Department Policy Code: D: MM-5675 Fairview .Department Policy Code: D: MM-5675 Entity: Fairview
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Code: D: MM-5675
Entity: Fairview Pharmacy Services
Department: Fairview Home Infusion
Manual: Policy and Procedure Manual
Category: Home Infusion
Administration of Medications - FHI
Purpose: To provide guidelines for safe administration of medications in the
Policy: I. FHI staff in collaboration determines the appropriate infusion control devices for patient care.
II. Medications will be administered in the home setting using appropriate equipment and technology to ensure patient
safety and to facilitate the achievement of desired outcomes.
Related to Device
I. The Fairview Home Infusion (FHI) Clinical Safety Committee will approve all infusion control devices used for
II. FHI clinicians will evaluate and select the appropriate infusion control device for individual patients; options
include manual, mechanical and electronic devices.
III. The evaluation should include, but not be limited to:
A. Patient age and condition B. Prescribed therapy; mechanical or electronic devices
should be considered for the following :
1. To provide more accurate infusion rate control than gravity or manual mode.
2. To initiate and maintain very high or extremely low rates of flow
3. To give potent drugs at specific and reliable infusion rates
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C. Patient ease of use
IV. Electronic Pump Failure Management A. Should equipment fail, FHI will arrange for a pump to be
delivered to the patients home.
B. If an equipment failure poses immediate danger to the patient a second pump will be in the home to prevent an
interruption in medication administration.
1. Patients receiving continuous inotropes will be sent a back up pump.
2. Patients receiving other therapies (i.e. pain management), or patients living outside the metro
area may fall into this category. The need for a
back up pump will be determined on a case by
V. Upon initiation of a new therapy, or upon changing therapy, the device to be used will be documented in the medical
VI. Staff who select, use or teach patients about infusion devices are knowledgeable about the devices being used.
VII. Manufacturers instructions are followed when using and teaching patients about equipment. Written instructions are
provided to patients and caregivers.
I. See Attachment I for preferred administration methods.
II. Medications are dispensed only after verifying the prescribers order for the medication, the dose, type of access
device, time and duration of administration. Any dose of a
medication that falls outside the manufacturers prescribing
indication, literature citation, or standard of practice in the
community will be verified with the prescriber for accuracy
and supporting documentation that will substantiate the dose
being prescribed. Prior to the dispensing of a medication the
appropriateness of therapy will be assessed. Refer to the
following policies for more information:
A. Patient Care Orders http://intranet.fairview.org/Policies/S_073425
B. Drugs Approved for Home Administration http://intranet.fairview.org/Policies/S_072892
C. Assessment & Reassessment http://intranet.fairview.org/Policies/S_074437
D. Medication Reconciliation
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III. Prior to the administration of a medication the medication label will be verified by checking the patients name, drug,
dose, route, solution, time and duration of infusion,
expiration date. Any questions regarding the accuracy of the
information on the label will be resolved with the pharmacist
prior to administration.
IV. The Infusion pump program must be verified for accuracy prior to dispensing.
No pump will be reprogrammed in Lock Level 0 by a
patient or caregiver. (Lock Level 0 permits complete access
to all programming and other operating features).
A. All parenteral pumps will be programmed and reviewed by two (2) clinicians after the pump has been locked. Clinicians
will verify the pump program using the pump programming
verification record/ Prescription Form printed from CPR+.
If a second clinician is not available, the same clinician must
check the pump program twice, with at least 5 minutes time
elapsing between checks.
B. Any pump program changes while a pump is in the home must be done by a clinician in the home, and verified by an
office clinician via telephone. This must be documented in
the Clinical Record.
C. If a clinician is not in the home, a newly programmed pump, with pump programming verification record (if sent from
FHI office), will be sent to the patients home.
D. Patient/caregiver may titrate pain medication dose in Lock Level 1 (if order/program includes titration) over the phone
if previously instructed. Refer to Pain Management policy
V. Visually inspect all medications prior to use. No medication should be given that is cloudy, or contains precipitates. All
medication shall be used and discarded according to the
directions on the medication label.
NOTE: Once opened, multi-dose vials of heparin and saline
shall be dated, stored in the patients refrigerator, and
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discarded if not used within 28 days.
VI. Observe instructions provided by the pharmacy for proper use, storing and handling of drug and solution containers.
Administer medications at room temperature whenever
VII. Pediatric patients require special consideration. Refer to policy: Pediatric Home Infusion Therapy
VIII. Filters of appropriate size will be used as indicated by the patients condition, prescriber order, pharmaceutical practice
and/ or as recommended by the manufacturer.
I. CONNECTION, PRIMING, DISCONNECTION
A. Select Necessary Equipment
1. Prescribed drug or solution
2. Intravenous administration set, if applicable (with appropriate size filter if indicated by drug therapy)
3. Alcohol swabs
5. Normal saline-filled syringe
6. Heparin filled syringe, if applicable
7. Infusion device, if applicable
B. Administer Medication
1. Wash hands and don gloves.
2. Prepare administration supplies aseptically; prime tubing, spike fluid container, etc. as indicated by infusion method
and by manufacturer directions.
3. Cleanse catheter end cap with alcohol swab for 15 seconds and allow to air dry completely prior to each
4. Flush catheter with normal saline to establish patency of the IV access device per protocol. See policy Access
Device Management, General Policies for flushing
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5. Cleanse catheter end cap. Aseptically attach administration set or syringe to access device. Regulate
infusion or activate infusion device to deliver
medication/solution. Never infuse more than one
medication or parenteral solution via the same
6. When infusion has completed, disconnect infusion device/tubing and discard expended supplies in
7. Cleanse catheter end cap. Flush catheter with normal saline and/or heparin per policy.
8. Remove gloves, dispose in appropriate receptacle and wash hands.
II. ADMINISTRATION SETS
A. Administration sets shall be changed utilizing aseptic technique immediately upon suspected contamination or
when the integrity of the product has been compromised.
B. Intermittent and Cyclic Therapy
1. Change administration sets with each dose for therapies provided on an intermittent basis (e.g., anti-infective
therapy) unless otherwise ordered by the physician.
2. Change administration sets every 24 hours for cyclic TPN and IV hydration administration.
C. Continuous Therapy
Change administration sets at the following frequencies for
therapies provided on a continuous basis, unless otherwise
ordered by the physician:
1. Administration sets utilized for TPN and IV hydration every 24 hours.
2. Administration sets for all other therapies (pain management, inotropes, anti-infective therapy)
administered via an electronic infusion pump must be
changed at least every 7 days. Refer to medication label
for frequency of cassette/bag change; tubing must be
Code: D: MM-5675