When you compound your chemotherapy preparations, do you account for overfill vs the final labeled volume?
1. Remove "estimated" volume of overfill.
2. Add "estimated" volume of overfill to the final volume on the label.
3. Pump bags to exact base fluid volume stated on the label.
4. Do not account for overfill in the final volume stated on the label.

Hello everyone,

In the past ~ 60 hours our organization has experienced three events of rapid over-infusion of a medication utilizing BD/CareFusion Alaris infusion pumps. Initial investigations indicate that the pumps were programmed correctly according to the medication orders and a crosscheck with Epic/Alaris Interop. Thankfully all three patients have avoided serious harm.

There is suspicion for a pump malfunction, which is being escalated. We are working with the vendor and implementing mitigation strategies across the system.

Hello everyone,

In the past ~ 60 hours our organization has experienced three events of rapid over-infusion of a medication utilizing BD/CareFusion Alaris infusion pumps. Initial investigations indicate that the pumps were programmed correctly according to the medication orders and a crosscheck with Epic/Alaris Interop. Thankfully all three patients have avoided serious harm.

There is suspicious for a pump malfunction which is being escalated. We are working with the vendor and implementing mitigation strategies across the system.

Hello All,
I am curious as to how others are sharing pertinent information from the ISMP Alerts to all staff members. Our Medication Safety Subcommittee was reviewing the Targeted Best Practices and wanted to develop a process to address best practice #14 specifically to share external stories with all staff. Could you please share your processes surrounding this best practice?
Thanks so much!

Cicely Williams,PharmD.

For those that have converted to ENFit or are in the process, how have you addressed the clogging caused by crushing medications. ENFit has a smaller lumen so it is harder for crushed medications to pass through the tube.

Have you made changes to limit which medications you crush at your institutions? Have you had success with any pill crusher which prevents clogging?

Looking forward to hearing how you are handling this situation.

Thanks!

HI All,

My organization has a 35+ year old EHR and it was "boxy but good" to quote the movie actor. It was a mainframe with GUI applications but pharmacy worked in the blue mainframe called VISTA - we could see everything. It was fast and was molded to the highest possible functionality for medication safety (like fully integrated with safety checks in our mail order pharmacy, very sophisticated clinical rules, etc.).

HI All,

My organization has a 35+ year old EHR and it was "boxy but good" to quote the movie actor. It was a mainframe with GUI applications but pharmacy worked in the blue mainframe called VISTA - we could see everything. It was fast and was molded to the highest possible functionality for medication safety (like fully integrated with safety checks in our mail order pharmacy, very sophisticated clinical rules, etc.).

HI All,

My organization has a 35+ year old EHR and it was "boxy but good" to quote the movie actor. It was a mainframe with GUI applications but pharmacy worked in the blue mainframe called VISTA - we could see everything. It was fast and was molded to the highest possible functionality for medication safety (like fully integrated with safety checks in our mail order pharmacy, very sophisticated clinical rules, etc.).

Hello all,

HI All,

We have had very tightly integrated health system that relies on 30+ year old mainframe software. It was "boxy but good" to quote an old movie.

We are currently converting to Cerner. We have one very small site live but we are struggling with the lack of integration between Cerner EHR and Meds Manager Retail aka MMR (essentially a "retail pharmacy" module, rather than an integrated health system ambulatory care software). It is installed in the Department of Defense but their care model and our care model are not close to being similar.