Pre-Spiking IV Bags

Pre-spiking IV bags is a new, featured FAQ that needs your attention.

Pre-Spiking IV Bags

We sometimes see this practice in infusion clinics and operating room areas. For example, when you expect a high volume of morning patients it allows you to prepare for the rush. By pre-spiking IV bags you have a case of IV fluids ready for the arriving patients. In fact, sometimes you see the 20 IV bags hanging in the medication room. Furthermore, when visiting late in the day, you just see the med room coat hooks lined up where bags had been.

A decade ago, USP Chapter 797 had an FAQ on this subject. At the time, they prohibited it. But later, USP decided that plain IV fluids (not compounded) were not in their purview. So, they removed their guidance on this subject. Well, TJC reintroduced it using the logic that the IV bag is a single dose vial, without preservative. Thus, penetration outside of an ISO 5 environment should only occur 1-hour or less before actual use.

If these coat hooks exist in your hospital, or an IV pole full of pre-spiked IV fluids is a common practice, it’s time to change that process.

Patton Healthcare Consulting

Patton Healthcare Consulting provides Joint Commission Compliance Assistance and a full range of pre-survey and post survey services.

Contact our office at 888-742-4621, via email or through our website contact page to schedule a discussion of your needs and learn more about our compliance and readiness expertise.