Does your institution use standardized concentrations for remifentanil and/or sufentanil infusions administered to patients in ORs? If yes, what concentration(s) do you utilize and in what patient populations (i.e. adult, pediatric, etc.)? What approach have other institutions taken in general to standardize other infusions given in OR spaces?

Hello Members - We have a request to have 4 gm/100 mL IVPB instead of 2 of 2 gm/50 mL IVPB. Pharmacy is concerned about error from mixed up due to LASA issue. I would like to see what other sites do. Thank you.

Hello all,

I wanted to see if any of you have seen a relatively significant increase in the use of dexmedetomidine use in your OR areas by anesthesia providers? In blocks and for sedation?

Looking forward to responses.

Jameika Stuckey, PharmD
University of Mississippi Medical Center

How do you handle transferring a patient on a PCA? Our nurses wanted me to ask as they are thinking of restricting the practice.

Please share best practice when replacing the lithium battery in cactus smart sink .

Looking for an update on when the March briefing will be available to view on YouTube. Thanks!

I was wondering if anyone has any best practices with regard to the new ISMP Best Practices, specifically Best Practice 19-Layer numerous strategies throughout the medication-use process to improve safety with high-alert medications. Hoping for some suggestions so we can implement within our facility. Thanks!

Is there anyone that has a Just Culture Committee within their organization and would be willing to share your experiences with us? We are looking to be more transparent with this work and include frontline staff and multidisciplinary support. Any insights would be greatly appreciated!

Hello Med Safety Team,

Would anyone be interested in putting together an open letter in response to the RaDonda Vaught case? I feel a lot of us are disappointed with this case and I think this is an opportunity to speak up about just culture, the complexity of the medication use process, system failures, and risk-reduction strategies.

Best,
Allison

Allison Hanson, PharmD, BCPS, FISMP
Manager, US Medical Affairs
Worldwide Medical
Baxter Healthcare Corporation
allison_hanson@baxter.com

Hello, My health system sees limited pediatric patients. We are developing an insulin drip orderable for kids in DKA to be used while awaiting transfer to a nearby children's hospital. We use Baxter Sigma pumps; hence at the lowest rate (0.5 mL/hr), they may be off as much as 20%.

Key players are debating risks and benefits of using a non-standard insulin drip concentration (0.2 or 0.5 units/mL) in these patients given variability of pump accuracy at low doses using the standard 1 unit/mL concentration.