I am looking for information about adding medication to an existing Large Volume Bag that is infusing on a patient. For example: Potassium Chloride or Oxytocin. I know that it is bad practice but looking for back up.

I seem to recall that this was written up in the ISMP newsletter but cannot find the article. Interested in your thoughts/feedback and what policies that you may have in place.

Thank you in advance for your help
Doug Shafer

How does your org prevent RNs from inadvertently increasing heparin dose after holding for critical PTT when post-hold PTT comes back therapeutic or subtherapeutic?

For example, my org's protocol is that if PTT is critical, hold heparin x 1 hr, recheck PTT, and if less than x secs, restart at 3 units/kg/h less than pre-hold dose. However, if post-hold PTT is subtherapeutic, for example, some RNs may misinterpret the protocol (which has been reviewed by human factors engineer) and increase dose, not as intended.

Does anyone else perform safety rounding with staff members to ask them for feedback on current procedures? We are planning on starting to do this at the hospital I work at and was hoping to to get recommendations for things I could ask that would spur responses but not bias responses. If anyone has any resources for effective safety rounding, I would greatly appreciate it.

Hi! A group of healthcare professionals, industry and human factors experts, predominantly based in the UK, are planning to set up a project to address the known risk of inadvertent use of glucose infusions to flush arterial lines. This is being led by The Chartered Institute of Ergonomics and Human Factors (CIEHF) and chaired by Brian Edwards who also chairs ISoP.

I would appreciate your response to the following:
1. Does your institution limit use of PCAs with basal rates on opioid-tolerant patients only?
2. Does your institutions limit the location where PCA​ with basal rate may be used (ICU, Step-Down, etc.?)
3. Any limits on prescribing authority of PCA with a basal rate (i.e. only a specific service(s) may initiate)?
4. Is EtCO2 monitoring required for patients on PCA, with or without basal rate?
5. Any other safety measures in place?
Thank you.

Dear all,

Can you please share with me your latest medication safety committee charters. I went through the discussion board and most of the stuff dates back to 2016. I was wondering if you could share something more recent.

Thank you
Rabih

We are looking for recommendations or best practices for use of buprenorphine IV in pediatric patients. This medication has recently been added to our formulary - we are a free standing pediatric hospital.

- buprenorphine is supplied as 0.3mg/mL
- pediatric dosing is 2 to 6mcg/kg/dose every 4 to 6 hours IV undiluted

We are looking to implement risk reduction strategies throughout the medication use process, including CPOE build, that will prevent potential error with this medication.

We are looking for recommendations or best practices for use of buprenorphine IV in pediatric patients. This medication has recently been added to our formulary - we are a free standing pediatric hospital.

- buprenorphine is supplied as 0.3mg/mL
- pediatric dosing is 2 to 6mcg/kg/dose every 4 to 6 hours IV undiluted

We are looking to implement risk reduction strategies throughout the medication use process, including CPOE build, that will prevent potential error with this medication.

Our organization remains in a hybrid state with some fully activated Cerner sites and some non-CPOE sites with many paper components.
We are revising our fentanyl patch procedure and are curious about the way that multiple patches show on a paper MAR.
One entry (line on the MAR) to sign for the total dose or multiple entries for different strengths? E.g. one MAR entry for 150 mcg/h or one entry for the 50 mcg/h patch and a separate entry for the 100 mcg/h item?

We are looking for recommendations or best practices for dispensing of low dose enoxaparin for patients that will ultimately transfer to home based therapy.

Typically when faced with small dose volumes, we compound a dilution within the pharmacy to make measuring small doses more precise. With our enoxaparin patients, this has proven problematic as they discharge to home. Writing discharge prescriptions for a compounded enoxaparin dilution is problematic on multiple fronts and has lead to dosing errors in the past.