MSOS Discussion Board

BD Alaris Primary IV Tubing Malfunction

Danielle Pray's picture

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Has anyone encountered a malfunction in the primary IV tubing with the secondary IVPB backglowing into the primary tubing and solution.

Here's what we know.

- 4 occurence with chemo agents

- The RNs had the primary set up, attached the secondary (primary tubing was in the pump but pump turned off). When the secondary was unclamped the medication from the secondary back flowed (past the back flow check valve) and into the primary solution rather quickly.

The secondary bag was higher than the primary.

PRN frequency - lockout

Jaime L Gray's picture

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Hi - we are an Epic Institution. I have identified issues with our PRN orders where there is no lockout period to prevent PRNs from being given as frequently as the Rn wants up to the max # of doses based on frequency ordered. For example: oxycodone 5mg q4h PRN can be administered at 1305 and 1310 without any warning that this is too close together or shorter than the ordered PRN frequency. The only alert the Rn will get is when they have reached 6 doses of oxycodone and they try to administer a 7th dose in 24h.

Drawing up Moderna full dose and booster doses

Tanvi Shah's picture

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If your institution has just a handful of Moderna vaccine administrations a day, do you use the same vial to draw up full dose and booster doses?
Mass vax sites/clinics it makes sense to use separate vials. We have been practicing that on the inpatient side however have been wasting more than half the doses daily, which is a waste of drug, supplies and resources.

Thanks!

Regulation on Methadone Use in the ED

mark heelon's picture

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Our clinical, regulatory, and legal teams are wrestling with a question that has arisen from some of the complications of COVID. Like many emergency departments, we are holding patients with complex psychiatric needs for placement at other facilities, sometimes for a week or more. Some of these patients also have opioid use disorder and are maintained on methadone. Of note, these patients are NOT admitted to our hospital and are still under the care of our ED providers.

Separate pumps for IV infusion and enteral feeds in NICU?

Tanvi Shah's picture

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We are evaluating why our NICU isn't able to reach our goal DERS compliance and found out that some staff members haven't been switching profiles in the pumps from IV infusion to Enteral feeds and are using the basic mode in the IV infusion for feeds. Although low, there is a risk of enteral feed been given IV if the profile isn't changed. We are assessing the need to have a totally different pump for our enteral feeds. Wanted to know what other NICU's in the community do.

Any insight is appreciated

Caring for Adult Patients in Pediatric Care Areas

Carley Castelein's picture

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Hello,
I am curious to learn about how others care for adult patients in pediatric care areas. For example, congenital heart patients start with the team as peds patients and are followed by the team often into adulthood. The care team is more familiar with pediatric concentrations and ordering processes but when volume restriction is a concern using adult concentrations can be very beneficial.

How does your organization care for these patients? How are systems built in your EMR, IV pumps, etc. to ensure safety systems are effective?

Topical Thrombin

Emily K D'Anna's picture

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Hello!

Couple questions regarding topical thrombin and your organization's practice:

1) Which topical thrombin product do you use?

2) Is this prepared by / come from Pharmacy?
OR does it come from Pyxis and prepared by bedside clinical staff?

3) Any additional "safety precautions / measures" in place based on your current process?

thanks so much in advance,
Emily

Errors related to Epinephrine autoinjector Trainer Pens

Nitty Joseph's picture

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Hello everyone,

Does anyone have a mechanism in place to prevent the accidental distribution/circulation of Epinephrine autoinjector trainer pens?

We use EPipens for a limited patient population.

We have a process/education in place, scanning out of robot/scanning in Omnicell in place, but I still find occasional trainers in our stock

Thank you.

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