TThis policy will ensure that there is a process whereby all clinical staff who are involved with the administration of injectable medicines are competent to do so and therefore will be able to deliver safe and effective care.


Duties within the Organisation

  • The administration of injectable medications via an intravenous route may only be undertaken by Registered Healthcare Professionals (HCPs) who have received the Trust intravenous therapy training and can provide evidence of competence.
  • Registered HCPs must complete the relevant theory training modules from the E-learning for Health Website, IV Passport Module and attend the Trust IV Practical Study Day. They must also have a period of time to complete the necessary sign-off competencies in the Capital Nurse IV Therapy Passport Practice Learning and Assessment Document (PLAD)
  • Registered HCPs must receive more specialist training to administer IV Chemotherapy.
  • Drugs for IV administration will be checked on reconstitution prior to administration by two competent staff at the same time (see double checking process for IV drugs – appendix 1).
  • The identity of the patient who will receive the injectable drug will be checked verbally and visually by use of the identity band, by the person administering the medication. Allergy status must also be clarified and the patient must be wearing a red allergy identification wristband.
  • Where the IV drug is to be administered using an infusion device the practitioner must have had documented training on the use of this device.
  • Medical staff who have undergone the appropriate training must provide evidence of this.
  • Registered HCPs who have undergone the appropriate training, achieved the necessary competencies and can provide evidence of this may only give IV drugs on the specific authorisation of a doctor by means of a written prescription that is legally valid and legible or under a Patient Group Directive.
  • Registered midwives may also administer those IV medications included in the Midwives Formulary under Exemptions to the Medicines Act 1968, NMC 2011.


Policy Details

Download: N/A
Compiled by: Paul Darling-Wills, Operational Lead Resuscitation Services
Louise Hamilton, IV Specialist Nurse
Ratified by: Drugs and Therapeutics Committee
Date Ratified: August 2023
Date Issued: August 2023
Review Date: August 2026
Target Audience: All Clinical Staff who are involved in the administration of Injectable medicines via intravenous route.
Contact name: Paul Darling-Wills, Operational Lead Resuscitation Services


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