MSOS Discussion Board

DIscontinuation of Ammonul (sodium phenylacetate and sodium benzoate injection) for the treatment of hyperammomnemia

Carol Sutherland's picture

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Hi all,
We have been notified that Bausch Health US is discontinuing production of this product used for urea cycle disorders. Does anyone know whether Zydis and Foshun brands are available in the US? I am in Canada so we would have to petition Canda's version of the FDA (Health Canada) for the product to be available in Canada.
Any leads would be greatly appreciated.
Have a great day,
Carol

List of US Hospitals that employ an MSO

Marinela Villejo's picture

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Hello everyone! I'm an Advanced Practice Nurse and have been in healthcare for almost 40 years. I received my first Masters Degree (Nursing) in May 1995 and 30 years later, I'm on this journey to complete my 2nd Master's Degree (MJ in Health Law).

I'm on my final stretch here and working on my Thesis: Legal Implications of Medication Safety in US Hospitals and of which, my entire proposal is for mandating an MSO in every hospital.

Baxter Shanghai Bags 0.9% NaCl 250 mL Bags- potential coring with CSTDs?

Jennifer Carroll Noped's picture

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As part of our Baxter IV fluid allocation, we have received two imports from Shanghai of normal saline 250mL bags. Import codes are A6C1322 (bag printed in Mandarin with no barcode), and A6C1322US (bag printed in English with barcode). When these bags were used to prepare hazardous medications using a closed system transfer device (CSTD) in the cleanroom, particulate matter was detected in the bag immediately after preparation. This occurred with two trials and so our health system plans to not use these bags with CSTDs.

Anaphylaxis to Vancomycin x 3

Sara Meyer's picture

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Hi everyone-
We have had three patients experience anaphylaxis and subsequent cardiac arrest after receiving vancomycin at one of our facilities. Two of the patients received the same LOT and exp. I have submitted a manufacturer and MedWatch report, and we are sending drug off for testing, but I wanted to see if anyone else has experienced something similar. I know anaphylaxis after vanc is possible, but rare, and its alarming that we have had three events somewhat close together.

Variable concentration products & Pump integration?

Jennifer Marie Soto Meyer's picture

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Hello safety colleagues! Hoping to hear insights from other sites live on pump/EHR integration regarding products that have a variable concentration. Examples of variable concentration products would be "factor products" such as Kcentra or products such as alpha-1 proteinase inhibitor.

1. Do you have any variable concentration products "in scope" with pump integration?
2. If yes can you share tips or would you be willing to connect?

Single Bolus Air-In-Line (AIL) Alarm Setting

Jason Topolski's picture

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Our infusion pump system now offers multiple Single Bolus Air-In-Line (AIL) Alarm Settings. At the lowest setting, it contributes to an enormous number of alerts. I understand that there are various causes to these alerts (e.g., nursing practice, characteristics of infusion, etc) as well as potential interventions; however, is there any guidance around what bubble size is considered clinically significant (or non-significant)? From my brief research on air embolism, it doesn't seem the highest pump setting would be of clinical concern.

ASHRM Patient Safety Tip Sheet - Medication Safety - ADE-ADR Definition

Kirsten Parker's picture

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Recently ASHRM has posted a Medication Safety Tip Sheet that provides a succinct overview on Medication Errors and Recommendations.
https://www.ashrm.org/system/files/media/file/2025/02/Medication-Safety-...

I would be interested in others thoughts on their definition for Adverse Drug Reactions as "side effects experienced by patients even when there is no error (PSNet 2019, NCCMERP 2015)."

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