Administration of Intravenous Drugs

Document name: Medicines Code: Administration of Intravenous Drugs Ref.
: 703
Issue date: 11 February 2013 Status: Approved
Author: J ulian Hunt, Geoff Allen and Regina Brophy Page 1 of 33

Medicines Code: Administration of
Intravenous Drugs

Reference Number: 703
Author & Title:
J ulian Hunt, Nurse Consultant
Geoff Allen, Risk Management Pharmacist
Regina Brophy, Chief Pharmacist
Responsible Director: Director of Nursing
Review Date: 6 February 2016
Ratified by:
Mary Lewis
Acting Director of Nursing & Accountable
Officer: Controlled Drugs
Date Ratified: 6 February 2013
Version: 11

Related Policies & Guidelines: All Medicines Code policies

Incident Reporting and Management Policy
and Procedure; Including the Management
of Serious Untoward Incidents

Document name: Medicines Code: Administration of Intravenous Drugs Ref.: 703

Index:

1. Introduction __________________________________________________ 3
2. Definitions and Competencies ___________________________________ 3
3. Summary ____________________________________________________ 5
4. Training and Assessment of Competence _________________________ 7
5. Administration / Recommendations for Safe practice / Checking_______ 8
6. Authorisation of Medicines for IV Administration___________________ 10
7. Unlicensed Medicines / Clinical Trial Medicine _____________________ 11
8. Cytotoxic Therapy ____________________________________________ 11
9. Verbal Orders for IV treatment __________________________________ 12
10. Routes for the Administration of IV Medicines _____________________ 14
11. Potency and Incompatibility of IV medicines ______________________ 15
12. Responsibilities of Clinical Pharmacists __________________________ 16
13. Procedure (See Detailed Guidelines Appendix 4) ___________________ 17
14. Incident reporting ____________________________________________ 19
15. Monitoring and Review ________________________________________ 19
16. References __________________________________________________ 20
Appendix 1: IV Drug Administration Manual Form 1 ___________________ 21
Appendix 4: Detailed Preparation Requirements ______________________ 24
Document Control Information ______________________________________ 31
Ratification Assurance Statement _____________________________________ 31
Consultation Schedule _______________________________________________ 32
Equality Impact: (A) Assessment Screening ____________________________ 33

Amendment History

Issue Status Date Reason for Change Authorised
10 Approved J anuary
2010
Planned Review Operational Governance
Committee
11 Approved 6 February
2013
Planned Review Mary Lewis
Acting Director of Nursing
& Accountable Officer:
Controlled Drugs

1. Introduction

1.1 It is essential that the reader adheres to terms, definitions, and processes as
described both in the Medicines Code Policy and in the other relevant policies
contained in the Medicines Code e.g. Prescribing Policy.
1.2 The purpose of this policy is to inform all practitioners of their responsibility in
the safe and effective administration of intravenous (IV) medicines. The term
IV refers to medicines administered using both peripheral and central
cannulae.
1.3 The Medicines Management Policy lays down clear responsibilities for
individuals in the implementation of the Policy. Failure to comply with the
Medicines Management Policy may be regarded as misconduct and dealt with
in accordance with the Trusts Conduct Procedure.

2. Definitions and Competencies

Any practitioner or member of medical staff who administers IV medicines must
ensure that they are competent to do so as assessed by either their line
manager or professional supervisor. The nature of this assessment will be
determined locally by their line manager or professional supervisor. In addition
they must maintain evidence as part of their continuous professional
development portfolio and are expected to identify any training needs in their
personal development plan.

Practitioner The term practitioner includes medical staff, registered
nurses, midwives, operating department practitioners,
radiographers, cardiology, diagnostic and nuclear medicine
technicians and all practitioners who administer IV
medicines.
Nurse practitioners With nurse practitioners, the RUH nurse IV competence
assessment framework is used
IV Trained
practitioner
A practitioner who has satisfactorily completed the
appropriate training for IV administration
Anaesthetists For anaesthetists, the Royal College of Anaesthetists
Guidelines competence assessment framework is used.
Medical staff Any other medical staff who administers IV medicines must
also ensure that they are competent to do so and maintain
evidence as part of their continuous professional
development portfolio
Medusa Medusa is the name of a UK hospital pharmacy medicines
information collaborative database of IV and IM medicine
monographs. It is available on line and has been customised
for trust-specific information in addition to the standard text.

It contains more information than our current IV monographs
which it will completely replace during 2013
Non-professional
staff
Non-professional staff are doctors assistants, health care
assistants, assistant practitioners to which some of this
policy will apply. This list will be subject to periodic review by
the Medicines Advisory Group
Assistant
practitioners
Non-professional staff employed at Band 4 who provide
support to professional staff.
ANTT Aseptic non-touch technique see trust policy
Double checking This is a method of checking to ensure low risk of error. The
accepted standard is to have two checks. In most instances
independent double checking is where two individuals will
check a medicine separately and then share their calculation
to confirm accuracy. In some instances one individual may
double check, but that person is required to check twice with
a separation in time.
A single check of a medicine for intravenous
administration is not acceptable.
Intravenous Bolus Introduction of a small volume of medicine solution into the
cannula or the injection site of an administration set. A bolus
injection should be administered slowly over 3-5 minutes
unless otherwise specified.
Intermittent Infusion Administration of an infusion over a set time period, either as
a one-off dose or repeated at specific time intervals.
Continuous Infusion Intravenous administration of a volume of fluid with or
without Medicines added over 24 hours or over a number of
hours to achieve a clinical end point. The infusion may be
repeated over a period of days. Large volume i.e. 25-
1000ml or small volume infusions (e.g. 50ml of heparin) may
be delivered continuously.
PCA Patient Controlled Analgesia is a continuous infusion via a
PCA pump which allows the patient to administer preset
bolus doses of the analgesic with a time lock out between
doses.
Controlled Drugs in
Schedule 2 and 3 of
the Misuse of Drugs
Act 1971
This comprises all drugs that the RUH trust requires to be
stored in a Controlled Drug Cupboard. (see Controlled Drugs
policy)


3. Summary

3.1 Where this policy applies to non-professional staff, individuals administering
intravenous medication (currently normal saline boluses only) will have
received training and have their competency formally assessed. The
administration of intravenous medicines will form part of their job description.

3.2 The administration of IV medicines forms an integral part of the registered
nurse role. All registered nurses will be expected to administer IV medicines
following appropriate training. Any practitioner who does not feel fully
competent in the administration of any particular medicine must seek advice
before administering that medicine

3.3 Administration of first and subsequent doses of IV medicines is covered by
this policy and all medicines should only be administered when they have
been prescribed by an approved prescriber, using an official prescription
chart.

3.4 All intravenous medicines should be administered by a competent IV trained
practitioner acting in accordance with the relevant RUH IV monographs.
During 2013 these will be replaced by those on Medusa. Both these state the
areas in which the medicines may be used and the competence of the staff
who can administer them. These areas and competencies are formalised by
the Medicines Advisory Group.

3.5 For medicines which do not have a RUH IV Monographs or marked not
approved on Medusa, these are likely to have already been approved for
one-off use by pharmacy and may be given subject to pharmacy approval and
using the Summary of Product Characteristics (SPC) as an additional check.
(available on www.medicines.org.)

3.6 IV Medicines may be administered to neonates in the Neonatal Intensive Care
Unit in accordance with the Neonatal Formulary (NNF6 0 J an 2011 (or latest
edition) or British National Formulary for Children (BNFC) (latest edition)

3.7 When administering intravenous medicines to children the latest version of the
British National Formulary for Children must be used.

3.8 The intravenous Medicine Monographs are available on-line from Medusa.
The URL of the site is:
http://medusa.wales.nhs.uk/?ID=6cdb33ff278efa39e355c8bd6814c9f82312
however there is a link in the hospital intranet dashboard as well as in the
pharmacy section. This address has the embedded password, so anyone with
internet access can use it. It cannot be used from WARD usernames.


3.9 In the trust header for each medicine there is an indication of the area/staff
group that can give the medicine. These are:

List 1.This is a general list, which covers all medicines that may be
administered in any ward or department within the Trust. For specific
Medicines which may need to be given by bolus the monograph will identify
when this must only be administered by a doctor or nurse consultant.
List 2. Additional medicines that can only be administered by practitioners IV
trained in Medicine administration in critical care areas i.e. Accident and
Emergency Department, Coronary Care Unit (CCU), Critical Care Services
(ITU and HDU), all Operating Theatres, Post Anaesthetic Care Units- Main
Theatre & PAW (PACUs), Day Surgery Unit Recovery, Orthopaedic
Recovery.
List 2a Additional medicines that can only be administered by practitioners IV
trained in Medicine administration in Advanced Care Areas Medical
Admissions Unit (MAU) and Chest Pain Unit (CPU).
List 3 Additional medicines that can only be administered by practitioners
trained in IV Medicine administration in Diagnostics, Radiology, and the
Cardiac Catheterisation Lab
List 4 Additional medicines that can only be given by RUH practitioners
trained in IV Medicine administration in Central Delivery Suite and the
Obstetric and Gynaecology wards of the Princess Anne Wing.
List 5 Additional medicines that can only be given by practitioners trained in
IV Medicine administration in William Budd Cancer Unit and Chemotherapy
Out Patients
List 6 Additional medicines that can only be given by practitioners trained in
IV Medicine administration on the Paediatric wards (see note 2.5 and 2.6
above).
List 7 Medicines that may ONLY be administered by practitioners trained in IV
medicine administration in the Nuclear Medicine Department.
List 8 Additional list of medicines which may be administered only by Doctors.
List 9 List of medicines for intra-arterial use only on specific designated areas
see 6.3
.
3.10 Exceptions to the restrictions on areas where medicines are to be given will
be allowed where it is not possible for the patient to be treated in that area.
Initiation of therapy and responsibility for monitoring guidance must be under
the responsibility of a member of staff who is from an area where the
medicine can be given and who is experienced in its use. This role can be
performed by Night Nurse Practitioners who are experienced in the use of the
medicine and have evidence of competence.

3.11 Medicines in list 9 are not included on Medusa, so the trust will maintain a
local list on the intranet. (see under Pharmacy, medicines guidance)

3.12 Staff may choose to print these monographs, either from the RUH IV
Monograph site on the intranet, or from Medusa. However if they use one
already printed it is their responsibility to ensure that it is the latest version.

4. Training and Assessment of Competence

4.1 Newly qualified or registered nurse practitioners will be expected to undertake
the approved Trust training for Administration of Intravenous medicines. This
education and training will consist of theoretical knowledge and practical skills
and will include a period of supervised practice and assessment of
competence. Included in training will be specific training in methods of
rigorous double checking.

4.2 For junior medical staff appointed to the Trust training must be undertaken
within the first month of employment. Prior to this time junior doctors may
administer IV medicines but in accordance with individual accountability. They
should ask for support and supervision by IV trained practitioners.

4.3 The training and assessment of nurse practitioners will normally be
undertaken six months after qualifying. Assessors will be appropriately trained
and will carry out assessment of competency.

4.4 Ward and Departmental managers are responsible for ensuring that a regular
assessment of competence for each practitioner who administers IV fluids is
carried out.

4.5 Agency Nurses must provide evidence of previous education and training in
IV medicine administration and evidence of competence assessment to their
ward manager prior to administering IV medicines.

4.6 All newly appointed staff, including bank staff, must provide evidence of
previous education and training in IV medicine administration and undergo an
assessment of competence prior to administering IV medicines. If evidence is
not available, staff must undertake the Trust approved training for the
administration of IV Medicines and assessment of competence.
This is the responsibility of the ward or department manager.

4.7 Registered Childrens Nurses may, following the approved Trust training and
assessment of competence, administer intravenous medicines to children. All
IV medicines across the Trust administered to children must be second
checked. Outside the Childrens Unit (e.g. Emergency Department) the
second checker must be a registered nurse. Only in the Childrens Unit the
second check can be provided by a third year student nurse.

4.8 Radiographers may prepare and administer medicines for intravenous
administration under the supervision or at the request of an anaesthetist
/surgeon or radiologist.

4.9 Nuclear Medicine technicians may administer pre-prepared IV
radiopharmaceuticals under the licence, supervision and training of a named
Consultant Radiologist.

4.10 Certain specific non-professional roles may have the administration of
intravenous normal saline as part of their role (e.g. doctors assistants).


5. Administration / Recommendations for Safe
practice / Checking

5.1. The administration of IV medicines must be carried out by an appropriately
trained individual.

5.2. The administration of medicines is an important aspect of the professional
practice of persons whose names are on the Councils register. It is not solely
a mechanistic task to be performed in strict compliance with the written
prescription of a medical practitioner. It requires thought and the exercise of
professional judgment... Nursing and Midwifery Council - Standards for the
Administration of Medicines August 2008 (reissued 2010)

5.3. Wherever possible two practitioners should check intravenous medication,
one must be the person who then administers the drug. Independent checking
is always required:
a. Where the Designated Practitioner is instructing a student.
b. Where the administering practitioner requests a second check.
c. Where two practitioners need to be involved to support the interests of
the patient e.g. in Paediatrics. All medicines (including Intravenous
medicines) administered to children aged 16 years or less (not on the
Childrens Unit) must be checked by a second practitioner.
d. Where administering an IV medicine via an infusion pump a second
check is required including the set pump rate.
e. Practitioners working in the Neonatal Intensive Care Unit.
f. All chemotherapy including that being administered by the Intrathecal
route (see separate Intrathecal Policy and Procedure).
g. All Controlled Drugs in Schedule 2 and 3 of the Misuse of Drugs Act
1971. Both must be Registered Practitioners except in the case of Pre-
registration student nurses who if deemed competent are able to
second check a controlled medicine.
h. Where a Potassium Chloride 15% Injection is being diluted before
being administered (NPSA, 2002) see Medicines Code - Prescribing,
Storage, Ordering, Handling and Checking of Parenteral Potassium
Solutions
i. Where local (departmental) preference or policy dictates.
j. Where a complex calculation is involved in administering the medicine.
k. Where a bolus of normal saline is being administered by a non-
professional staff member specifically trained in intravenous
cannulation (check must be with a practitioner who is required to sign
the Medicines Administration Record (MAR).

5.4. Where (apart from the list in 4.3) a second practitioner check is not possible,
intravenous medications should be checked with another competent person.
This could be a carer or the patient (himself or herself). Single-person double-
checking with a time delay between each check may be appropriate in other
(rare) situations. The standard is independent (two person) double checking.


5.5. It must be realised that full accountability for the correct administration of the
medicine lies wholly with the administering practitioner, not the second
checker.

5.6. Where two persons check; both must sign the Medicines Administration
Record (MAR) as a record of administration.

5.7. The above recommendations apply to all aspects of intravenous medicine
therapy including first dose administration and intravenous fluid regimes.

5.8. Intravenous medicines cannot normally be prepared, checked or administered
by assistant grades (e.g. HCAs), unless it is a specific part of that individuals
role and identified within their job description.

5.9. It is recognised that there may be circumstances where practitioners are
accustomed to using medicines from different lists and are working within
areas where these lists do not apply. Medicines from different lists must not
normally be administered in areas where the lists do not apply.


6. Authorisation of Medicines for IV Administration

6.1 The Drug Policy Group by means of the BCAP J oint Formulary approves
which medicines are on the formulary and where appropriate restrictions on
prescribing apply.

6.2 The current RUH IV Monographs comprise those medicines that have been
approved for use in the hospital and the practitioners and areas where they
are permitted to be given. It is intended that Medusa will replace these
monographs during 2013.

6.3 This information will be included in the header of each Medusa monograph.
However all medicines for which a monograph has been written will appear in
the database, even though a number are not approved for routine use in the
trust:: The formulary status of each medicine will be given in the header.
Other medicines listed may only be used in controlled situations or as
ingredients in manufacture, e.g. cytotoxic medicines, TPN ingredients.

6.4 The Medusa database is compiled from manufacturers licensed information.
If a product is being used outside the licence it may not be used in this way
until a supplementary local guide has been prepared and approved by the
Medicines Advisory Group.

6.5 In addition the Medicines Advisory Group may produce a local guide to
clarify the licensed recommendations for example by producing a table to
reduce the need for calculations, or to give the most commonly used dilutions
used in the trust.

6.6 The procedure for requesting an additional local guide or if the medicine is
not included in Medusa is as follows:

The request must be made on Form in Appendix 1 and signed by the
consultant whose team will be using the guide. It should be sent to the
Chair of the Medicines Advisory Group/Chief Pharmacist for inclusion
at the next meeting.
The Medicines Advisory Group will inform the requestor of the
outcome.
The Medicines Advisory Group will commission the production of a
local guide to go into Medusa

Any new medicines or local guides will only be published on Medusa, but will
be cross-indexed from the RUH IV Monographs intranet

6.7 Where a medicine has been procured for a specific unlicensed indication, it
may be given subject to pharmacy approval who will provide adequate
information to the user for the safe administration of the medicine


7. Unlicensed Medicines / Clinical Trial Medicine

7.1 Unlicensed / clinical trials Medicines to be administered by the intravenous
route must only be administered by medical staff. It is recommended that
any clinician administering these medicines by the intravenous route has the
medicine checked by a second professional prior to administration. An
individual trial protocol may specify who is allowed to administer the
medicine.

7.2 Medicines prescribed off label (i.e. licensed medicines for an unlicensed
indication or by an unlicensed route (e.g. intra-arterial) or in an unlicensed
concentration) may only be administered within the terms of locally agreed
departmental policies i.e. Critical Care Unit, Oncology, Cardiac
Catheterisation Lab, X ray Department, Waterhouse Ward, and Endoscopy.

Where uncommon medicines are to be administered or no locally agreed
policy exists pharmacy advice must be sought.

7.3 A separate section of the IV Drug Administration Manual (List 9) contains
details of medicines which are administered intra-arterially. This will
continue to be maintained after the switch to Medusa.

8. Cytotoxic Therapy

8.1 The satellite pharmacy department will prepare all IV Cytotoxic Medicines. In
accordance with the national guidelines all IV chemotherapy treatments may
only be administered by registered nurse practitioners or medical staff who
have undergone further training specifically in the IV administration of
Cytotoxic Medicines. see RUH Trust Policy and Procedure Prescribing,
Handling and Administration of Cytotoxic Medicines.

8.2 The practitioner must be assessed as competent.

8.3 The practitioner administering Cytotoxic treatments must have the medicine
checked by a second practitioner i.e. registered nurse, pharmacist, medical
practitioner.


9. Verbal Orders for IV treatment

9.1 The Nursing and Midwifery Council (NMC) Standards for Medicines
Management (2007 and updated 2010) states that A verbal order is not
acceptable on its own. The fax or email prescription or direction to administer
must be stapled to the patients existing medication chart. This should be
followed up by a new prescription signed by the prescriber who sent the fax or
email confirming the changes within normally a maximum of 24 hours (72
hours maximum bank holidays and weekends). In any event, the changes
must have been authorised (via text, email or fax) by a registered prescriber
before the new dosage is administered. The registered nurse should request
the prescriber to confirm and sign changes on the patients individual
medicines administration record (MAR) chart or care plan.

9.2 The standards document continues: In exceptional circumstances, a medical
practitioner may need to prescribe remotely for a previously unprescribed
medicine, for example, in palliative care or remote and rural areas the use of
information technology (such as fax, text message or email) must confirm the
prescription before it is administered. This should be followed up by a new
prescription signed by the prescriber who sent the fax/email confirming the
changes within normally a maximum of 24 hours (72 hours maximum bank
holidays and weekends). The registrant is accountable for ensuring all
relevant information has been communicated to the prescriber and s/he may
refuse to accept a remote prescription if it compromises care to the patient. In
this instance she should document accurately the communication that has
taken place.

9.3 Verbal orders should onl y occur in exceptional circumstances. In this
trust that is interpreted as an emergency situation.

9.4 An emergency is defined as a situation where there is immediate risk to life
and limb of the patient and no medical practitioner can immediately attend.
An emergency situation is where failure to act may be perceived as a failure in
a practitioners duty of care.

9.5 It is not appropriate to accept verbal orders as a convenience

9.6 Where a verbal order is accepted the incident must be reported through the
critical incident risk reporting system

9.7 If a verbal order is taken, the registered practitioner must adhere to the
procedure in the Medicines Code, Prescribing of Medicines -.
Only in exceptional circumstances should medicines be administered on
verbal order of a Medical Practitioner and for ONE dose only.
A reason why the Medical Practitioner is unable to come to the
ward/department and write a prescription should be documented by the
nurse in the patients clinical record.

Controlled Drugs must NOT be authorised as a verbal order.
A verbal order can only be accepted for a drug that has been previously
prescribed and administered (on this hospital admission).
The Registered Nurse must clarify the process with the Prescribing
Medical Practitioner explaining their role to supply a written prescription
within 8 hours.
The Registered Nurse must listen to the message and repeat the
message back. (The numbers 13-19 can be misheard as 30-90 therefore
the dose must be repeated separate numerals e.g. one, three for 13).
An email fax or text message confirming the verbal order must be
received prior to administration of the drug. If an email or a fax it must be
printed and attached to the medicines administration record until the
prescription is signed by the prescriber, when it should be filed in the
clinical records. Where a text message is received the telephone number
from which the text is received should be recorded in the medical notes,
along with the number to which the text message was sent. The precise
wording of the text should be recorded in the clinical record. A second
nurse should check the content of the fax, email or text message. (Note;
text messaging is not an ideal way of transmitting clinical information and
is not preferred).
The medication may then be administered, or the dose adjusted as per
the verbal instructions.
The Registered Nurse must then make a record of the medication, dose,
route and time on the Once Only section of the Patients Medication
Record, stating clearly that it is a verified verbal order.
The checking nurse should also sign the medication record
The Registered Nurse must refer back to the Registered Medical
Practitioner if the patient has either deteriorated or show no sign of
improvement and needs medical assessment


10. Routes for the Administration of IV Medicines

10.1 IV medicines may be administered by the following routes:

Peripheral cannula / butterfly
Central lines all types
Implanted devices (see below)

Specific training, knowledge and experience may be required for specific line types
guided by local / departmental procedure. This training includes administration
via Y site connectors.

10.2 IV medicines may be administered in the following ways:

Fast intravenous injection (bolus/push)
Slow intravenous injection (slow bolus)
Intermittent infusion (by gravity or pump or burette chamber)
Continuous Infusion (by gravity or pump or burette chamber)
PCA Patient Controlled Analgaesia Infusion

See Appendix 4

10.3 The practitioner may only administer medicines via the methods for which
they have received education and training.

10.4 Where medicines need to be given using a syringe pump or volumetric
infusion pump, the practitioner must have received education and training in
the use of that equipment.

10.5 When IV medicines are being administered via a pump as an infusion the
infusion must be checked within15 minutes of commencement then at each
medicine round unless otherwise directed in the monographs. The infusion
must also be checked at each shift handover.

10.6 Changing of IV infusion lines must be carried out every 72 hours unless the
following applies
10.6.1 Giving a lipid emulsion e.g. (Propofol, Total Parenteral Nutrition (TPN))
the line must only be used for 24 hours and must be discarded at the
end of infusion.
10.6.2 If a medicine is being administered via an intermittent infusion the line
must be changed at every dose.
10.6.3 For blood administration the line must be changed at least every 12
hours.

Each line should be labelled with date and time of setting up (in order to facilitate line
changing)


10.7 Where medicines have been added to bags, mini bags or syringes an
intravenous additive label (available from pharmacy) must be completed and
attached to the bag or syringe. The following information must be included:
Patients name and Hospital number
Medicine name/ Dose/Batch number/Expiry date and time
Date and time Medicine added
Details of diluents, including batch number and expiry date
Signature of administering practitioner and checker

N.B. Dial ysis lines must not be used for IV therapy unless specific advice has
been sought from the renal physicians, Critical Care Services (ITU and
HDU) or the Bath dialysis centre.

11. Potency and Incompatibility of IV medicines

11.1 Medicines administered by the IV route have a more immediate and
potentially greater effect than those administered by other routes. There is
also a risk of incompatibility between medicines and intravenous solutions.
Clinical Pharmacists or the Medicines Information department will advise on
compatibility and incompatibility.

11.2 When adding and mixing medicines the monographs must be checked to
ensure there is no incompatibility. Medicines must not be added to the
following:
Blood, plasma, and blood products.
Parental nutrition regimes
Mannitol
Sodium bicarbonate
Medicines prepared as an emulsion (e.g. propofol)

11.3 A Sodium Chloride 0.9% flush, (except where incompatible) should be
administered before and after giving any intravenous medicines including
those fluids listed above (in 10.2).

11.4 Any IV flush should be prescribed. This is now pre-printed on all prescription
charts. They may also be administered according to a Patient Group
Direction.

11.5 IV medicines must be administered or added to intravenous solutions
immediately following reconstitution. Delay may result in degradation and loss
of potency and microbial growth.

11.6 The practitioner (or appropriately trained non-professional) who is to
administer the medicines must prepare the medicines for use. Medicines must
not be pre-prepared for another practitioner to administer unless that person
is present or there are specific written protocols agreed by the pharmacy and
department staff.

12. Responsibilities of Clinical Pharmacists

12.1. Pharmacists are responsible for monitoring both the prescribing and the
administration of medicine therapies, alerting prescribers and other health
care professionals to potential problems.

12.2. This is achieved by:

a. Checking and reviewing the appropriate selection of specific medicines
and medicine regimens (dose, route, frequency, administration method
and dilution, compatibility and the duration of therapy)

b. This is endorsed by signing and dating the Medicines Administration
Record (medication chart) (MAR) in accordance with the Pharmacy
Endorsement Standards.

c. Recording and documenting interventions made and their outcomes.

d. Ensuring that the risks of medicine errors are minimised throughout the
process from prescribing, dispensing to administration.

e. Responding to specific enquires raised by health care professionals
regarding all aspects of medicine therapies including:

Method of administration
Diluents and infusion fluids
Medicine stability
Delivery systems e.g. pumps
Medicine compatibility
Rate of administration
Contraindications and side effects
Interactions
Unlicensed Medicines and their use

f. Training of the members of the healthcare team as appropriate

g. Advising on appropriate treatment for the management of
extravasations and preparation of anaphylaxis boxes in accordance
with written guidelines

h. The RUH IV Drug Administration Manual will be replaced by Medusa
during 2013. Medusa is subject to regular updates practitioners must
always use the current version (online) for reference. For amendments
and local policy updates see section 6


13. Procedure (See Detailed Guidelines Appendix 4)

13.1 Read and understand the prescription, if in doubt check with another
practitioner or the prescriber. Check that the prescription is dated and signed
as well as clear and legible

13.2 Check medicine in accordance with RUH IV Monographs (or Medusa when
implemented in 2013 )and the Medicines Code - Administration of medicines
policy and procedure and any locally agreed policy. This may involve a
second person to check the Medicine.

13.3 The practitioner giving an intravenous medication must know the therapeutic
use of the medicine to be administered, its normal dosage, side effects,
precautions and contra-indications (NMC, 2010)

13.4 The practitioner must be aware of the patients plan of care / treatment
pathway (NMC, 2010)

13.5 Where contra-indications to the administration of a medicine exist, the
prescriber, or another authorised prescriber must be notified immediately.

13.6 The practitioner giving an intravenous medication must be aware of the
medicines normal dosage, side effects, contra-indications and any special
precautions required by checking the monograph, the BNF or package insert.
Also note any special instruction on the Medicines Administration Record
(medicine chart) (NMC, 2010)

13.7 Check:
Medicine, Medicine dosage and prescribed route for administration
expiry dates of Medicine , diluents, infusion fluid required
ensure no faults in vials ampoules and equipment,

13.8 Use Aseptic Non-Touch Technique (ANTT) throughout

13.9 Prior to preparation wash hands, apply alcohol hand rub and wear latex (or
latex-free) gloves

13.10 Prepare Equipment as follows
Plastic tray for each patient
Syringes of required size
Needles
Swabs
Medicines and diluents as prescribed (check to ensure that storage
instructions for medicine have been met)


13.11 Where an intravenous insulin infusion is being prepared, it is important to use
an insulin syringe to draw up the insulin dose which can then be mixed with
appropriate diluent in a larger syringe for infusion.
UNDER NO CIRCUMSTANCES SHOULD THE INSULIN DOSE BE DRAWN
UP USING ANY OTHER TYPE OF SYRINGE.

13.12 Prepare medicine, checking for any discoloration or cloudiness. Preparation of
substances for injection in advance of their immediate use or administration of
medication drawn into a syringe or container by another practitioner when not
in their presence is not acceptable (NMC, 2010)

13.13 Check patient identity with Medicines Administration Record (medication
chart) (MAR)

13.14 Check that the patient consents to receiving the prescribed intravenous
medicines

13.15 Check for allergies or medicine sensitivity

13.16 Check patency of cannula and IV lines

13.17 Check cannula site for signs of infection, extravasations or phlebitis If VIP
score is than 2 then the cannula must be removed and new one re-sited
prior to drug administration.

13.18 If appropriate, stop infusion and flush cannula with (prescribed) Sodium
Chloride 0.9% unless incompatible or unless otherwise stated

13.19 Administer medicine at the correct rate, in accordance with the monograph
instructions, using the correct delivery systems including pumps lines and
filters.

13.20 Observe for adverse reactions, monitoring the patient as appropriate. For
some IV medicine administration this may involve documenting vital signs
assessment and early warning score (EWS).

13.21 Flush cannula with (prescribed) Sodium Chloride 0.9% (where compatible)
and / or re-start infusion.

13.22 Record and sign for medicine administration on the patients Medicines
Administration Record (medication chart) (MAR). If a medicine is not
administered, the appropriate code must be entered in the MAR and where
required an entry in the clinical patient record. The prescriber or another
authorised prescriber must be notified immediately.

13.23 Ensure that all sharps and non-sharp waste are disposed of safely and in
accordance with Trust Infection Control policies.


14. Incident reporting

If an incident has occurred or an error observed, there is a duty to take action to
prevent any harm (or further harm) to the patient.
If an incident may have affected the patient he/she must be assessed and
immediate actions taken to assure safety. The prescriber must be informed
immediately and the senior nurse (on call, if immediate line manager is not
available).

All incidents/ errors should be reported using the current RUH Trust incident
reporting process. (see 213 - Incident Reporting and Management Policy and
Procedure; Including the Management of Serious Untoward Incidents)

Any omitted or delayed doses must be recorded on the last page of the
prescription, together with the reason, and if necessary and contact made to
advise medical staff of situation.

The objective is to identify changes needed to prevent future errors. The risk
team will forward copies of all medication errors to the Chief Pharmacist for
review. The Medicines Advisory Group will also review prescribing incidents as
part of an on-going review of medication incidents, identify any trends and
propose actions to reduce errors in future.

15. Monitoring and Review

This policy for medicines reconciliation and the use of patients own medicines will
be monitored via the following processes:
The Specialty review of monthly Incident Reports, including medications
provided by the Risk Management Team;
The Medicines Advisory Group will review medication incidents and findings
of investigations on a quarterly basis, to identify trends and key risks,
proposing actions to reduce errors in the future;
Medicines Reconciliation is audited monthly as part of the South West Quality
and Patient Safety Programme.

This policy will be in effect for three years, unless it is considered that some changes
are needed. Prior to the third anniversary of the policy the author will be asked to
review it and make any necessary changes prior to further ratification.


16. References

British Medical Association and the Royal Pharmaceutical Society of Great
Britain. British National Formulary for Children. RPS Publishing. London. Latest
edition available on http://www.bnf.org and follow link

British Medical Association and the Royal Pharmaceutical Society of Great
Britain.. British National Formulary. RPS Publishing. London. Latest edition
available on www.bnf.org

National Patient Safety Agency. (2002). Patient Safety Alert: Identifying and
Reducing Risks from Potassium Chloride Concentrate Solutions. NPSA. London

National Patient Safety Agency. (2007): Promoting safer use of injectable
medicines: A template standard operating procedure for prescribing, preparing and
administering injectable medicines in clinical areas. NPSA. London.

Northern Neonatal Network. NNF6 (2011). Neonatal formulary: Drug use in
Pregnancy and the first year of life. Sixth edition. BMJ Books. London

Nursing and Midwifery Council (2007) Standards for Medicine Management.
NMC. London (reissued 2010)


Appendix 1: IV Drug Administration Manual Form 1

IV Drug Administration Manual
This Form may be photocopied.

1. Request for an existing Medicine to be included on additional lists.
(Complete the box below and return to the Chief Pharmacist/Chairman of the
Medicines Advisory Group, Pharmacy Department, RUH)

2. Changes to an existing local practice monograph or notification of
error).
(Complete the box below and return IMMEDIATELY to the Chief
Pharmacist/Chairman of the Medicines Advisory Group, Pharmacy
Department, RUH)

Name of requester: Bleep/Phone Number:

Ward/ Department of requester:

Medicine: Date of request:

New list requested:

Reason for request:

Signature of ward / department Manager:
Name of practitioner: Bleep/Phone Number:

Ward/ Department of practitioner:

Medicine: Date of notification:

Details of error or change in local practice:

Signature of ward / department Manager:



Form 2

Authorisation for Administration of Unlicensed Medication

Medicine:

Usual Dose Range:

Route of Administration:

Indication:

Names of authorised IV trained Practitioners:

Advice and agreement from Pharmacy sought

Signature of Pharmacist:
Declaration by Consultant

I understand that does not have
a Product License under the Medicines Act. I take responsibility for the
administration of this Medicine by the above named IV trained practitioners, if it
has been prescribed on my authority and is given in accordance with the
recommended procedure.

Signature of Consultant

Date


Form 3

Authorisation for Administration of Medication not covered by existing
monograph

Medicine:

Usual Dose Range:

Route of Administration:

Indication:

Patient name: Hospital Number

Names of authorised IV trained Practitioners:

Advice and agreement from Pharmacy sought

Signature of Pharmacist:
Declaration by Consultant

I understand that does not have
a Product License under the Medicines Act. I take responsibility for the
administration of this Medicine by the above named IV trained practitioners, if it
has been prescribed on my authority and is given in accordance with the
recommended procedure.

This declaration allows administration of the Medicine to the patient named above.

Signature of Consultant

Date

Appendix 4: Detailed Preparation Requirements

General

1. Read all prescription details carefully and confirm that they relate to the patient to
be treated.

2. Cleanse hands as per trust policy.

3. Ensure that the area in which the medicine is to be prepared is as clean,
uncluttered and free from interruption and distraction as possible. Ideally,
preparation should take place in an area dedicated to this process.

4. Gather all materials and equipment: sharps bin for waste disposal, medicine
ampoule(s)/vial(s), diluent, syringe(s), needle(s), alcohol wipes, disposable
protective gloves, clean re-usable plastic tray. Check the following:
expiry dates;
damage to containers, vials or packaging;
that medicines were stored as recommended, e.g. in the refrigerator.

5. Beware of the risk of confusion between similar looking medicine packs, names
and strengths. Read all labels carefully.

6. Check that:
the formulation, dose, diluent, infusion fluid and rate of administration
correspond to the prescription and product information;
the patient has no known allergy to the medicine
you understand the method of preparation.

7. Calculate the volume of medicine solution needed to give the prescribed dose.
Write the calculation down and obtain an independent check by another qualified
healthcare professional, where calculations are complicated. Calculation
examples may be included in individual medicine monographs. It is good practice
to record complex calculations in the clinical record.

8. Prepare the label for the prepared medicine. Blank labels should have the drug
name written on them to avoid accidental confusion of multiple syringes in a tray.

9. Cleanse your hands according to trust policy.

10. Use a 70% alcohol wipe to disinfect the surface of the plastic tray. (Ensure that
plastic tray is socially clean; if not sure then a detergent wipe should be used
first). Allow wiped tray to dry.

11. Cleanse hands with alcohol hand rub as per trust policy

12. Assemble the syringe(s) and needle(s). Open wrappers carefully and arrange all
ampoules/vials, syringes and needles neatly in the tray as per ANTT guidelines.

13. Use an aseptic non-touch technique, i.e. avoid touching areas where bacterial
contamination may be introduced, e.g. syringe-tips, needles, vial tops. Never put
down a syringe attached to an unsheathed needle.

14. Put on non-sterile examination gloves (latex rubber or nitrile as per personal
preference. Consider whether patient has latex allergy.

15. Prepare the injection by following the manufacturers product information or local
guidelines.

Withdrawing solution from an ampoule (glass or plastic) into a syringe

1. Tap the ampoule gently to dislodge any medicine in the neck.

2. Snap open the neck of ampoules, using a disposable ampoule snapper if
required.

3. Attach a needle to a syringe and draw the required volume of solution into the
syringe. Tilt the ampoule if necessary.

4. Invert the syringe and tap lightly to aggregate the air bubbles at the needle end.
Expel the air carefully.

5. Remove the needle from the syringe and fit a new needle or sterile bung.

6. Label the syringe.

7. Keep the ampoule and any unused medicine until administration to the patient is
complete to enable further checking procedures to be undertaken.

8. If the ampoule contains a suspension rather than solution, it should be gently
swirled to mix the contents immediately before they are drawn into the syringe.

Withdrawing a solution or suspension from a vial into a syringe

1. Remove the tamper-evident seal from the vial and wipe the rubber septum with
an alcohol wipe. Allow to dry for at least 30 seconds. (Some vials, such as those
containing insulin are designed for multiple use and a tamper proof seal is not
appropriate).

2. With the needle sheathed, draw into the syringe a volume of air equivalent to the
required volume of solution to be drawn up.

3. Remove the needle sheath and insert the needle into the vial through the rubber
septum.

4. Invert the vial. Keep the needle in the solution and slowly depress the plunger to
push air into the vial.

5. Release the plunger so that solution flows back into the syringe.

6. If a large volume of solution is to be withdrawn, use a push-pull technique.
Repeatedly inject small volumes of air and draw up an equal volume of solution
until the required total is reached. This equilibrium method helps to minimise the
build-up of pressure in the vial. For some vials it may be appropriate to use a
spiked filter to allow the syringe to be filled from the vial. It is not acceptable to
equalise pressures in syringe and vial by using an unfiltered needle.

7. With the vial still attached, invert the syringe. With the needle and vial uppermost,
tap the syringe lightly to aggregate the air bubbles at the needle end. Push the air
back into the vial.

8. Fill the syringe with the required volume of solution then draw in a small volume
of air. Withdraw the needle from the vial.

9. Expel excess air from the syringe. Remove the needle and exchange it for a new
needle or a sterile bung.

10. The vial(s) and any unused medicine should be kept until administration to the
patient is complete.

11. If the vial contains a suspension rather than solution, it should be gently swirled
to mix the contents, immediately before they are drawn into the syringe.

Reconstituting powder in a vial and drawing the resulting solution or
suspension into a syringe

1. Remove the tamper-evident seal from the vial and wipe the rubber septum with
an alcohol wipe. Allow to dry for at least 30 seconds.

2. Withdraw the required volume of diluent (e.g. water for injections or sodium
chloride 0.9%) from ampoule(s) into the syringe, as described above.

3. Inject the diluent into the vial. Keeping the tip of the needle above the level of the
solution in the vial, release the plunger. The syringe will fill with the air which has
been displaced by the solution (if the contents of the vial were packed under a
vacuum, solution will be drawn into the vial and no air will be displaced). If a large
volume of diluent is to be added, use a push-pull technique (see above).

4. With the syringe and needle still in place, gently swirl the vial(s) to dissolve all the
powder, unless otherwise indicated by the product information. This may take
several minutes.

5. Withdraw the required volume of solution from the vial into the syringe as
described.


6. If a purpose-designed reconstitution device is used, the manufacturers
instructions should be read carefully and followed closely.

Adding a medicine to an infusion

1. Prepare the medicine in a syringe using one of the methods described above.

2. Check the outer wrapper of the infusion container is undamaged.

3. Remove the wrapper and check the infusion container itself in good light. It
should be intact and free of cracks, punctures / leaks.

4. Check the infusion solution, which should be free of haziness, particles and
discolouration.

5. Where necessary, remove the tamper-evident seal on the additive port according
to the manufacturers instructions or wipe the rubber septum on the infusion
container with an alcohol wipe and allow to dry for at least 30 seconds.

6. Depending on the type of infusion container it may be appropriate to consider that
if the volume of medicine solution to be added is more than 10% of the initial
contents of the infusion container (more than 50ml to a 500ml or 100ml to a 1litre
infusion), an equivalent volume must first be removed with a syringe and needle.

7. Inject the medicine into the infusion container through the centre of the injection
port, taking care to keep the tip of the needle away from the side of the infusion
container. Withdraw the needle and invert the container at least five times to
ensure thorough mixing before starting the infusion.

8. Do not add anything to any infusion container other than a burette when it is
hanging on the infusion stand since this makes adequate mixing impossible.

9. Before adding a medicine to a hanging burette, administration must be stopped.
After the addition has been made and before administration is re-started, the
contents of the burette must be carefully swirled to ensure complete mixing of the
contents.

10. Check the appearance of the final infusion for absence of particles, cloudiness or
discolouration.

11. Label the infusion according to Trust policy.

Diluting a medicine in a syringe for use in a syringe-dri ver

1. Prepare the medicine in a syringe using one of the methods described above.

2. Draw the diluent into the syringe to be used for administration by the pump or
syringe-driver. Draw in some air (slightly more than the volume of medicine
needed) and remove the needle.

3. Hold the diluent syringe upright. Insert the needle of the syringe containing the
medicine into the tip of the diluent (administration) syringe and add the medicine
to it. Alternatively, a disposable sterile connector may be used to connect two
syringes together directly.

4. Check the following:
the total volume of injection solution in the syringe is as specified in the
prescription and that the infusion can be delivered at the prescribed
rate by the administration device chosen;
the rate of administration is set correctly on the administration device
and according to the manufacturers instructions.

5. Fit a sterile bung to the administration syringe and invert several times to mix the
contents.

6. Remove the blind hub. Tap the syringe lightly to aggregate the air bubbles at the
needle end. Expel the air and refit the bung.

7. Carefully check the syringe for cracks and leaks and then label it especially
noting the requirements specific to syringe drivers.

8. Check that the rate of administration is set correctly on the device before fitting
the syringe, priming the administration set and starting the infusion device. The
rate of infusion set should be independently checked wherever possible.

Labelling injection and infusion containers

1. All injections should be labelled immediately after preparation. For syringes intended
for immediate push (bolus) administration by the person who prepared them, labels
should be used if more than one medicine is being used or if a flush and one
medicine is being given. Under no circumstances should an operator be in
possession of more than one unlabelled syringe at any one time, nor must an
unlabelled syringe be fitted to a syringe driver or similar device.

2. Labels used on injectable medicines prepared in clinical areas should contain the
following information: and
name of the medicine;
strength (dose);
route of administration;
diluent and final volume;
patients name;
date and time of preparation;
expiry date and time;
initials of the practitioner preparing the medicine
initials of second checker

If the injectable has been prepared for immediate administration as a bolus by a
practitioner, a simple label with the name of the drug only is appropriate. A label to
distinguish flush from other medications is required.

3. Place the final syringe or infusion and the empty ampoule(s)/vials(s) in a clean
plastic tray with the prescription for taking to the patient for administration.

Administration of an injectable medicine

Before administering any injection

1. Check all the following:
patients name, hospital number and date of birth (check identity bracelet)
prescribers signature;
the approved medicine name;
the dose and frequency of administration;
the date, time and route of administration;
the allergy status of the patient.

2. Also check, where relevant:
Approved name and formulation of the medicine;
concentration and total quantity of medicine in the final infusion container
or syringe;
name and volume of diluent and / or infusion fluid;
rate and duration of administration;
type of rate-control pump or device(s) to be used;
the age and weight of any patient, where relevant;
date on which treatment should be reviewed.

3. Check that the medicine is due for administration at that time and has not already
been given.

4. Cleanse hands according to local policy.

5. Assemble everything you need including any flushing solution(s) needed.

6. Explain and discuss the procedure with the patient. Obtain consent for
administration of medicine.

7. Check any infusion already in progress. It should be free of haziness, particles
and discolouration.

8. Check that an appropriate access device is in place. Flush it immediately before
and after administration of a medicine, and between doses of different medicines
administered consecutively, according to local policy. Also check the
administration site for signs of leakage and Visual Infusion Phlebitis (VIP) score


Administration of injections general

1. Check infusions. They should be should be free of haziness, particles and
discolouration.

2. Use ANTT at all times.

3. Attach administration sets to infusion containers carefully, using the technique
appropriate to the type of container.

4. Prime the access device (three way tap, needless connector if used) according to
local policy immediately before starting an infusion.

5. Before adding a medicine to a hanging burette, administration must be stopped.
After the addition has been made and before re-commencement, the contents of
the burette must be carefully swirled to ensure complete mixing.

After administration

1. After completion of an intermittent infusion, flush the access device according to
local policy, disconnect any giving sets no longer used and dispose of according
to Trust policy

2. Ask the patient to report promptly any soreness at the injection site or discomfort
of any sort.

3. Document administration on Medicines Administration Record (medication chart).

4. Discard the empty ampoules / vials from which the injection was prepared and
any unused medicine. Ampoules or vials should never be used to prepare more
than one injection unless specifically labelled by the manufacturer for multi-dose
use.

5. Re-check the administration site for signs of leakage, VIP score and continue to
monitor the patient, contents of the infusion container and the rate of infusion
according to local policy.

6. Check that arrangements for monitoring fluid balance or clinical parameters have
been made. Ensure that relevant documentation is made available for
subsequent regular monitoring to take place.


Document Control Information
Ratification Assurance Statement

Dear Mary

Please review the following information to support the ratification of the below named
document.

Name of document Medicines Code: Administration of Intravenous Drugs

Names of authors: Regina Brophy J ulian Hunt Geoff Allen

Chief
Pharmacist
Nurse Consultant Risk Management
Pharmacist

I, the above named author confirm that:
The Policy presented for ratification meets all legislative, best practice and other guidance
issued and known to me at the time of development of the Policy;
I am not aware of any omissions to the Policy, and I will bring to the attention of the Executive
Director any information which may affect the validity of the Policy presented as soon as this
becomes known;
The Policy meets the requirements as outlined in the document entitled Trust-wide Policy for
the Development and Management of Policies (v4.0);
The Policy meets the requirements of the NHSLA Risk Management Standards to achieve as
a minimum level 2 compliance, where applicable;
I have undertaken appropriate and thorough consultation on this Policy and I have
documented the names of those individuals who responded as part of the consultation within
the document. I have also fed back to responders to the consultation on the changes made to
the Policy following consultation;
I will send the Policy and signed ratification checklist to the Policy Coordinator for publication
at my earliest opportunity following ratification;
I will keep this Policy under review and ensure that it is reviewed prior to the review date.
Signature of Authors: Date: 4 February 2013
Name of Person
Ratifying this policy: Mary Lewis
Job Title:
Acting Director of Nursing & Accountable Officer:
Controlled Drugs
Signature: Date: 6 February 2013

To the person approving this policy:

Please ensure this page has been completed correctly, then print, sign and
post this page only to: The Policy Coordinator, J ohn Apley Building.

The whole policy must be sent electronically to: ruh-tr.policies@nhs.net

Consultation Schedule

Name and Title of Individual Date Consulted
Francesca Thompson, Director of Nursing March 2009
J an Lynn, Assistant Director of Nursing March 2009
Gareth Howells, Assistant Director of Nursing March 2009
Sharon Preston, Assistant Director of Nursing March 2009
Mark Bonson, Clinical Skills Facilitator October 2008
J enny Chen March 2009
J ulie Blackman March 2009
Regina Brophy, Chief Pharmacist J anuary 2009
Alex Lucas March 2009
J ulian Hunt August 2010
Mary Lewis, Acting Director of Nursing J anuary 2013

The following people have submitted responses to the consultation process:

Name and Title of Individual Date Responded
Sharon Bonson, Assistant Director of Nursing J anuary 2013
Liz Cowdrey, Clinical Co-ordinator J anuary 2013

Name of Committee/s (if applicable) Date of
Committee
Medicines Advisory Group J anuary 2009
Operational Governance Committee October 2009
Senior Nurses Group September 2008
Operational Governance Committee J anuary 2010

Policy Group November 2010
Medicines Advisory Group December 2010


Equality Impact: (A) Assessment Screening

To be completed when submitted to the appropriate Executive Director for
consideration and approval.

Person responsible for the assessment:
Name:
Job Title:

Does the document/guidance affect one
group less or more favourabl y than another
on the basis of:
Yes/No Comments
Race
Yes No
Ethnic origins (including gypsies and travellers)
Yes No
Nationality
Yes No
Gender (including gender reassignment)
Yes No
Culture
Yes No
Religion or belief
Yes No
Sexual orientation
Yes No
Age
Yes No
Disability
(learning disabilities, physical disability, sensory impairment and
mental health problems)
Yes No
Is there any evidence that some groups are affected
differently?
Yes No
If you have identified potential discrimination, are there
any valid exceptions, legal and/or justifiable?
Yes No
Is the impact of the document/guidance likely to be
negative?
Yes No
If so, can the impact be avoided?
Yes No
What alternative is there to achieving the
document/guidance without the impact?
Yes No
Can we reduce the impact by taking different action?
Yes No

If you answered NO to all the above questions, the assessment is now complete, and no
further action is required.

If you answered YES to any of the above please complete the
Equality Impact: (B) Full Anal ysis

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