saline 10units/mL if
not used within 8
hours
Umbilical
Venous
Catheter
Vygon Double
Lumen UVC
Vygon
Umbilical
Catheter 4G
Check VIPS
(Visual
Infusion
Phlebitis
Score)
2mL per flush
Skin-tunnelled
Catheters
1. Broviac
line2.7F
2. Broviac Line
4.2F
Check VIPS
(Visual
Infusion
Phlebitis
Score)
2- 5mL per flush
12 hourly with 0.5mL
0.9% sodium
chloride
1. 0.15 mL
heparinised saline
10units/mL if not to
be used within 8
hours
2. 0.3mL heparinised
saline 10units/mL if
not used within 8
hours
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Appendix 17: Table of possible complications of intravenous
medication administration
Information taken from RCN Standards for Infusion Therapy, 2010; The
Royal Marsden Hospital Manual of Clinical Nursing Procedures, 9th
edition, 2015; MHRA Device Bulletin: Infusion Systems DB2003 (02), v
2.1, 2010.
Complication
Possible Signs &
Symptoms
Infiltration
The RCN (2010) defines
this as the inadvertent
administration of nonvesicant medication or
solution into the
surrounding tissue instead
of into the intended
vascular pathway.






Actions/Treatment

Localised swelling
Skin blanching
Pain
Numbness
Leakage of infusate
Discolouration and
circulatory
impairment





Extravasation
The RCN (2010) defines
this as the inadvertent
administration of vesicant
medication or solution into
the surrounding tissue
instead of into the
intended vascular
pathway.




Localised swelling
Redness
Warmth
Burning, stinging pain
Vesicant medication can
include boluses or
infusions that are:
acid e.g. Clarithromycin or
alkaline e.g.
Aminophylline, or
vasoconstrictor e.g.
Noradrenaline, cytotoxic
e.g. Vincristine or
hypertonic e.g. Sodium
chloride 1.8%
Speed shock/ fluid overload
When an intravenous
 Headache
Stop the infusion and
record severity of
infiltration
Inform doctor
Report and record
actions
Remove the cannula and
treat site as requested
Elevate and monitor the
site
Re-site the cannula as
appropriate (Royal
Marsden)


Stop the infusion
DO NOT remove the cannula
until instructed to do so
 Seek IMMEDIATE advice
from doctor
 Instigate treatment as
requested
 Report and record actions
Doctors may :
 Aspirate through the
cannula to remove
medication if possible
 Use steroid injections,
antihistamines and
analgesia, antidote (Royal
Marsden)
See Appendix 17: Guidance for
the management of
extravasation following
administration of cytotoxic
medication

Stop the infusion
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medication is given too
rapidly, ‘speed shock’ may
occur (Royal Marsden).




Flushing
Chest tightness and
irregular pulse
Tachycardia and fall in
blood pressure
Syncope and the risk of
cardiac arrest






Phlebitis
The RCN (2010) defines
this as inflammation of the
intima of the vein which
may be infective,
mechanical or chemical.




Air-emboli
Introduction of a bolus of
air into a vessel.




Redness
Tenderness and
swelling around the site
The vein feels hard on
palpation
Possible evidence of
‘tracking’ (red lines
running up the arm)


Rapid drop in blood
pressure
Tachycardia
Cyanosis
Unconsciousness







Thrombosis
The RCN (2010) defines
this as the formation of a
thrombus (small blood
clot) within a vessel.



Redness
Tenderness and
swelling around the site
The vein often feels
hard on palpation




Seek IMMEDIATE advice
from Doctor
Instigate treatment as
requested
Report and record actions
Always check the medication
information leaflet prior to
administration
Maintaining a fluid input/
output chart will aid
monitoring and prevention of
complication
Giving intravenous therapies
slowly and over the
specified time will aid
prevention of complication
(Royal Marsden)
Stop the infusion
Remove the cannula and
treat as required
Re-site the device as
appropriate
Report and record actions
(VIP score)
Stop the infusion
Seek IMMEDIATE advice
from Doctor
Report and record actions
Ensure all infusion lines are
carefully primed and
connections air tight
Doctor may advise turning
the patient on the left side
and lower the head of the
bed to prevent air entering
the pulmonary artery (Royal
Marsden)
Stop the infusion
Seek IMMEDIATE advice
from Doctor
Report and record actions
Ultrasound may be needed
to diagnose clot in the arm
(Royal Marsden)
Cannula-occlusion
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This may occur when an
infusion is allowed to run
dry or incompatible
solutions are
administered.

Unable to administer
bolus, infusion


Allergic Reactions
Allergic reaction due to
sensitivity to an
intravenous fluid, additive
or medication.



Itching
Rash
Shortness of breath





Septicaemia
Blood stream infection
causing sepsis.



Pyrexia
Rigors
Tachycardia




Flush the cannula before,
after and in between
medication administration
gently using a 10mL syringe
of 0.9% sodium chloride. If
resistance is met stop and
re-site the device (peripheral
device) (Royal Marsden)
Report and record actions
Stop the infusion
Seek IMMEDIATE advice
from Doctor
Report and record actions
Ensure hydrocortisone and
adrenaline are available
(Royal Marsden)
Always check for allergy
before administration of
medication
Stop the infusion
Seek IMMEDIATE advice
from doctors
Report and record actions
Always adhere to aseptic
techniques when performing
all intravenous procedures
ANTT (RCN, 2010)
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Appendix 18: Guidance for the management of extravasation
following administration of cytotoxic medication
EXTRAVASATION
This is the accidental administration of drugs into the extra vascular tissue instead of into the vein. If
the drug extravasated is a vesicant, the damage to the surrounding tissue can be extensive and
tissue necrosis can occur.
SUSPECT
PERIPHERAL
EXTRAVASATION
IF:
Extravasation
may be linked
to peripheral cannulation
or a Central Venous Access Device
a)
Patient
complains
of
burning
or
stinging
pain
at
or
around
cannula site
(CVAD).
b) There is evidence of swelling, induration, leakage at site
c) There is resistance on plunger of syringe or absence of free flow of infusion
d) There is no blood return (if found in isolation via a peripheral cannula this should not be regarded
as an indication of a non-patent vein).
Action;
A. If extravasation occurs during peripheral administration of chemotherapy; Act immediately
according to your local extravasation guidelines.
B. If a patient presents as an emergency following previous peripheral administration of
chemotherapy;
Act immediately Extravasation of a vesicant drug should be treated as an emergency. If it is
discovered the local Acute Oncology Team should be contacted, if out of hours contact the
oncology/Haematology on call SpR. The local extravasation policy should be followed:
http://nuhnet/nuh_documents/Guidelines/Cancer%20and%20Associated%20Specialties/Clinical%20
Haematology/1803a.pdf
Although administration of drugs via CVADs carry less risk of extravasation than peripheral
administration, if it does occur the damage is likely to be larger and more severe than with peripheral
administration. This is because the event is not likely to be noticed immediately and delays to the
treatment of extravasation result in damage limitation rather than cure.
SUSPECT CVAD EXTRAVASATION IF:
Signs and symptoms include;•
The patient complains of pain
•
There is evidence of redness and swelling
• There is visible leaking of the drug via the skin tunnel or around the exit site.
Extravasation of a vesicant drug should be treated as a medical emergency.
If it is discovered the local Acute Oncology Team should be contacted, if out of hours contact
the on call oncology/Haematology SpR. The local extravasation policy should be followed.
IMMEDIATE ACTION FOR ALL DRUG CATEGORIES IF CVAD EXTRAVASATION IS
SUSPECTED.
If the patient is receiving an active infusion STOP the infusion immediately
Leave the central venous catheter in place.
Attempt to aspirate as much drug as possible with a new syringe.
For ports, aspirate then remove needle
Inform a senior member of the Acute Oncology Team (or oncology/haematology on call SpR)
Organise X-ray of line or lineogram
For vesicant extravasations or large volumes of irritant drugs refer to plastic surgeon
as soon as possible after detection.
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Appendix 19: Double pumping
Double pumping may be appropriate when changing infusions of very short
acting drugs e.g. inotropes, where a break in therapy could be detrimental to
the clinical state of the patient. Only one drug should be double-pumped at any
one time. The goal of double pumping is to keep the parameters (e.g. blood
pressure) unchanged and may take up to 10 minutes during which time this
should be the practitioner’s sole focus.
Any double pumping episode taking longer than 15 minutes to get the first
infusion weaned off should necessitate a medical review of the patient (unless
a prolonged episode has been previously indicated). Please inform the nurse
coordinating the shift prior to commencing the procedure.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Double pumping should be commenced at least 1 hour prior to the old
infusion expiring or running out.
Prepare new infusion as per prescription and prime the giving set.
Insert into the infusion pump and program as per local policy and
prescription chart.
Connect to spare hub of the three-way tap using ANTT.
Attach drug name label near to the three-way tap.
Open the tap to allow delivery of both the old and new infusions to the
patient.
Commence the new infusion at the same rate as the old infusion.
Closely observe the patient’s parameters e.g. Blood Pressure in the case
of inotropes with continuous or 5 minute interval monitoring.
Decrease rate of old infusion according to patient parameters until it is on
the minimal dose and then place the pump on hold and monitor patient to
ensure no further fluctuations in parameters. The time-scale for double
pumping will vary according to infusion rate and position of new infusion
relative to patient.
Once the patient is stable, stop old infusion pump and turn off old infusion
at 3-way tap.
Disconnect old infusion using ANTT and discard as per policy.
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Appendix 20: What involvement can student nurses have in medication preparation and administration?
Route
Adult field students
Students at any stage of their training should be encouraged (where appropriate) to participate in
Oral
drugs rounds. Students in part 2 and 3 should be encouraged to undertake supervised drugs
rounds
On completion of appropriate theoretical input by the university or placement, students can
Subcutaneous administer SC injections under direct supervision. 1st year students can undertake once theoretical
and practical training has been provided by the placement area
On completion of medicines calculations test in part 2, students can act as 2nd checker for SC
injections.
Intravenous
Cannot be 2nd checker or rate check if infusion
Students are not permitted at any time to directly administer or act as 2nd checker for IV medications
or IV fluids
Students should however be encouraged to be involved in the preparation of IV’s and act as 3rd
checker in the presence of 2 RNs
Transdermal
Controlled
drugs
Students can assist in the preparation and recording of intravenous infusions and direct injections
under the direct supervision of 2 registered nurses but CANNOT administer the medication. The
supervising registered nurse(s) are responsible for the correct process throughout.
Students are not permitted to act as 2nd checkers for transdermal administration at any time
On completion of medicines calculations test in part 2 students can act as 2nd checker for oral or SC
CD medications – cannot be 2nd checker for syringe driver/pump rate – 3rd checker only
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Route
Medical
devices
Adult field students
Students cannot act as 2nd checkers for IV CDs at any time
Students should be encouraged to practice rate calculations
Students should be encouraged to practice using medical devices under direct supervision but are
not permitted to start a drug infusion or connect infusion lines to patient
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Appendix 21
Equality Impact Assessment (EQIA) Form (Please complete all sections)
Q1. Date of Assessment: 1/9/15
Q2. For the policy and its implementation answer the questions a – c below against each characteristic (if
relevant consider breaking the policy or implementation down into areas)
a) Using data and supporting
b) What is already in place in c) Please state any
Protected
information, what issues,
the policy or its
barriers that still need to
Characteristic
needs or barriers could the
implementation to address
be addressed and any
protected characteristic
any inequalities or barriers to proposed actions to
groups experience? i.e. are
access including under
eliminate inequality
there any known health
representation at clinics,
inequality or access issues to
screening
consider?
The area of policy or its implementation being assessed:
Race and
Ethnicity
Gender
N/A
N/A
N/A
N/A
N/A
N/A
Age
N/A
N/A
N/A
Religion
N/A
N/A
N/A
Disability
N/A
N/A
N/A
Sexuality
N/A
N/A
N/A
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Pregnancy and
Maternity
Gender
Reassignment
Marriage and
Civil Partnership
Socio-Economic
Factors (i.e.
living in a poorer
neighbour hood
/ social
deprivation)
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Area of service/strategy/function
Q3. What consultation with protected characteristic groups inc. patient groups have you carried out?
N/A
Q4. What data or information did you use in support of this EQIA?
N/A
Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from
surveys, questionnaires, comments, concerns, complaints or compliments?
N/A
Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups
identified or to create confidence that the policy and its implementation is not discriminating against any
groups N/A
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Appendix 22 Environmental Impact Assessment
The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the
significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b)
implement mitigating actions.
Area of
impact
Environmental Risk/Impacts to consider
Waste and  Is the policy encouraging using more materials/supplies?
materials
 Is the policy likely to increase the waste produced?
 Does the policy fail to utilise opportunities for
introduction/replacement of materials that can be recycled?
Soil/Land  Is the policy likely to promote the use of substances
dangerous to the land if released (e.g. lubricants, liquid
chemicals)
 Does the policy fail to consider the need to provide adequate
containment for these substances?
Water
 Is the policy likely to result in an increase of water usage?
(estimate quantities)
 Is the policy likely to result in water being polluted? (e.g.
dangerous chemicals being introduced in the water)
 Does the policy fail to include a mitigating procedure? (e.g.
modify procedure to prevent water from being polluted;
polluted water containment for adequate disposal)
Air
 Is the policy likely to result in the introduction of procedures
and equipment with resulting emissions to air? (e.g. use of a
furnaces; combustion of fuels, emission or particles to the
Action Taken (where
necessary)
N/A
N/A
N/A
N/A
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

Energy

Nuisances

atmosphere, etc.)
Does the policy fail to include a procedure to mitigate the
effects?
Does the policy fail to require compliance with the limits of
emission imposed by the relevant regulations?
Does the policy result in an increase in energy consumption
levels in the Trust? (estimate quantities)
Would the policy result in the creation of nuisances such as
noise or odour (for staff, patients, visitors, neighbours and
other relevant stakeholders)?
N/A
N/A
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Appendix 23
We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit
The We Are Here For You service standards have been developed together with more than 1,000 staff and
patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe and
confident in their treatment. The standards apply to how we behave not only with patients and visitors, but with all
of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their inclusion in
Policies and Trust-wide Procedures is essential to embed them in our organization.
Please rate each value from 1 – 3 (1 being not at all, 2 being affected and 3 being very affected)
Value
1.
Polite and Respectful
Whatever our role we are polite, welcoming and positive in the face of adversity, and are always
respectful of people’s individuality, privacy and dignity.
2.
Communicate and Listen
We take the time to listen, asking open questions, to hear what people say; and keep people
informed of what’s happening; providing smooth handovers.
3.
Helpful and Kind
All of us keep our ‘eyes open’ for (and don’t ‘avoid’) people who need help; we take ownership of
delivering the help and can be relied on.
4.
Vigilant (patients are safe)
Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates
attention to detail for a clean and tidy environment everywhere.
5.
On Stage (patients feel safe)
Score
(1-3)
1
3
1
3
1
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We imagine anywhere that patients could see or hear us as a ‘stage’. Whenever we are ‘on stage’
we look and behave professionally, acting as an ambassador for the Trust, so patients, families and
carers feel safe, and are never unduly worried.
6.
Speak Up (patients stay safe)
We are confident to speak up if colleagues don’t meet these standards, we are appreciative when
they do, and are open to ‘positive challenge’ by colleagues
7.
Informative
We involve people as partners in their own care, helping them to be clear about their condition,
choices, care plan and how they might feel. We answer their questions without jargon. We do the
same when delivering services to colleagues.
8.
Timely
We appreciate that other people’s time is valuable, and offer a responsive service, to keep waiting to
a minimum, with convenient appointments, helping patients get better quicker and spend only
appropriate time in hospital.
9.
Compassionate
We understand the important role that patients’ and family’s feelings play in helping them feel better.
We are considerate of patients’ pain, and compassionate, gentle and reassuring with patients and
colleagues.
10. Accountable
Take responsibility for our own actions and results
11. Best Use of Time and Resources
Simplify processes and eliminate waste, while improving quality
12. Improve
Our best gets better. Working in teams to innovate and to solve patient frustrations
TOTAL
2
1
1
1
3
1
1
19
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Appendix 24
CERTIFICATION OF EMPLOYEE AWARENESS
Document Title
NUH Intravenous Drug Administration Policy
Version (number)
1
Version (date)
5 February 2016
I hereby certify that I have:
 Identified (by reference to the document control sheet of the above
policy/ procedure) the staff groups within my area of responsibility to
whom this policy / procedure applies.
 Made arrangements to ensure that such members of staff have the
opportunity to be aware of the existence of this document and have the
means to access, read and understand it.
Signature
Print name
Date
Directorate/ Division
The manager completing this certification should retain it for audit and/or other
purposes for a period of six years (even if subsequent versions of the
document are implemented). The suggested level of certification is;
 Clinical Divisions - general manager or nominated deputies
 Corporate Directorates - deputy director or equivalent.
The manager may, at their discretion, also require that subordinate levels of
their directorate / department utilise this form in a similar way, but this would
always be an additional (not replacement) action.
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