We did a brief article in today's ISMP newsletter related to the recent tragic error in Oregon where a neuromuscular blocker was prepared in a bag labeled fosphenytoin.
http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=97
One of the safety strategies we mentioned was adoption of IV workflow systems like DoseEdge, BD Cato, Scriptpro, etc. I saw that Pyxis will be marketing a system soon too. I learned this week that only about 6 or 7% of US hospital pharmacies have adopted one of these systems. I'd love to hear why the uptake is so low since it's pretty clear it would have prevented this incident if used for compounded IVs. Would love to hear from those that use them too. What are your thoughts? The systems are recommended in our IV admixture safety guidelines on our website. This was a consensus opinion by over 50 experts who attended the summit that let to the guidlines. Thanks, Mike