BARNET AND CHASE FARM HOSPITALS NHS TRUST
Intravenous fluids and medications
administration clinical guideline
Policy and version number
Status
Date of ratification and implementation
Review date
Policy author
Accountable director
Approved by
Ratified by
Equality impact assessment completed
and impact
Document location
Distribution and dissemination
Principal target audience
CPP/109/3.2
Ratified
Ratification 10th March 2011
Implementation 18th March 2011
March 2014
Intravenous Therapy Group
Director of Nursing
The Drugs and Therapeutics Committee 3rd March
2011
Clinical Governance Committee 10th March 2011
Yes – sent to EIA panel
Trust Intranet
All staff via Intranet and news mail
Staff undertaking duties in relation to intravenous
medications
Through Directorate leads, and their colleagues
Responsibility for dissemination of policy
to new staff
NHSLA/Care Quality Commission/ALE
impact
REVISION AND RATIFICATION HISTORY
Version
Date
Summary of Changes
Ratifying body and date of
ratification
1.0
2001
New policy
Not known
2004
Addendum added
Clinical Audit and effectiveness
Committee June 2004
2.0
Nov 2006
Fully revised incorporating RCN Clinical Audit and effectiveness
Standards for Infusion Therapy
Committee
2nd November 2006
3.0.
Oct 2009
Fully revised incorporating RCN Clinical Audit and effectiveness
Standards for Infusion Therapy
Committee
October 2009
4.0
Mar 2011
Revised due to incidents
involving extravasation,
additions to the nursing
competency and new national
guidance for neonates from the
NPSA ahead of its revision
date.
MONITORING THE EFFECTIVENESS OF POLICY IMPLEMENTATION
Key Performance Indicators:
Competency framework, review if incidents
Frequency of audit:
Annual
Location of Audit Report:
Infection Control Committee
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Contents
Heading
1.0.
2.0.
3.0.
4.0.
4.1.
4.2.
4.3
4.4
4.5
5.0.
6.0.
6.1.
6.2.
7.0.
8.0
8.2
8.3
9.0
10.0
Page
Front sheet
POLICY STATEMENT
SCOPE
AIMS
RESPONSIBILITIES
Responsibility of the Trust Board
Responsibilities of the Accountable Director
Responsibilities of the Clinical Directors and Directorate
managers
Responsibilities of the Clinical Managers Ward managers,
matrons and radiology duty managers
Responsibilities for all staff who come into contact with
patients and their property
DEFINITIONS
POLICY DEVELOPMENT
Identification and consultation with stake holders
Equality impact screening
CORE PRINCIPLES
MONITORING COMPLIANCE
Process for monitoring compliance and effectiveness
Standards / key performance indicators
REFERENCES, LITERATURE SEARCH AND CRITICAL
APPRAISAL
ASSOCIATED DOCUMENTATION
4
4
4
4
4
4
4
4
5
7
7
7
8
8
22
22
22
23
24
Appendix 1 Launch Plan
Appendix 2 National Patient Safety Agency (NPSA) 2010 Prevention of over infusion
of intravenous fluid and medicines in neonates NPSA/2010/RRR015 – outline
Appendix 3 Equality Screening Tool
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1.0. POLICY STATEMENT
This clinical guideline sets out clinical standards and provides guidance to all
practitioners employed within the Trust, in order to ensure the safe administration
of intravenous fluids and medications. This version has been developed to give a
more direct approach to intravenous therapy. Rationale can be obtained by
reviewing the references. Peripheral cannulation and venepuncture can be
reviewed in the peripheral vascular cannulation policy (PVC).
2.0. SCOPE OF THE POLICY
These clinical guidelines cover administration of peripheral intravenous
medications for all patient groups (neonatal to elderly). Subcutaneous infusions
are not covered.
To administer by the following routes staff must have received specialist training
- refer to separate polices
 Administration of intravenous medications and fluids via Central
Venous pressure lines
 Cytotoxic therapy
 Femoral lines and peripherally inserted central cannula.
 Hickman lines
 Porta-caths
3.0. AIM
The aim of the guidance is to provide clear guidance to ensure evidence based
safe practice.
4.0.
RESPONSIBILITIES
4.1. Responsibility of the Trust Board
4.2.1 The Trust Board delegates authority for ratifying this clinical guideline to
the Clinical Governance Committee. The Clinical Governance Committee
reports to the Trust Board.
4.2. Responsibility of the Accountable Director
4.2.1 To present this revised clinical guideline to the Clinical Governance
Committee.
4.2.2. To ensure that the current version of the clinical guideline is on the
intranet and that an archive copy is retained within the directorate.
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4.3. Responsibilities of the Clinical Directors and Directorate managers
4.3.1. To ensure that this clinical guideline is disseminated to all staff and
implemented in their directorate.
4.3.2. To ensure that the clinical guideline is implemented and incidents and
concerns are reported through the relevant committee / clinical directorate
and appropriate action is taken.
4.4. Responsibilities of the Clinical Managers Ward managers, matrons
4.4.1. To ensure that this clinical guideline is disseminated to all staff and
implemented in all clinical areas.
4.5. Responsibilities for all staff
4.5.1. Training and competency
All practitioners undertaking any duties outlined in this policy must have
undertaken training and gained the correct competence for prescribing and the
administration of intravenous fluids and medicines;
 Nurses must have successfully completed an intravenous fluid and
intravenous medications competence (this covers the practical aspects of
using infusion or syringe pumps) – available on the intranet.
 Staff using a medical device must have received training and be registered
on the relevant medical devices equipment training record.
 Nurses must have successfully completed an Equipment Training Record for
all models of syringe and infusion pumps that they use part of the Medical
Devices Management and Training Policy.
 Midwives must undertake only the medical devices equipment training record.
 Staff who carry out duties in relation to the administration of intravenous
fluids and medicines, must maintain their knowledge and skills.
4.5.2. Aseptic Technique and hand washing
Administration of medications and fluids via any intravenous route directly into
blood stream bypasses the body’s normal defenses. Therefore contamination of
the medications / devices may result in rapid acquisition of local and systematic
infection such as cellulites, phlebitis, abscess formation, bacteraemia, septic
thrombophlebitis and septicaemia. Thus All staff MUST have been trained in
aseptic non-touch technique (ANTT) on a yearly basis. Staff MUST strictly
adhere to ANTT throughout all intravenous related procedures.
4.5.3. Consent
Always gain consent by explaining any procedures, the risks benefits and
alternatives to treatment. Ensure the patient is aware that some medications are
derived from animal origin and this may be not acceptable in terms of culture and
religion.
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4.5.4. General legal requirements
All practitioners must understand that when undertaking duties in relation to
intravenous therapy that they must comply with the law and their own
professional guidelines.
4.6. Responsibilities for prescribers
4.6.1. For those staff who prescribe intravenous medications these points are in
addition to core points from the medicines clinical guidelines. Ensure you have
used the:
 approved name of the medication to be administered intravenously
 dose of the medication (all paediatric medications must be calculated by
weight- use paediatric BNF or Neonatal Formulary as applicable)
 method of administration, i.e. bolus, into an administration set/cannula,
intermittent infusion or continuous infusion.
 infusion fluid in which the medication is to be diluted (unless already written
on prescription chart by clinical pharmacist)
 volume of infusion fluid/medication (unless already written on prescription
chart by clinical pharmacist
 final concentration of the medication infusion (unless already written on
prescription chart by clinical pharmacist)
 calculated rate at which the infusion/medication is to be administered, e.g.
‘mg per minute’, ‘drops per minute’, or ‘ml per hour’, etc.
 device to be used for administration of medications where more than one
device is in use, e.g. peripheral
Call a pharmacist if you are unsure. Outside of normal working hours you can
page the on-call pharmacist for out of hours for advice via switchboard
N.B. Anaesthetists in practice frequently do not prescribe medication, but will
document all medication given on the anaesthetic chart. They also give many
medications that are not checked by two practitioners, but any controlled drugs
must be witnessed as per Trust Controlled Drug Policy.
4.6.2 Responsibilities for Clinical Pharmacists
Clinical pharmacists are responsible for monitoring prescriptions and the
administration of medication therapies and alerting prescribing doctors, nursing
staff and other health care professionals to potential problems. Information can
be supplied by the medicines information insert, the online intravenous
medicines guide (Medusa), the clinical pharmacy service and by the on-call
pharmacist out of hours.
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Pharmacists responsibilities include (Dougherty and Lamb 1999):
 selection – ensuring appropriate medications & medication regimes are
prescribed e.g. dose, route, frequency, administration method, duration of
therapy
 prescription chart endorsement with relevant and necessary information
e.g. medication preparation method, dilution details of infusions
 responding to enquiries from practitioners on all aspects of medication
therapies including methods of administration, diluents and infusion fluids,
medication stability, delivery systems (pumps, burettes), medication
compatibility information, rate of administration, contraindication and side
effects, interactions, unlicensed medications and their use, anaphylaxis
guidelines and medication administration guidelines
 signing and dating prescription chart to inform practitioners that the
prescription chart has been reviewed
 minimising the risk of medication errors throughout the process, from
prescribing, dispensing to administration
 training the multi-disciplinary health care team in all aspects of medication
therapy
 advise on treating complications such as extravasation N.B. Ready made
anaphylaxis boxes should be available to the clinical areas.
N.B. Occasionally a prescription may have two or more different routes on
the one section if the dosage is the same, ensure that the route is clearly
documented. Additionally the medication may have been prescribed in two
areas if the dosage varies by routes ALWAYS ensure that the drug you are
giving has not been recently administered by a different route.
4.7
Responsibilities for the practitioner undertaking intravenous
administration of medicines
Responsibilities in relation to intravenous medication administration include:
 Knowing the therapeutic use of the medication or solution to be administered,
its normal dosage / route and rate of administration (particularly for bolus
doses) and appropriateness for patient age and condition. Its side-effects,
precautions (e.g. protection from light) and contraindications, compatibilities.
Scrutinising information on the relevant container / medication insert.
 Checking the prescription chart and contacting the independent /
supplementary prescriber immediately if the mediation is contraindicated and
/ or pharmacist if the prescription or container information is illegible, unclear,
ambiguous or incomplete.
 Knowing the principles of reconstituting including, ANTT, compatibility,
(physical chemical, and therapeutic), stability, labelling, interactions, dosage
and calculations and appropriate equipment.
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 Preparing the medication in a well lit area aseptically and safely, checking the
container and medication for faults, using correct diluent and only preparing
immediately prior to administration.
 Wearing of protective clothing during preparation and administration, gloves
aprons and goggles as required.
 Adults – identifying the patient by asking the patient to recite their first name,
surname, date of birth and cross referencing the information with the wrist
identification band hospital number1 and medication chart. Two nurses to
check from start to finish.
 Paediatrics – Identifying the patient; two nurses must check the identification
band and cross reference the first name, surname, date of birth and hospital
number2 against the medication chart.
 Paediatrics – Checking, signing and confirming the total volume to be infused
and the infusion rate with another registered nurse at
 Change of infusion
 Changes to the rate
 Change of shift
 Checking allergy status to avoid a serious adverse reaction.
 Checking and maintaining the vascular access device (see PVC policy)
 Inspecting the site of the vascular access device and managing/ reporting
complications where appropriate
 Controlling the flow rate of infusion and/or speed of injection.
 Ensuring that the prescribed fluid or medication is given to at the correct time
via the right route.
 Making immediate clear records of all medications administered
 Monitoring, evaluating and documenting, the effectiveness of prescribed
therapy; condition of the patient, in particular any adverse events to the
medication and subsequent interventions.
5.0. DEFINITIONS
Extravasation - the inadvertent administration of vesicant medication or solution
into the surrounding tissue instead of into the intended vascular pathway.
6.0. POLICY DEVELOPMENT
6.1. Identification and consultation with stake holders
The NPSA require that the NHS number be used – the Trust will give further communication
when practitioners are required to substitute the hospital number for the NHS number
2 The NPSA require that the NHS number be used – the Trust will give further communication
when practitioners are required to substitute the hospital number for the NHS number
1
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The clinical guidance had been circulated to consultants representing all
directorates, the Intravenous Therapy work group, Matrons and ward managers.
The medicines safety committee have been asked to approve the clinical
guidelines.
6.2. Equality impact screening
These clinical guidelines have been considered in terms of The Equality Act.
There are physiological differences between patients of different ages.
Neonates, babies, adults and elderly have different responses to physiological
stress. Statements in the guidance refer to age recognising the differences in
physiology in different ages. Therefore age is not used in a discriminatory sense
for equality and diversity concerns. The guideline’s primary purpose is to ensure
safe administration of intravenous infusions and reduce the associated risks,
therefore it affects all patients equally.
As per the administration of medicines clinical guidelines consent must cover
consideration of the derivative of the medication to ensure that it is acceptable
for the patient’s religion or personal beliefs.
If a patient’s disability affects their communication, practitioners should enlist the
use of the interpreting services to aid understanding. The interpreting services
cover signing for Braille and touch signing for deaf blind. Clinical areas should
enlist the Learning needs liaison nurse and use the range of books / prompts /
interpreting aids for patients with learning disabilities or confusion.
If a patient’s race nationality or ethnic origin affects their communication,
practitioners should enlist the use of the interpreting services to aid
understanding. The interpreting services cover different languages spoken,
Where patient information is provided it should be printed in the appropriate
language and interpreted / translated as required.
7.0. CORE PRINCIPLES
7.1. Advantages and disadvantages of using the intravenous route
Advantages
 An immediate, therapeutic effect is achieved owing to rapid delivery of the
medication to its target site, which allows a more precise dose calculation and
therefore more reliable treatment
 Pain and irritation caused by some of the substances when given
intramuscularly or subcutaneously are avoided
 The vascular route affords a route of administration for the patient who
cannot tolerate fluids or medications by the gastrointestinal route.
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 Some medications cannot be absorbed by any other route; the large
molecular size of some medications prevents absorption by the
gastrointestinal route, while other medications, unstable in the presence of
gastric juices, are destroyed.
 The intravenous route offers the facility for control over the rate of
administration of medications; prolonged action can be provided by
administering a dilute infusion intermittently or over a prolonged period of time
(Campbell 1996 Weinstein 2000)
Disadvantages
 There is an inability to recall the medication and reverse its action. This may
lead to increased toxicity or a sensitivity reaction.
 Insufficient control of administration may lead to speed shock or circulatory
overload. This is characterized by a flushed face, headache, congestion,
tightness in the chest, etc.
 Additional complications may occur, such as the following:
a) Microbial contamination (extrinsic or intrinsic)
b) Vascular irritation, e.g. chemical phlebitis
c) Medication incompatibilities and interactions if multiple additives
are prescribed
d) Infiltration
e) Extravasation / burns
 Needle phobia
 Altered body image
 Time taken for administration
7.2.
Equipment essentials
Product requirements
All products must have CE marking, and be stored in a clean and dry
environment. Any product not meeting the requirements should be withdrawn
from use (retained for inspection) and reported to the Medicines and Healthcare
Products Regularity Agency (MHRA).
Product defect reporting
All defective products must be reported in writing to the appropriate department
within the Trust e.g. Pharmacy for medications, supplies for equipment and / or
Electro Bio Medical Engineering (EBME). National regulatory agencies such as
the MHRA or National Patient Safety Agency may also need to be informed.
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Expiry dates and storage checking of IV equipment, fluids and medications
All medications / fluids and related equipment, must be; within their expiry date,
in intact packaging and must have been stored and used according to
manufacturers instructions. Do not use if faulty in any way. Inspect all
medications / fluids and related equipment packaging for:
 Leakage
 Expiry date
 Cloudiness
 Particle formation
 Precipitate formation
 Tampering
Gloves and plastic aprons
Gloves must be worn in conjunction with ANTT procedures. Plastic aprons must
be worn in addition when performing infusion procedures where there is a risk of
contamination by blood and bodily fluids. Consider latex sensitivities in both
practitioner and patient.
Face masks / eye protection.
These are not essential items, but should be worn where the practitioner
considers themselves at risk of splashes from either substances or bodily fluids,
or practitioner allergy.
Intravenous related equipment
Add-on devices
All items must be extension sets with closed needle free systems.
All intravenous medications should be given through the multilumen extension
tube (needle free closed system) attached to the cannula.
Top ports of cannula MUST NOT be used for medication administration (unless
an emergency) and MUST remain closed at all times.
All equipment should be disconnected and discarded immediately
 upon suspected contamination
 when the integrity of the product or system has been compromised.
 if residual blood remains within the access site N.B. Other policies may
advise to send tip of catheter etc.
For Paediatrics:
When using a syringe pump to administer intravenous fluids a bag of fluid should
not be left attached to the syringe.
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MDA/2007/089
Action:
 Where appropriate, consider using IV lines with one-way valves to prevent
backtracking. (Examples of one-way valves are check, non-return or antireflux valves or anti-siphon/anti free-flow valves).

Apply clamps (where available) to lines not in use.

Be aware that needle free connectors are not one-way valves and will
allow back-tracking when connected to IV devices.
Additional in-line filters
Additional in-line filters should be reserved for use by those patients who are
immunodeficient, immunocompromised and/or those receiving multiple infusions
with many additives such as ITU patients, currently they are not used in the Trust
for these patients. Certain specialist medications may require that a filter be
used. It is however considered good practice to use in-line filters on all
administration sets for neonatal patients, currently they are used on central
lines and total parenteral nutrition.
Air Inlets
Use only approved single use ‘air inlet needles’ in infusion bottles to prevent the
contamination of IV fluids by the influx of air.
7.3. Changing equipment (see also PVC policy)
 Primary and secondary administration sets should be changed after 72
hours (RCN 2005) and immediately upon suspected contamination. N.B.
The administration (giving set) line MUST be labelled with the set up
date and time.
 An infusion bag where a medication has been added and its
corresponding administration line must be discarded within 24 hours.
 The primary administration set change should be at the same time as
peripheral cannulae change and or starting of new solutions. The
secondary administration set change should be at the same time as the
primary administration set and or starting of new fluids.
 If there is a break in the intravenous circuit, all parts must be changed.
 The type of solution used must dictate whether the administration set be
changed more frequently e.g. A line used for blood must be changed after
12 hours or at the end of the transfusion.
 Once a secondary administration set is detached from the primary
administration set it must be discarded e.g. secondary antibiotics.
 Primary intermittent administration sets should be changed every 24
hours if remaining connected to device or discarded after each use if
disconnected.
 Changing of add-on devices such as, but not limited to, extension sets,
filters, stopcocks, and needleless devices should coincide with the
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
changing of the administration set and no longer than 72 hours in line with
the original cannula insertion.
Any time an injection access site is removed from a vascular device, it
should be discarded and a new sterile injection access site should be
attached
7.4. Needles used to draw up and inject IV medications
The practitioner must use the smallest gauge, shortest needle that will
accommodate the prescribed therapy.
 For ease of reconstitution and drawing up, 21G (green) needles should be
used.
 Orange needles (25G) for aspiration from rubber bung vials
 Orange needles for glass ampoules is recommended by pharmacy, unless a
filter needle is supplied by the manufacturer.
 New 23G (blue) needles must be used when injecting medications into a bag,
bottle or burette and must be discarded after each entry through a rubber
bung or latex.
Neonates: When drawing up medications from glass ampoules ‘filter needles’
are advocated to minimise the risk of injecting glass particles into patients, if
unavailable, use orange 25G needles.
7.5. Syringes
Only use syringes that are manufactured for intravenous use
7.6. Disposal of equipment
This must be done according to Trust waste disposal policies.
7.7. Management of IV fluids and IV patency
Preparation of an intravenous infusion
The nurse must have completed the sodium chloride Patient Group Direction
(PGD) to give an unprescribed flush. PGDs are located on the intranet.
Choosing the administration set
Choose the correct administration set for the IV fluid/medication in conjunction
with patient’s age, condition and care setting. A new administration set must be
used after giving blood.
N.B. For neonates and paediatrics fluids must be infused via an infusion
devices due to the need for pressure monitoring and rapid occlusion
alarms and prevention of overload of fluids.
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Features of specialist administration sets
Set
Use mainly for Feature
Blood
Red cells
with a
administration Fresh Frozen
170mm filter
set
Plasma
Cryoprecipitate
Platelet
Platelets (blood Shorter
administration giving set can
length than
set
be used if
blood giving
necessary)
sets.
Set with
Paediatrics &
Burette
burette
Neonatal
(& elderly with
heart failure)
Straight line
Paediatrics
administration
sets
Straight line
with filter
Reason
To avoid aggregate formation
(BCSHBTTF1999).
To avoid aggregate formation
(BCSHBTTF1999).
Prevents over-infusion of large
volumes of fluid.
Also permits medication
administration as can mix
medications in chamber to
allow slow administration.
In line filter
Intravenous infusion administration set drip rates
Ensure the correct drip rate/administration set is chosen some rates are:
 Standard administration set – 20 drops/ml
 Blood administration set – 15 drops/ml (refer also to Blood Transfusion
Policy)
 Burette – 60 drop/ml
N.B. There are specialist calculations for neonatal areas.
Priming and connecting an infusion set
Use Clinicalskills.net - Intravenous therapy: Priming an infusion set (includes
connecting) according to the ANTT guideline for preparation and administration
of IV medications.
To change an existing infusion
The same principles of ANTT and safety apply to changing an infusion as they
do to commencing an infusion.
Therefore follow the principles for priming and connecting an infusion set in
clinicalskills.net according to the ANTT principles and remembering to:
 Close the roller clamp on the administration set prior to the change over
 Remove old infusion from stand & pull out administration set, taking care not
to contaminate spike.
 Insert the new bag of fluid and adjust roller clamp to the prescribed rate and
place on the infusion stand.
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 Dispose of the previous infusion set etc. as per Trust waste disposal polices
and complete any related documentation.
Flushing technique
Use Clinicalskills.net - Intravenous therapy: Care of a peripheral intravenous
cannula
Flushing solution and frequency before and after medication administration
Medications given by intermittent infusion and/or bolus/push will require the
cannula to be flushed prior to (to check for patency) and after (to prevent
mediation interactions in the line) administration according to the ANTT
principles. See Clinicalskills.net: Injections - Intravenous and Intravenous
cannula for flushing technique.




Adult patients: The required amount is 5ml before and after or 5mls between
each medication administered peripherally
Paediatric patients: (one month to 16 years) - use Patient Group Direction for
flushes available on the paediatric wards.
Neonatal patients: Use 0.6 ml to flush before and 0.6mls after giving
medication. After blood transfusion up to 1 ml to clear the line.
N.B. Specialist lines may require different amounts – check individual
policies.
ALERT! Amount and frequency may vary with paediatric and neonatal
patients. Refer to paediatric or neonatal formulary and physician caring for
the patient.
ALERT! Certain medications may require an alternative flushing agent
e.g. glucose. The clinical pharmacist will notify ward/prescribing doctor if
this is the case.
7.8.
Administration of intravenous medications and fluids
7.8.1. Common principles for intravenous medication administration
Resources
Use the following to provide guidance when reconstituting / administering
intravenous medications/fluids:
 Trust IV Administration Medusa ,
 British National Formulary (BNF),
 Children’s BNF / Neonatal Formulary
 Accompanying manufacturer’s literature
 Medication information department in the pharmacy / on call pharmacist
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 Prescriber
Preparations in advance / medication labels
A medication being prepared in a syringe should ideally be prepared immediately
prior to use by the person who is going to administer it and must not be prepared
in advance of its immediate use.
Practitioner’s must only prepare medications or IV fluids for one patient at a time.
If more than one medication is being prepared for administration to the patient
each should be identified with a medication additive label that is timed and
dated.
Where medications need to be prepared in advance for emergency use, a
national standard labelling system should be used and the following information
included on the label: Approved/generic name of the medication, strength of the
medication in mg/ml or international units (IU)/ml, route, dosage, diluent, and
final volume, the patient’s name, the expiry date and warnings where applicable
and name of practitioner preparing the medicine. The syringes should be easily
accessible but stored away from the immediate work area.
The practitioner should not administer a medication he/she has not prepared,
unless when taking over the care of a patient receiving medications via
continuous infusion. In this case he/she must ensure that the container is clearly
labelled to show contents, date and signature and the prescription chart is signed
and dated. In addition the person who assumes responsibility for the care of the
patient must satisfy themselves that the medication is being delivered as
prescribed.
For paediatrics at handover of care:
 Double check the infusion rate and total volume to be infused with the
registered nurse taking over care (NPSA Aug 2010)
 For infants receiving dextrose infusions check the most recent blood
sugar level is within acceptable limits in accordance with the clinical
management plan.
 Ensure that all discontinued infusions have been disconnected from the
infant/child.
Cannula patency prior to medication
Cannula patency must be checked prior to the administration of medications, by
flushing.
Medication interactions / Compatibilities / Stabilities
 Staff should have a thorough knowledge of medication interactions and
consider whether the compatibilities of chemical, physical and prescribed
medicines will or may dangerously interact with each other.
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 Always adequately flush, with appropriate flush between each medication to
prevent incompatibilities from occurring
 Ideally medications should be administered through separate devices (multi
lumen needleless system) to prevent medication interactions
 Critically ill patients may have limited venous access and require multiple
intravenous medication therapy, in these situations medications may be given
through the same device if they are known to be compatible, providing they
are adequately and appropriately flushed between medications as above.
 There are several factors affecting medication stability but the commonest
are light, temperature, concentration and pH, observe for medications that do
not mix correctly and seek help from a pharmacist.
7.8.2. Checking procedure / five rights
IV fluids and medications must be checked and signed3 by two
practitioners one of whom should also be the registrant with relevant
competency who then administers the intravenous medication, the other
must be competent to undertake the check.
N.B. The person undertaking the administration must sign after the fluid or
medication has been commenced delivered.
In paediatrics / neonates one of the nurses must be paediatric trained.
In maternity for administration to newborns one must be a midwife.
In the following situations a second nurse/ eligible practitioner must check
sign and witness all aspects of IV medication administration:
 Administration to children under 16 years of age including neonates
 Administration of controlled medications
 Administration of any medications requiring calculation or weight related
doses
 Reconstituting (i.e. mixing of any two items)
 Blood transfusion (see Trust Blood Transfusion Policy)
 Chemotherapy
N.B. Packaging and names of products may be similar – check carefully
1
Right
patient
2
Right
Checking procedure – the five rights
(Clayton cited in Dougherty and Lamb 1999)
 Positive identification – confirm with the patient and
check the name band for name, hospital number & date
of birth
 Ensure correctly prescribed using generic name (not
3
The second practitioner is only signing to say that they have checked the prescription, drug and
any relevant calculation and not the administration.
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medication

3
Right dose

4
Right
Time
Right route

5


trade), and no abbreviations, legible.
Prescription must include patient’s name, hospital
number, name of medication, strength, dose, route,
frequency, and timing of administration
Dose must be clearly written using recognised
abbreviations
Timing of IV medication therapy is important in order to
maintain therapeutic levels
The accompanying medication insert/data sheet must
confirm suitability of medication for the prescribed route
If in doubt the clinical pharmacist must be contacted
N.B. Chemotherapy preparation may be prescribed according to body
surface area.
7.8.3.
IV medications requiring special precautions
Certain medications require special precautions during preparation, calculation
and administration, e.g. administration via a flow counter, slow injection,
administration in a specialist area (CCU), paediatrics, neonates or cardiac
monitoring.
7.8.4. Medication/administration set interactions
Some medications are incompatible with the polyvinylchloride (PVC)
administration sets and bags. The medication may become absorbed by the
PVC thus not reaching the circulation. These medications are presented in glass
bottles by the manufacturer.
ALERT!
If the current/previous infusion contains substances that are incompatible
the administration tubing must be changed and the IV cannula must be
flushed
7.9.
Procedures for intravenous medication administration
This section will describe principles in addition to the Clinicalskills.net procedures
for giving intravenous medications via three basic methods:
 continuous
 intermittent infusion
 bolus/push
7.9.1.
Administration of intravenous medication by continuous infusion use clinicalskills.net “Priming and connecting an infusion set”
Examples of continuous infusions are insulin preparations, patient controlled
analgesia, they may be the only intravenous preparation or run concurrent with
an existing intravenous fluid. They may be given via a bag, bottle or burette, or
syringe driver.
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 Follow the steps for clinicalskills.net: Intravenous injections, preparing the
medication as per Medusa / manufacturer guidance.
 Invert the container several times to mix the contents
 Check for discoloration or cloudiness - do not administer discolored, cloudy
solutions or solutions that have not mixed correctly.
 Complete medication additive label and fix to bag, burette or syringe driver.
 If the medication is in a bag, stop the existing infusion, connect the bag /
medication on a flat surface and restart the infusion checking for
compatibility.
 If the medication is to be a new primary or a secondary infusion follow
guidance as per Clinicalskills.net Priming and connecting an infusion set,
remembering to check the patency and flush the cannula, stopping the
infusion prior to connecting and then re-starting and adjusting to deliver the
dose prescribed.
 If connecting to an existing infusion ensure that the new medication/infusion
and existing infusion are compatible and that the intravenous fluid is running
freely (cannula patent). If compatible and cannula patent the new
intravenous infusion can be connected.
 Ensure that the patient is monitored throughout the infusion.
 If more than one IV fluid is connected to a single cannula use a multi-lumen
one way valve extension set to prevent back flow.
7.9.2. Administration of intravenous medication by intermittent infusion
Examples of intermittent infusions can be metroniadazole (prepared fluids in
bags) and Vitamin B12 they may be the only intravenous preparation or run
concurrent with an existing intravenous fluid. They must be delivered through a
(multi-lumen) needleless system.
 Follow the steps for clinicalskills.net: Intravenous injections, preparing the
medication as per Medusa / manufacturer guidance.
 If a fresh administration set (giving set) is being used for the administration of
medications via intermittent infusion it should be primed with infusion mixture
prior to it being hung on the infusion stand.
 Use the same principles / methods as for continuous infusions above
 When the infusion is complete it should be stopped, disconnected and the
cannula flushed.
 Close all clamps prior to the removal of an administration set from the
infusion device
7.9.3. Administration of IV medication by bolus or push - use
Clinicalskills.net: Intravenous injections (Intranet)
This is where a medication is prescribed, prepared for immediate use and
administered to the patient in one delivery according to the manufacturer’s
guidance.
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 Follow the guidance – injecting a bolus intravenously without intravenous
infusion (clinicalskills.net).
7.10. Monitoring of the patient
The patient must be monitored hourly and more frequently if required throughout
intravenous therapy for:
 Clinical signs of desired treatment effect
 Change in vital signs
 Check blood sugar level within one hour of start of dextrose infusions, and
subsequently in accordance with the clinical management plan.
 Discomfort at the insertion site / localized reactions. Neonate, babies and
children should be observed for signs of discomfort. Checks should
be recorded on the intravenous chart.
 Systemic reactions, vomiting or rash.
 If infant/child deteriorates, consider the possibility of fluid overload
alongside other potential causes.
7.11. Monitoring of the intravenous fluids / medications
The infusion should be checked to ensure:
 The fluid is running at the prescribed rate
 The contents of the previous medication infusion prescription have been
completed.
The frequency of checking must be dependent upon the condition of the patient
and the infusion / medication being given.
7.12. Documentation
Patient health records must contain the following details as applicable:
General
 Evidence of consent
 Patient or caregiver participation in and understanding of therapy and
procedures.
 Healthcare professional communication regarding patient care and
monitoring / patient’s tolerance of therapy
 Patient’s response to therapy and / or appropriate laboratory tests taken
and results documented.
 Appropriate IV related Care plan
Medication / fluid related
 Type of therapy: medication, dose, rate, time and method of administration.
N.B. Only sign for intravenous infusions or medications when they have
been commenced or given.
 Omission codes on the medication chart, writing the reason for none
administration in the patient health records
 Diagnosis, assessment and monitoring of vital signs.
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 Complications and side-effects of infusion therapy – and actions following a
complication – detailing the patient’s condition, proposed/advised action and
the evaluated response to treatment in the patient’s health records.
 Discontinuation of therapy
 Positive and negative effects of the medicine/s administered should be
recorded and made known to the prescribing medical practitioner and clinical
pharmacist.
 Accurate fluid balance by recording input and output on a fluid balance chart.
7.13
Local and systemic complications of intravenous therapy
The situations outlined below require rapid management and immediate referral
to the medical team. If the resuscitation is required the team should be called.
For children and babies the parents/guardians should be informed as soon as
possible.





Speedshock / fluid overload
Allergic reactions
Pulmonary embolism
Air embolism
Haemorrhage
See PVC policy for
 Intravenous device infections
 Phlebitis
 Thrombophlebitis
 Occlusion
 Infiltration (tissuing) and Extravasation*
 Haematoma
* If Extravasation is suspected, treatment should be determined prior to the
cannula removal. In addition to urgent medical aid being called, the (on call)
pharmacist should be called and referral made to plastic surgeons’ at the Royal
Free, who will advise on further treatment. An extremity should not be used for
subsequent vascular access device placement. In neonates there is an
extravasation protocol in the neonatal guidelines on the ‘T’ drive.
7.14. Intravenous medication and fluid calculations
All new staff must undertake the administration of medications competency
(which requires them to have done a calculations test).
Refer to Trust calculations workbook and clinicalskills.net they give worked
examples for key calculations.
Call the pharmacist (on call) if unsure of medication / fluid calculation.
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Ask the prescriber if unsure.
7.15.
Infusion Devices
Introduction
All infusion devices must be used in accordance with the medical devices policy.
Infusion devices affect the delivery of fluids / medications so that they are
delivered at a constant, accurate rate in order to achieve a therapeutic response
and prevent complications such as over- or under-infusion. Infusion device
errors are serious and potentially fatal, with human error being implicated in the
majority of incidents involving infusion devices and syringe pumps. Infusion and
syringe pumps are considered high risk in the medical devices management and
training policy.
Using infusion devices
 Only Trust approved devices should be used.
 Practitioners responsible for monitoring the patient with a device must
have completed the relevant medical devices competency and nursing
infusion or syringe pumps competency.
 If an error occurs both the device and infusion should be stopped – the
patient should be treated according to the clinical features and the doctor
caring for the patient must be contacted immediately, the device should
be sent to EBME / Seimens to be checked.
 Only the recommended or designated administration set should be used
in electronic infusion devices
For children under 16 years and neonates:
 All intravenous fluids must be administered via a flow control device as
fluids and medications administered to children and neonates necessitate
precision and flow at a constant rate.
 Neonates - hourly pressure readings must also be recorded on fluid
balance charts.
 Syringe pumps should be used for the intermittent administration of
intravenous medications. The syringe pump should have a variable
pressure facility and be able to accommodate different sizes of syringes
for accuracy of medication dosage in children (Dougherty and Lamb
1999).
Documentation
It is recommended that the following information is recorded: date and time that
the infusion started, expected completion time, route, device serial number, rate
setting, volume to be infused, total volume infused, volume remaining, checks of
infusion site and indication of any reason for alteration (MDA 2003).
Neonates - hourly pressure readings, site checks and infusion rates must be
recorded on fluid balance charts.
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Paediatrics – Hourly site checks and infusion rates must be recorded on fluid
balance charts and a running total of input collated.
8.
8.1.
MONITORING COMPLIANCE
Process for monitoring compliance and effectiveness
Risk management and incident reporting
The following situations require incident reporting using Trust IR1:
 A medication error e.g. wrong patient, wrong medication, wrong dose, wrong
route, wrong time, over or under dose.
 An equipment failure or medication problem that involves a patient
 Complications / patient safety incidents as described in section 6.
In addition report all complications of intravenous therapy to the medical clinician
caring for the patient.
8.2. Standards / key performance indicators
 Practitioner’s performance and learning needs should be evaluated through
the competency framework and/or through their annual appraisal.
 The practitioner should be referred to the relevant module of the Trust’s IV
education and training programme if learning needs are identified.
 Directorates are responsible for reviewing, evaluating medication related
incidents through their clinical governance structures. They must in addition
develop action plans to resolve any deficits issues and ensure adequate
follow up. They must escalate any concerns appropriately e.g. Medical
device related to medical devices committee. Medication related incidents
are also reviewed by the Medicines Safety Committee.
Audit – The intravenous nurse specialist will undertake yearly audits in line with
NPSA and Saving Lives. Reports will be fed back to the Nursing and Midwifery
Group and the Directorates for local action.
8.3. Education and Training Standards
See section 4.5 for specific training requirements.
Nurses and midwives undertaking the administration of infusion therapy will have
undergone theoretical and practical training in the following aspects:
 Legal, professional and ethical issues.
 Fluid balance and blood administration.
 Calculations related to medications.
 Pharmacology and pharmaceutics related to reconstitution and
administration.
 Local and systemic complications.
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





Infection control issues
Use of equipment, including infusion equipment.
Medication administration.
Risk management/health and safety
Care and management of vascular access devices.
Infusion therapy in specialist areas covering separately (paediatrics,
oncology, parental nutrition, transfusion therapy) (Delisio 2001 cited in RCN
2005)
9.0.
REFERENCES, LITERATURE SEARCH AND CRITICAL APPRAISAL
9.1. References
The reference list will be in a table with SIGN grading see example below
Papers graded for evidence using SIGN tool
Clinicalskills.net. (Trust Intranet)
Department of Health (2007). Saving Lives: reducing Infection,
delivering clean, safe care.
Royal College of Nursing (2010) Standards for infusion
therapy. [online] London. RCN. Available from
http://www.rcn.org.uk [Accessed 15th November 2010]
National Patient Safety Agency (NPSA) 2010 Prevention of
over infusion of intravenous fluid and medicines in neonates
NPSA/2010/RRR015
http://www.nrls.npsa.nhs.uk/alerts/?entryid45=75519 [Accessed
3rd March 2011]
Nursing & Midwifery Council (2008) Standards for mediceines
management. [online] London: Nursing & Midwifery Council.
Available from http://www.nmc-uk.org [Accessed 28th June
2009]
Nursing & Midwifery Council (2009) Record Keeping: Guidance
for nurse and midwives [online] London: Nursing & Midwifery
Council Available from http://www.nmc-uk.org [Accessed 28th
June 2009]
Pratt R. J., Pellowe C. M., Loveday H.P., Harper P. J., Jones
S.R.L.J., McDougall C., Wilcox M.H. (2007) Epic2: National
evidence-based guidelines for preventing healthcare associated
infections in NHS Hospitals in England. Published / printed by
The Hospital Journal of Hospital Infection. DH.
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BCFH Trust
Level of
evidence
1V
IV
1V
IV
1V
1V
1V
Page 23 of 33
9.2. Literature search
This clinical guideline has been revised in line with RCN Standards for infusion
therapy (2010), and NPSA alert re over infusion in neonates.
9.3. Critical appraisal
Critical appraisal of evidence was not applicable due to the inclusion of the
above document.
10.0
ASSOCIATED DOCUMENTATION
10.1. To be read in conjunction with
 Administration of medicines clinical guidelines
 Aseptic no touch technique (ANTT) policy
 ANTT guideline for preparation and administration of IV medications
 Blood Transfusion Policy
 Clinicalskills.net (on the intranet)
 Central Venous Pressure (CVP) policy
 Consent
 Hand hygiene policy
 Haemodialysis policies
 Infection control policies
 Intravenous and Intra-arterial surgical cutdown site
 Intravenous conscious sedation
 Intravenous immunoglobulin therapy
 Medical devices management and training policy
 Neonatal and Paediatric Protocols
 Oncology and chemotherapy
 Patient controlled analgesia
 Peripheral vascular device policy
 Total parenteral nutrition policy (as this can be delivered intravenously)
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Appendix 1
Launch Plan
The policy will be launched on the intranet and advertised through the Newsmail / Team brief
The policy will also be distributed to the Matrons to ensure dissemination within their
Directorates.
Directorate leads, and their colleagues are responsible for dissemination.
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Appendix 2
Barnet and Chase Farm Hospitals NHS Trust
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Appendix 3
Barnet and Chase Farm Hospitals NHS Trust
Equality Impact Assessment First Stage Screening Template (Draft until EIA ratified)
To be completed and attached when submitted to the Equality Impact Assessment Panel for consideration and
recommendation. EQUALITY SCREENING TOOL – Intravenous fluids and medications administration clinical
guideline
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The Equality Act 2010
9 Protected Characteristics
Does the content
of the policy have
an impact that
affects any group
of patient/staff in
any of the 9
Protected
characteristics?
Comments (state any evidence
available that helped you to answer
the “Yes or No” question)
Is it relevant?
Yes or No
 Age
No
 Disability
Yes
 Gender Reassignment
No
As above
 Marriage / Civil Partnership
No
As above
 Pregnancy / Maternity
No
As above
 Race, Nationality, Culture, Ethnic
origins (including gypsies and
travellers)
Yes - Possible
negative impact
overcome by…
Race, ethnicity, nationality and culture are
relevant where they affect language and
communication however the Trust has in
place an, interpreting service, that covers
for example interpreters and language
line for emergencies, this is a service
issue not an issue specific to the delivery
of this clinical guideline.
 Religion or Belief
No
The clinical guideline’s primary purpose is
safety therefore religion or belief not an
issue
 Sex (Gender)
No
The clinical guideline’s primary purpose is
safety therefore sex (gender) is not an
issue
 Sexual orientation including
lesbian, gay and bisexual people
No
The clinical guideline’s primary purpose is
safety therefore there is no impact for
sexual orientation including lesbian, gay
and bisexual people
2.
Have you identified any
potential discrimination, or
are any exceptions valid, legal
and/or justifiable?
No
3.
Is the impact of the policy
likely to be negative on
patient/ staff?
No
1.
Intravenous fluids and medications March 2011
The clinical guideline takes account of
body size and physiological differences
for safety reasons not for discrimination
If a patient’s disability affects their
communication, practitioners should
enlist the use of the interpreting services
to aid understanding. The interpreting
services cover signing for Braille and
touch signing for deaf blind. Clinical
areas should enlist the Learning needs
liaison nurse and use the range of books
/ prompts / interpreting aids for patients
with learning disabilities or confusion.
BCFH Trust
Page 28 of 33
4.
What alternative steps can be
taken to avoid any detrimental
impact identified?
N/a
State if this policy will be proceeding to a full impact assessment: Please tick as appropriate –
Yes
□
No 
If you have identified any potential discriminatory impact of this procedural document, please refer it to the Equality Impact Assessment Panel,
together with any suggestions as to the action required to avoid/reduce this impact.
For further information or support, please contact Yemisi Oluyede, Associate Director of HR – Workforce Health on ext 2699, to whom this form
should also be returned. If you have indicated in the 9 protected characteristics that they are relevant to the policy and they are more than 2
areas then proceed to a full impact assessment.
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Equality Impact Assessment: Partial Equality Impact assessments
Person responsible for the assessment: Intravenous Therapy Group
Name of policy to be assessed
EIA Panel Members:
Intravenous fluids and medications
Date of
administration clinical guideline
assessment
Yes but revised Is this a full equality
Yes to applicable
Is this a partial equality
areas
impact assessment?
impact assessment?
The aim of the guidance is to provide clear guidance to ensure evidence based safe practice. Where patients
cannot understand English or have a communication difficulty e.g. deaf or person has learning disabilities their care
may be affected as they may not fully co-operate with the care required, this could lead to adverse outcome.
Harm free care for patients
Existing Policy
(delete as appropriate)
1. Briefly describe the aims,
objectives and purpose of the
clinical guidelines
2. Are there any associated
objectives of the policy? Please
explain
Patients to prevent harm in relation to intravenous therapy
3. Who is intended to benefit from
this clinical guidelines, and in
what ways?
Harm free care for patients
4. What outcomes are wanted from
the clinical guidelines?
The clinical guidelines not being applied in practice
5. What factors/forces could
contribute/detract from the
outcomes?
6. Who are the main stakeholders in Clinical staff who undertake an intravenous therapy role and patients
relation to the clinical
guidelines?
The intravenous therapy group
7. Who implements the policy and
who is responsible for the
clinical guidelines?
RCN National associated documents and Consultation through Directorates, Matrons, ward managers.
8. Name the internal and external
groups and experts who have
been consulted:
9. Are there concerns that the
Possible negative
Please explain: Race, ethnicity, nationality and culture are relevant where they affect language and
communication. However the Trust has in place an, interpreting service, which covers for example
clinical guidelines could have a
interpreters and language line for emergencies, this is a service issue not an issue specific to the
differential impact on some racial
delivery of this clinical guideline.
groups?
No evidence, but it is possible that patients who do not understand English, may suffer more
10. What evidence (presumed or otherwise) do you have
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for this?
11. Are there concerns that
Positive impact
the policy could have a
differential impact due to
gender reassignment,
including transgender?
12. What evidence (presumed or otherwise) do you have
for this?
13. Are there concerns that
Possible negative
the policy could have a
differential impact due to
disability?
14. What evidence (presumed or otherwise) do you have
for this?
15. Are there concerns that
Positive impact
the policy could have a
differential impact due to
sexual orientation?
16. What evidence (presumed or otherwise) do you have
for this?
17. Are there concerns that
Positive impact
the policy could have a
differential impact due to
sex?
18. What evidence (presumed or otherwise) do you have
for this ?
19. Are there concerns that
Positive impact
the policy could have a
differential impact due to
pregnancy / maternity ?
20. What evidence (presumed or otherwise) do you have
for this ?
21. Are there concerns that
Positive impact
the policy could have a
differential impact due to
Intravenous fluids and medications March 2011
BCFH Trust
pain on insertion due to inadequate explanations. They may also not receive or misinterpret
key information to prevent a cannula related infection.
Please explain: It is intended to have a positive impact for all patients to prevent harm
Please state evidence:
Please explain: If a patient’s disability affects their communication, practitioners should
enlist the use of the interpreting services to aid understanding. The interpreting services
cover signing for Braille and touch signing for deaf blind. Clinical areas should enlist the
Learning needs liaison nurse and use the range of books / prompts / interpreting aids for
patients with learning disabilities or confusion.
Please state evidence:
Please explain: It is intended to have a positive impact for all patients to prevent
harm
Please state evidence:
Please explain: It is intended to have a positive impact for all patients to prevent harm
Equality and Diversity Policy
Please explain: It is intended to have a positive impact for all patients to prevent harm
Maternity Guidance
Please explain: It is intended to have a positive impact for all patients to prevent harm
The clinical guideline has very specific instruction for different age groups.
Page 31 of 33
age?
22. What evidence (presumed or otherwise) do you have
for this?
23. Are there concerns that
Positive impact
the policy could have a
differential impact due to
marriage / civil partnership?
24. What evidence (presumed or otherwise) do you have
for this?
25. Are there concerns that
Positive impact
the policy could have a
differential impact due to
religion or belief?
26. What evidence (presumed or otherwise) do you have
for this?
Please explain:
Please explain: It is intended to have a positive impact for all patients to prevent harm
Equality and Diversity Policy
Please explain: It is intended to have a positive impact for all patients to prevent harm
Please state evidence:
27. Are there concerns that
Positive impact
the policy could have a
differential impact due to
dependents/caring
responsibilities?
28. What evidence (presumed or otherwise) do you have
for this?
Please explain: It is intended to have a positive impact for all patients to prevent harm
29. Are there concerns that
Positive impact
the policy could have a
differential impact due to an
offending past?
30. What evidence (presumed or otherwise) do you have
for this?
Please explain: It is intended to have a positive impact for all patients to prevent harm
31. Could the differential
impact identified in 9-29
amount to unlawful adverse
impact?
Positive impact
Intravenous fluids and medications March 2011
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Please state evidence:
Please state evidence:
All reasonable attempts are made to resolve the problem, as identified above.
It is intended to have a positive impact for all patients to prevent harm.
Page 32 of 33
32. Could the differential
Positive impact
impact identified in 9-29
amount to adverse impact,
which is not unlawful?
33. What evidence (presumed or otherwise) do you have
for this?
34. If there is insufficient evidence in any area, what
further research needs to be commissioned?
If yes, what action/s do you propose to take to mitigate this adverse impact?
Please state evidence:
Please state research needed:
Need to find out if information is collected for racial groups / not understanding English –
emailed Lisa Henderson re cannula acquired MRSA.
N.B. This information is not retained, but numbers of MRSA bacteraemia are low (1-4) so
would statistically insignificant.
35. Involvement and Consultation
36. Decision on the clinical guidelines
37. Other Remarks
38. Actions Agreed
39. Date of Reviewing
40. Signature and Date
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