I want to alert everyone that our nurses discovered some 1-L normal saline bags from Baxter that had no barcode printed on the bag to enable BCMA. Please see the attached pictures.

I reported this labeling error to ISMP.

NDC: 0338-0049-04
Lot: Y427043

I would be appreciative if anyone has a policy or guidance regarding use/administration of papaverine in the pediatric population to share. Additionally, do you have an established standard or guidance for utilizing heparinized fluid vs. normal saline for maintaining arterial line patency in children? Thank you. Mark

Hello,
Has anyone implemented BMCA in the radiology space or control room? And does anyone know if MRI compatible BCMA technology is available?
Thanks,
Casey

Does anyone have a policy they are willing to share regarding IV use of Haldol? How many of you even allow IV use?

Thank you

For continuous infusions where pharmacists are picking appropriate volumes based on rate, do any other pediatric institutions using Epic ever experience issues with volumes changing to default dispense upon order transfers? If so, has anyone escalated the concern to Epic? Also interested to see if anyone has ideas for mitigation strategies.

A discussion surrounding use of preferred names on labels (med labels, lab labels, name bands, etc) has resurfaced in our Med Safety group. During our discussions we identified several risks with including these, but also understand the importance of including particularly in the case of transgender patients.

S: A patient within our health system received two, influzenza vaccine Fluzone High-Dose Quadrivalent vaccine doses because of confusing packaging.

B:
• A single dose is one single prefilled syringe, 0.7 mL, given intramuscularly
• The manufacturer of the high dose influenza vaccine, Sanofi Pasteur, packages 10 prefilled-syringes in a box. Each box contains 5 sleeves. Each sleeve contains 2 syringes

Hello,
I'm an Australian pharmacist. We have recently had andexanet alfa approved in Australia and I have several concerns about its safe administration, particularly as in Australia we don't have 24/7 onsite pharmacy services and nursing staff make up the majority of the intravenous medications.

Does your institution utilise an empty bag to prepare andexanet (and if so, which brand/plastic)?
Do you have both the bolus and infusion in the same bag?
What do you use for flushing please given there is lack of compatibility data for common fluids?

We recently had an event where a full 50-mg tenecteplase vial was administered to a stroke patient. The root cause was that the nurse followed the dosing chart on the box, which is intended for the STEMI indication only.

Although tenecteplase is FDA approved for STEMI only, many hospitals are using it for stroke, which is endorsed by AHA/ASA guidelines.

Hi everyone,

I am wondering how everyone handles bulk bottles (ie, amoxicillin reconstituted solution) when it comes to ADCs? Do you pull up individual doses into syringes (or dosing cups) and store those in the cabinets instead? It appears that the stability is limited for certain medications (Augmentin) based on a study from 1988.

Thanks!
Tamra Pierce, PharmD, BCPS
Medication Safety Pharmacist
Indianapolis, IN