Hi all,

I know this has been a frequent discussion topic for years, but my institution is once again reviewing our practices for IVPB medications given on primary vs. secondary line. My nursing colleagues are soliciting input on the following question:

When giving small-volume IVPBs (~50 mL or less) on a secondary line, after infusion is complete, there may be some residual drug in the secondary line. What is your procedure when IVPB has completed infusing? Do you flush the residual? What do you flush with? Do you have orders entered for this flush in your EHR or not?

For those sites using BD Alaris pumps, has your organization opted to move forward with the System software update (to v12.1.2) ahead of official FDA clearance? If so, is your organization planning any sort of specific surveillance of these devices?

Appreciate your insight!

Don't forget to visit the MSOS website to sign up for our upcoming Member Briefing webinar on Thursday, January 27th.

Safeguards around adult use of continuously inhaled epoprostenol
Sammy Burton, PharmD, FISMP
Cleveland Clinic

Utilizing the EMR to assure safe paralytic infusion practices
Mara Weber, PharmD
OhioHealth

Multi-chamber bag parenteral nutrition
Andrew Mays, PharmD
ASPEN PN Safety Committee

ISMP Update
Mike Cohen

Does anyone have benchmarks related to % Encounters with ADE and/or ADEs/1000 Admins that you are willing to share? Thanks in advance!

We are analyzing diversion risk related to propofol across our organization. Please fill out the following survey for us to assess how other organizations are addressing propofol related to security and diversion.

Thanks in advance!

https://forms.office.com/Pages/ResponsePage.aspx?id=bvPUxCdsp0KouPRl8Oda...

Hi!

Any suggestions for how we can refer to the Pfizer COVID vaccines without using the cap color? It's like nails on a chalkboard to me (this analogy likely shows how old I am!).
It feels like the right thing to do is to think of another way to refer to these.

Anyone have any good ideas?
thanks,
Helen
Cambridge Health Alliance
Cambridge, MA

In December, ISMP published an article re: adverse glycemic events and critical emergencies. Safe practice recommendations included steps to avoid insulin mix-ups. Historically, we have experienced these errors in our ED and worked to limit the number of insulin products available, with a goal of removing regular insulin vials from the ED and sending patient-specific doses (diluted) for IV administration. Note: we also recently moved to EPIC with some prospective order review in the ED and Pyxis profiling, but there are still some gaps in coverage to be fixed)

Hi all,
I know many of us are still struggling with how to eliminate injectable promethazine (or at least reduce utilization).
Have any of you had success with offering alternatives via an alternative alert for a provider? If so which meds/doses have been well received?

Ondansetron IV/PO, promethazine PO, prochlorperazine IV/IM? others?

If you have an alternative alert do you allow the provider to continue with original order with documentation of a reason (central line, intolerance to other agents, etc?)

Thanks!

Do ambulatory clinics in your organization use barcode medication administration (BCMA)?
If yes, is it used in all clinics or only certain clinics (e.g. PCMH, specialty, etc.)?

Thanks!
Stacie Ethington MSN RN-BC
Med Safety Nurse Specialist

Hello MSOS,

How frequently are you requiring formal and documented medication storage area inspections at your facilities?

Currently our system policy requires monthly documented inspections, but there has been a request to change this to quarterly. The Joint Commission requires inspections to take place periodically, but des not define a timeframe.

Thank you in advance for your response!