/policies/,/policies/clinical/,/policies/clinical/uw-health-clinical/,/policies/clinical/uw-health-clinical/medications-and-pharmacy/,

/policies/clinical/uw-health-clinical/medications-and-pharmacy/618.policy

201612343

page

100

UWHC,UWMF,

Policies,Clinical,UW Health Clinical,Medications and Pharmacy

Administration of Intravenous Medications (6.1.8)

Administration of Intravenous Medications (6.1.8) - Policies, Clinical, UW Health Clinical, Medications and Pharmacy

6.1.8


UW HEALTH CLINICAL POLICY 1
Policy Title: Administration of Intravenous Medications
Policy Number: 6.1.8
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: December 6, 2016

I. PURPOSE

To standardize the administration and monitoring of intravenous medications across all care settings.

II. DEFINITIONS

A. LEVEL I Medications: May be administered on all General Care Nursing Units and Clinics.
B. LEVEL II Medications: May be administered only to patients in monitored telemetry beds.
C. LEVEL III Medications: May only be administered on Intermediate Care Units (IMC) and in Interventional
Radiology. Each IMC area is qualified to administer different Level III medications based on specialty
populations served and clinician experience with administration and monitoring of the medication.
D. LEVEL IV Medications: May be administered on Intensive Care Units, the Emergency Department, Cardiac
Catheterization and Echocardiology Laboratories, Operating Room and Recovery Room, Interventional
Radiology and IMCs may administer selected level IV medications based upon clinician experience with
administration and monitoring of the medication.

III. POLICY ELEMENTS

A. Intravenous medications may be administered by personnel as defined in UWHC policy #8.17,
Administration of Medications, and according to the UW Health Clinical Practice Guidelines “Intravenous
Administration of Formulary Medications-Adult-Inpatient/Ambulatory” or “Intravenous Administration of
Formulary Medications-Neonatal/Pediatric-Inpatient/Ambulatory.”
B. Exceptions to the guidelines may occur in emergency situations when transitioning of patients from a lower
level to higher level of care or when consensus is reached that benefits outweigh risks for a specific patient
by a faculty physician, nurse manager, and pharmacy manager.
C. The administration of chemotherapy is governed by UW Health clinical policy #6.1.1 Chemotherapy
Processes: Informed Consent, Ordering, Verification, Administration, Documentation, and Patient/Family
Education.

IV. PROCEDURE

A. Prior to administration of an intravenous medication, clinicians may use the policy and associated guidelines
to maximize the safety of administration and monitoring of intravenous medications.
B. The UW Health Pharmacy and Therapeutics Committee will assess the level of a given medication as part of
the formulary approval process as well as make an interim update to the associated clinical practice
guidelines.

V. COORDINATION

Author: Manager, Drug Policy Program
Senior Management Sponsor: SVP, CNO and Patient Care Services
Reviewers: Director, Surgical Nursing; Director Nursing Clinics Clinical Support; Director Nursing Operations
Support; Director TAC Overnight Services; Director, Pediatric Nursing; Clinical Nurse Specialist IV Pumps;
Director, Nursing Practice Innovation
Approval committees: Pharmacy and Therapeutics Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: November 21, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL



UW HEALTH CLINICAL POLICY 2
Policy Title: Administration of Intravenous Medications
Policy Number: 6.1.8


Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

UWHC policy #8.17, Administration of Medications
UWHC policy #8.38, UWHC Adult Sedation Policy
UW Health clinical policy #6.1.1, Chemotherapy Processes: Informed Consent, Ordering, Verification,
Administration, Documentation, and Patient/Family Education
UW Health Clinical Practice Guideline Intravenous Administration of Formulary Medications-Adult-
Inpatient/Ambulatory
UW Health Clinical Practice Guideline Intravenous Administration of Formulary Medications-
Neonatal/Pediatric-Inpatient/Ambulatory

VIII. REVIEW DETAILS

Version: Revision
Next Revision Due: December 2019
Formerly Known as: Hospital Administrative policy #8.31