Beth Israel Deaconess Hospital - Needham Pharmacy Manual Title: I.V. Admixture Program PURPOSE: I.V. ADMIXTURE PROGRAM The LV admixture program allows for intermittent intravenous infusions to be made under the sterile conditions provided by pharmacy equipement. Quality control guidelines must be followed in order to assure sterility of the I.V.’s mixed Procedure: 1. LV Additives: The Pharmacy staff will prepare LV. “piggy-backs” containing the following additives:
a. Antibiotics as stated on the attached list b. H2 Antagonists Chemotherapy agents will continue to be prepared by the Pharmacy under separate policies/procedures..
LVs NOT MIXED BY THE PHARMACY (i.e., must be prepared by the nursing staff): a. STAT orders b. Orders received in the Pharmacy after 1300 hours c. All I.V.s ordered when the Pharmacy is closed: 1) Weekdays 1700-0700 2) Weekends: 1500-0700
Hours of Operation: .
The LV. Admixture Program will function during hours of operation. I.V.s will be prepared according to a 1400 to 1400 cycle. For example, at 1400 on Monday, I.V.s for the next 24 hours will be delivered to the nursing units. At the time I.V.s are delivered, discotntinued I.V.s will be picked up and returned to the Pharmacy by the Pharmacy technician. Detailed Protocol - Pharmacy: 0815-0845:Pharmacy technician arrives on nursing unit. a. Picks up all discontinued I.V.s from nursing unit refrigerator. Note: Labels, not the bags, should be marked discontinued by the nursing staff. b. Picks up Order Sheet (next to Pharmacy basket), showing all new LV. orders. c. Picks up daily discharge list. 0845-1100: Pharmacy technician prepares I.V.s in the Pharmacy, working from a daily list of I.V.s. a. All Pharmacy charting will be completed at this time. All I.V.s will be checked by a Registered Pharmacist before they ~re prepared and delivered. New orders must be received in the
Pharmacy by 0900, in order to be included in the 1300 delivery. 1300-1400: Pharmacy technician delivers I.V.s to the nursing units. a. New I.V. orders received between 1030 ·and 1600 will be delivered PRN (prior to 1600). The Pharmacy staff will attempt to fill all new I.V. orders received between 1030 and 1600. Depending on Pharmacy workload, the Nursing staff may need to prepare the initial dose. During hours the Pharmacy is not in operation, the Nursing Supervisor may check the Pharmacy LV. refrigerator for possible stock of pre-mixed I.V.s. A "pink slip" must be completed for each LV. taken from the Pharmacy stock.
4. Physician's Orders: Reconstitution solution: Unless otherwise ordered by the physician, all I.V.s will be mixed according to the Admixture Guidelines as stated on the attached "Expiration" list. Discontinued/changed LV. Orders: The Pharmacy must be notified as soon as possible when an LV. order is changed or discontinued. The requisition slips noting the order change should be placed in the Pharmacy basket, for a volunteer to take to the Pharmacy. Infection Control Guidelines: The Pharmacy Technician will absent him/herself from the Admixture Program if the Technician experiences: 1) Diarrheal illness 2) Draining or weeping wounds 3) Viral respiratory illness (during primary phase) 4) Diagnosed strep throat (for the first two days of treatment) If in doubt, consult the BID-Hospital Infection Control Nurse. Attire: Clean lab coat, sterile gloves, hair covering and mask. a. EducationlTraining: The Pharmacy Technician must attend the Beth Israel Deaconess Hospital-Needham Orientation Program (including Infection Control presentation) and periodic infection control inservice education sessions. The Technician must demonstrate proper aseptic technique. b.The Laminar Flow Hood must be maintained according to protocol outlined in the Pharmacy policies on Laminar Flow Hood Maintenance and Use. NOTE: No food or drink are permitted in the Laminar Flow Hood room. c. Hand Scrub: 1) remove jewelry
3) 4) 5)
wash hand thoroughly above the wrists with hospital approved agent: a) each finger separately, then b) surfaces of each hand, then c) wrists rinse thoroughly keep hands elevated above the elbow so water will not run down from upper arms Dry thoroughly, using paper towels to turn faucet off.
Procedure: Prior to preparing I.V; Meds, all necessary paper work completed and equipment assembled. Transport equipment to Laminar Flow Hood Room. Don hair cover. Don mask. Thorough hand scrub--see procedure. When ready to proceed, don gloves maintaining sterility. Prepare only one type solution at a time rather than all of one patient's medications at a time (Le., all the Penicillin orders then all the Keflin, etc.). When all day orders are prepared and checked by the supervising Registered Pharmacist, the Pharmacy Technician delivers them to the appropriate nursing unit refrigerators. 9. I.V. medications are stored in these refrigerators in racks which keep them separated to permit air flow. 10. Each morning any unused medications are picked up from the refrigerators and returned to the Pharmacy by the Technician. 11. These medications may be kept as long as manufacturer's recommendations permit or until manufacturer's expiration date. If needed, they may be relabeled and dispensed to another patient.
Sponsor/Author: Approved By: Original Date Approved: Reviewed Date: Revisions: 1/93, 1/96, 5/99, 11/00, 5/02, 6/05 Next Review Date: Eliminated: