We are attempting to hardwire feedback of errors across our system (or at least within our department). One aspect is when/how we communicate back about a specific error. Regardless of if we had human error and system-level influences, the person who made or at least contributed to an error needs to be made aware. During these feedback sessions, system-level contributions that can be worked on are uncovered. While this occurs with the vast majority of errors that have some sort of Pharmacy contribution, we cannot verify that it happens 100% of the time.

Does your institution routinely monitor narcotic prescribing practices by your providers to determine appropriateness or outliers? If yes, please provide some details of what your monitoring program entails. Thanks!!

Wanted to compare practices across organizations regarding required baseline laboratory monitoring for anticoagulation in response to the Joint Commission National Patient Safety Goal (NPSG) for anticoagulation.

Hello!

I was wondering how facilities handle orders/authorization for medications to be administered outside the established administration window. Are nurses able to do this for certain meds (i.e. non-time-critical) per their discretion? Is a provider's order required each time a med is to be administered outside of the admin window? If so, how is that implemented in a CPOE environment? Any information you have is greatly appreciated! Thank you!

Amber Lorenzen, PharmD

Have had multiple areas in our organization requesting to use aromatherapy (QueaseEase) for nausea. Our understanding is that the Joint Commission expectation is that aromatherapy used for specific therapeutic purpose would be considered a medication and would need to be treated as such.

Would like to hear how others have addressed this issue--including formulary management approach, supply from pharmacy or from warehouse/storeroom, policies/procedures.

Thanks!

Don

Have had multiple areas in our organization requesting to use aromatherapy (QueaseEase) for nausea. Our understanding is that the Joint Commission expectation is that aromatherapy used for specific therapeutic purpose would be considered a medication and would need to be treated as such.

Would like to hear how others have addressed this issue--including formulary management approach, supply from pharmacy or from warehouse/storeroom, policies/procedures.

Thanks!

Don

Hi all,

Just wondering if anyone has a process in place to prevent incorrect weight entries?

We are an Epic based site and recently had an error where a patient weighed 96lbs (44kg) and this was accidentally entered as 96kg, resulting in high vancomycin loading dose leading to SCr of ~4 and nearly starting HD. Incorrect weights have led to a few errors in the past as well.

I know there was an old post a few years back, but just wondering if anything new has been tried since.

Thanks!

Hello,

Does anyone put high alert labels on medications in the crash cart? A Joint Commission surveyor cited one of our ambulatory clinics for not having medications in the crash cart labeled. This is something I have never done and is not currently done within our system. Trying to see if this is surveyor specific or if we're out in left field somewhere. Appreciate any thoughts.

Carol

We are working to update the ISMP FMEA template forms. Right now, we are focusing on FMEA when new drugs are being added to formulary. Does anyone do this in practice right now? If so, do you mind sharing the tools with me so we can get a better sense of what may be happening currently?
Thanks!!
Merissa
ISMP Fellow