A novel format for management of intravenous medication guidelines – a pharmacist-led guideline working group
Jeanie Misko
A * , Emma Fox A , Tim Chang A and Matthew Rawlins A
A
Abstract
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) 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.
The Intravenous Medications Guidelines Working Group consists of clinical pharmacists from multiple specialties and specialist pharmacists (medicines information, medication safety). The Intravenous Medications Guidelines Working Group meets monthly, and discusses feedback from end-users, improvements to consistency and readability of guidelines, as well as maintaining a robust review process.
Since its inception nearly 10 years ago, the Intravenous Medications Guidelines Working Group 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.
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, standardised processes and user feedback are key to maintaining a high standard.
Keywords: guideline development, hospital pharmacy, intravenous administration, medication governance, medication guidelines, medication safety, policy, quality improvement.
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