We are working with our nursing partners to optimize the process for concealing PHI on labels when used medications are discarded. Beyond redacting this information with a black security marker, have any institutions implemented other measures, such as privacy stickers, stamps, or self-shred / perforated labels? If so, what are you using, and how is it working?

Thank you,
Heather Erwin
Barnes-Jewish Hospital
St. Louis, MO

ISMP would like to know if the ongoing shortage of parenteral nutrition (PN) components or supplies has resulted in medication errors or close call events.

We would appreciate if you could share your experiences via the ISMP Medication Errors Reporting program: https://www.ismp.org/report-medication-error

Thank you!

Wondering what others are doing to incorporate medication safety into your PGY-2 program? We are in the process of increasing our PGY-2 residents and wanted to develop a more formalized approach with med safety. In the past, the PGY-2 resident has reviewed and trended critical care events then worked to develop an improvement process and have worked with an individual unit to identify and develop an improvement process. We would like to get the residents involved while keeping focus on their specialty area. Thank you for your time.

Carol

I came across a practice during control drug audits that I was unaware was occurring. A PACU nurse will transport a patient to med/surg floor, carrying a 'labeled' syringe of fentanyl that was being used in PACU. They may use the fentanyl to administer to the patient after transport if the patient is in discomfort due to the transport. They are using the PACU orders for the fentanyl. Their comment is they are still considered a PACU patient until handoff is complete. A couple of concerns with this, but thought I'd post here to see if this is an accepted practice that I was unaware of.

Hi,

For those with a MedCarousel system, how do you store your non-refrigerated neuromuscular blockers in the Carousels. Is there a way to have a lidded pocket or do you not allow storage in the Carousel.

Thank you,

Joyce Lee
Medication Safety Officer
Mount Sinai Medical Center

In an ISMP Quarterly Action Agenda they describe a situation in which hospital computer systems convert oral ibuprofen suspension doses to a metric volume, however, it is unknown what concentration the patient will actually receive.

The action item: Prior to discharge, counsel parents about the availability of the two liquid ibuprofen strengths. Refer to the two strengths as "children's ibuprofen" (100mg/5 mL) and "concentrated infant drops" (50 mg/1.25 mL). Ensure parents understand that the dose in mL is based on which concentration they use.

Good morning we are trying to align with ISMP's best practice for antidotes. Does anyone have standardized protocols/administration instructions for their antidote list that they would be willing to share?

Hi,

If you have a policy restricting what medications can be given on a particular kind of unit, how do you set your prescribers, pharmacists, and nurses up to succeed when these medications are ordered? For example, if a medication can only be given to a patient on a monitor, and another can only be given in ICU or an intermediate unit, how do you ensure that everyone knows that?

We have a policy, but we are relying on people to remember what the policy says, which is not an effective strategy.

Thank you,
Dan

Hello,

Curious to know how often are we reviewing medication order sets. Does anyone have a standing review frequency of every 1, 2, or 3 years for all order sets at your facility?

Thought it would be easier to gather data via a Google form: https://forms.gle/GkHqQwQ3y7kdpmjo9

If we get a decent response rate, I will update with the results.

Thanks all,
RB

Does anyone have a policy for a hospital or health system "standard administration times" (for example, "daily" meaning 9 am, etc)?

I'm not specifically looking at a time-critical medication policy, but an attempt to standardize typical administration times in a shared computer system.

My health system currently has pretty wide variability in these administration times, and looking at potential opportunities to streamline this work for our eRecord team.