We recently observed two patients experience severe and concerning reaction to carfilzomib. Both had tolerated this medication well in the past and were in good health the day of infusion. Lot# 1125072 was used and both patients experienced similar symptoms: nausea, vomiting, changes in mental status, profound weakness, and possible syncopal episode. One patient recovered, the other remains in ICU. Has anyone else seen a similar constellation of symptoms with this medication? Notifications to medwatch and the manufacturer are in process.

What programs are being used for creating the discharge medication list for patients and families that integrates with your EHR system? For those who use oral liquids, how is the medication list presented on the discharge paperwork? For example, in "mL", in "mg", or in "mL=mg"? Thanks! -Melody Sun, CHOC Children's

Dear Friends and Colleagues,

ISMP has published a NAN Alert regarding Medication safety issues with newly authorized Paxlovid and the different dosing for normal renal function vs. impaired renal function (one less tablet).

Situation: Over the past 8-12 weeks, the pharmacy team at our 400+ bed hospital has seen an increase in unexpected or unexplained heparin anti-Xa levels whereby patients may be therapeutic and then have sudden unexplained undetectable results, or sustained sub-therapeutic levels. It seems that more patients are requiring much higher doses to achieve therapeutic anti Xa results; and patients are taking longer to achieve therapeutic anti-Xa levels.

Please note we have not undertaken a formal study but our observations seem to suggest something is different with heparin.

Situation: Over the past 8-12 weeks, the pharmacy team at our 400+ bed hospital has seen an increase in unexpected or unexplained heparin anti-Xa levels whereby patients may be therapeutic and then have sudden unexplained undetectable results, or sustained sub-therapeutic levels. It seems that more patients are requiring much higher doses to achieve therapeutic anti Xa results; and patients are taking longer to achieve therapeutic anti-Xa levels.

Please note we have not undertaken a formal study but our observations seem to suggest something is different with heparin.

Good afternoon,
We are still working on the Standardize for safety guidelines in regards to changing to weight based dosing (per ISMP and ASHP recommendations www.ismp.org/ext/446) for levophed (and epinephrine and phenylephrine).

I wanted to see if other sites are still using rate based dosing in mcg/min for levophed:
-What is your max rate in mcg/min?
-I'm curious if there was a particular rationale for not going to weight based dosing?

any feedback helps
Thank you!
Happy New Year Everyone!!

Hello everyone,

Our organization is actively evaluating our processes around smart pump events in an effort to improve our standardized response.

In your hospital/system/organizations, who is responsible for reviewing both the error and event logs from the pump and communicating out that information after a adverse event that involved a smart pump?

For context, our system utilizes Alaris pumps and currently has teams from Clinical Informatics, Clinical Engineering, and Medication Safety all involved after an event.

Thank you for your insight!

Is anyone is tracking medication-related metrics for staffing shortages? Barcode scans, overrides, late meds, etc?

Hi everyone,

Hi,

We've seen a noticeable increase in reactions to IVIG, from patients who have previously tolerated it. We seem to have identified one lot number that has been in common for all but one of them. We've contacted the manufacturer about it, but I was curious if anyone else has gotten reports of similar increases?

Thanks,
Kara Thornton
UVA Health
kara@virginia.edu