What protocols and policies are in place for the safe administration of IV therapy?

Comprehensive IV Therapy Protocols and Policies Required for Safe Practice

You must establish written, accessible protocols covering every aspect of IV therapy administration—from preparation through emergency management—as verbal knowledge or general policy statements are insufficient for regulatory compliance and patient safety. 1

Critical Documentation Gaps Requiring Immediate Attention

1. Standardized Formulations and Administration Protocols

You need written protocols specifying exact reconstitution procedures, dilution ratios, infusion rates, and hang times for each IV formulation you offer. 1

• Preparation specifications must include: specific diluent volumes, final concentrations, compatibility data, and step-by-step mixing instructions for each formulation 1
• All IV admixtures must be prepared in a laminar-flow hood using aseptic technique, with documentation of who prepared each solution, when, and where 1
• Single-dose vials are strongly preferred; never combine leftover contents from single-use vials for later use 1
• Lipid-containing solutions must be completed within 24 hours of hanging; lipid emulsions alone within 12 hours 1
• Standard IV solutions (dextrose/amino acids) require administration set replacement every 72 hours unless infection is suspected 1

2. Patient Selection Criteria (Inclusion/Exclusion)

Written inclusion and exclusion criteria must specify which patients are appropriate candidates for each IV therapy offered. 1

• Pre-administration screening must document: complete medical history, current medications, prior allergic reactions, vital signs (blood pressure, heart rate, respiratory rate, temperature), and assessment of venous access 1
• Absolute contraindications must be clearly listed for each formulation, particularly for patients with relevant allergies, organ dysfunction, or medication interactions 1
• A standardized checklist template should be incorporated into your charting system to ensure consistent documentation of all screening elements 1

3. Emergency Management Protocols Beyond Anaphylaxis

While your anaphylaxis plan is adequate, you need written protocols for managing other IV-related emergencies including extravasation, phlebitis, catheter-related infections, and infusion reactions. 1, 2, 3

Anaphylaxis Protocol Enhancement:

• Verify emergency medications are immediately accessible (not locked away), including: epinephrine 1mg/mL for IM injection, diphenhydramine 50mg IV, ranitidine 50mg IV, methylprednisolone, normal saline for fluid resuscitation, and oxygen 1, 2
• Establish a formal medication expiry review schedule (recommend monthly checks with documentation) and assign responsibility for this task 1
• Epinephrine dosing must be 0.01 mg/kg IM (maximum 0.5mg) into lateral thigh, repeatable every 5-15 minutes 1, 2
• Document the specific positioning protocols: Trendelenburg for hypotension, sitting upright for respiratory distress, recovery position if unconscious 1, 2

Additional Emergency Protocols Needed:

• Extravasation management: immediate cessation of infusion, aspiration of residual drug, application of hot/cold compresses depending on vesicant type 1
• Phlebitis/infection management: immediate catheter removal, site inspection, culture if indicated, hand antisepsis protocols 3
• Mild-moderate infusion reactions (Grade 1-2): stop infusion, switch to hydration fluid, administer antihistamines and antiemetics as needed, monitor for 15 minutes before considering rechallenge 2

4. Infection Control and Aseptic Technique

Your infection control procedures must be explicitly written with step-by-step instructions, not just referenced as "covered elsewhere." 1, 3

• Hand hygiene protocol: alcohol-based hand rub or antiseptic soap before and after every patient contact and IV manipulation 3
• Skin preparation: use 0.5-2% alcoholic chlorhexidine solution and allow complete drying per manufacturer recommendations before catheter insertion 3
• Injection port cleaning: wipe with 70% alcohol or iodophor before every access 1
• Catheter site assessment: daily palpation through dressing for tenderness; visual inspection if transparent dressing used 1
• Peripheral catheter replacement: at least every 72-96 hours in adults, or immediately if signs of phlebitis/infection 3
• Needleless component changes: at least as frequently as administration sets (every 72 hours); caps changed every 72 hours or per manufacturer 1

5. Medication Storage and Handling

You need written policies specifying storage conditions, temperature monitoring, and handling procedures for all IV medications and supplies. 1

• Document specific storage requirements: refrigeration temperatures, room temperature ranges, light protection needs for each medication 1
• Establish temperature monitoring protocols: frequency of checks, acceptable ranges, documentation method, and corrective actions for deviations 1
• Inspect all parenteral fluids before use: reject any container with visible turbidity, leaks, cracks, particulate matter, or expired dates 1
• Diluted epinephrine solutions can be stored for up to 4 hours at room temperature or 24 hours refrigerated 4

6. Consent Form Corrections

Your consent form requires immediate revision to remove template errors and unnecessary PHI release language. 1

• Remove all references to other facility names (you noted "[LOCATION]" appears multiple times—this must be corrected to your actual facility name)
• Eliminate the four PHI release options (referral, quality improvement, etc.) and replace with simple statement: "We are committed to privacy and all information will remain in the confidential chart following rules governed by [STATE] Health Information Act and [STATE] law"
• Ensure consent documents: specific risks of the IV therapy offered, alternative treatments, right to refuse, and procedure for withdrawing consent 1

7. Personnel Training and Credentialing

Only designated, trained personnel should perform IV therapy, with documented competency assessments. 1

• Initial training must cover: aseptic technique, catheter insertion, medication preparation, infusion rate calculations, recognition of complications, and emergency management including anaphylaxis 5, 6
• Competency documentation should include: initial training completion, annual skills verification, and remediation when indicated 1
• Scope of practice must be clearly defined in your medical directives, specifying which personnel can perform which IV therapy tasks 1

Common Pitfalls to Avoid

• Do not rely on verbal protocols or "knowledge in your head"—regulatory bodies require written, accessible documentation 1
• Avoid generic policy statements without accompanying procedural details—each policy must have a corresponding procedure showing exactly how compliance is achieved 1
• Never use steel needles for medications that could cause tissue necrosis if extravasation occurs 1
• Do not administer prophylactic antibiotics routinely before IV catheter insertion—this is not recommended and may promote resistance 1
• Avoid using lower extremity sites for IV access in adults—upper extremity sites have lower infection and thrombosis risk 1

Organizational Structure for Your Protocols

Create a master IV therapy manual organized as follows: 1

1. Clinical protocols section: indications, contraindications, patient selection criteria, prescribing guidelines
2. Preparation procedures section: specific formulations, reconstitution steps, dilution protocols, compatibility charts, storage requirements
3. Administration procedures section: catheter selection and insertion, site selection, infusion rates, monitoring parameters, documentation requirements
4. Emergency management section: anaphylaxis, extravasation, phlebitis, infection, other adverse reactions
5. Infection control section: hand hygiene, aseptic technique, site care, equipment handling
6. Quality assurance section: medication expiry checks, equipment maintenance, competency verification, incident reporting

Each section must include: specific step-by-step procedures, responsible personnel, frequency of tasks, documentation requirements, and references to supporting evidence 1