Policy Manual sample

MDT Home Health Care Agency, Inc. 62 PROCEDURE: 1. Check all medications and verify correct name, drug, dose, route, expiration date, patient allergy history, drug incompatibilities and frequency and duration of administration. Notify physician and pharmacist for any discrepancies. 2. Verify all pump programming immediately before initiating the infusion. 3. Inspect medication/solution for clarity, precipitates or potential contamination. 4. Wash hands and explain procedure to the patient and family. 5. Prepare workspace and gather equipment/supplies. 6. Close the flow control clamp on the administration set. 7. Remove protective covering from the solution container port. 8. Remove the protective cover from the spike of the administration set. Be careful not to contaminate the exposed spike. 9. Insert the spike into the solution container port using a gentle twisting motion. 10. Attach needle/access system to the end of the administration set. 11. Invert solution container and hang on IV pole or other hanging device. For gravity administration, the solution container should be at least 12 inches above the level of venous access. 12. Squeeze and release the drip chamber to fill half full with solution. Open the control clamp and hold the end of the needle/access system and administration set below the solution container, allowing the administration set to fill with solution and expel all air. Note: If using an in-line filter set or attaching a 1.2 micron filter to a non-filtered administration set, attach the filter (as applicable), invert the filter and continue filling, clearing of air and/or follow Manufacturer’s guidelines for priming. 13. Close the control clamp. 14. When connecting a primed administration set to the access device: a) Cleanse all catheter end caps with an alcohol swab and allow to air dry completely prior to accessing. b) Establish patency of the IV access device. c) Unclamp catheter, if applicable, and inject normal saline flush solution into the catheter cap if medication is incompatible with solution in the line. d) Remove protective cap from needle/access system at end of administration set. e) Insert needle/access system into injection cap and tape connection to secure placement. f) Verify the infusion parameters set on the infusion device (if applicable). g) Adjust the rate as ordered and open the flow control clamp. 15. When disconnecting the administration set from the access device: a) When the solution container is empty, close the flow control clamp. Turn off the electronic infusion device (if applicable). b) Disconnect the administration set from the catheter end cap. Replace needle/access system on the end of administration set with new cannula for intermittent sets that will be used for additional doses.