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A novel format for management of intravenous medication guidelines – a pharmacist-led guideline working group

Jeanie Misko , Emma Fox, Tim Chang, Matthew Rawlins

Abstract

Objective: Intravenous medications are frequently used within hospital settings. To safely administer these medications to patients, further instructions are required on preparation and administration details. We describe a novel working group of hospital pharmacists (the Intravenous Medications Guidelines Working Group, or IVWG) formed with the aim to produce and maintain consistently high-quality, site-specific intravenous medication guidelines across a multi-site hospital group with complex needs. Methods: The IVWG consists of clinical pharmacists from multiple specialties and specialist pharmacists (medicines information, medication safety). The IVWG meets monthly, and discusses feedback from end-users, improvements to consistency and readability of guidelines as well as maintaining a robust review process. Results: Since its inception nearly 10 years ago, the IVWG has reviewed 714 intravenous medication guidelines, maintaining a compliance review date for 98.4% of the 190 guidelines owned by the hospital group. Incident reports relating to high-risk intravenous medication preparation and administration are low (<1%). Informal feedback suggests the guidelines are also accessed from outside the hospital group via the state-based health intranet. Challenges remain in upskilling new pharmacy staff and further improving the usefulness of guidelines for end-user nursing staff. Conclusions: A pharmacy team-based approach has consistently produced high-quality guidelines for hospital staff over a prolonged period with low clinical incident numbers. Ongoing staff investment, standardized processes and user feedback are key to maintaining a high standard.

AH25025  Accepted 10 July 2025

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