When our floor pts go to our dialysis unit, we are having challenges ensuring continuation of correctional/mealtime insulin therapy. We dispense insulin as patient-specific pens, and often this pen does not follow the pt to dialysis. We can place insulin vials into the ADM, however this presents issues since floor orders do not link to the vial in the ADM. We are hesitant to create additional orders and insulin dispensing workflows for these dialysis unit patients, since this may create additional sources of error. Have others successfully navigated similar issues? Any suggestions?

How is it that the OR is able to scan meds that are either given IV or have been poured (and even labeled) on the OR table if the patient's armband is covered? A concern is that we do not want them scanning a sticker or an extra armband yet we want to follow best practice. Thank you for sharing your ideas.

I wanted to share a safety alert that circulated through our health system yesterday.

A pharmacist discovered that a box of cisatracurium from Meitheal contained vials that were labeled as phenylephrine in error. This has been reported to FDA, ISMP, etc., but given the severity of the potential error of a mislabeled paralytic, I wanted to share with this group ASAP.

I have attached pictures for your reference.

​​Hi all.

Hello,
I would like to know if anyone can share their best practices regarding RPH checking of UNIT dose packaging. In particular what do you have in place to ensure the wrong drug is not packaged ? I was considering to have the RPH check markings on the pill and do a drug ID but I am not sure this is the way to go. Any input is greatly appreciated. I see a potential for error when multiple drugs are being packaged at one time.
Thanks,
Nancy Makem PharmD

USP published a COVID-19 vaccine toolkit yesterday that we think will be very helpful.
Experts, stakeholders and members of USP expert committees were convened to identify and help address operational efficiency gaps to help increase COVID-19 vaccinations. ISMP and ASHP participated. When complete in early 2021, it will include operational strategies in three key areas: Preparation and labeling, Storage, handling and transport and Waste and disposal. The toolkit can be downloaded here.

How is everyone approaching expectations for anticoagulant education per the National Patient Safety Goal 03.05.01? Our institution is rolling out nurse training on how to educate on anticoagulants, and our AC Stewardship group, which includes someone from Regulatory Readiness, wants to target all nurses, including those in perioperative areas (preop/PACU). The thought behind this is that patients who need to be bridged or hold AC may have been educated outside of our organization and we may not have documentation of that education for outpatient procedures.

Good Morning,

I am wondering what educational resources hospitals are using to meet the element of performance below related to pain assessment, management, and opioid use education for practitioners?

LD.04.03.13: Pain assessment and pain management, including safe opioid prescribing, are identified as an organizational priority for the hospital.

Elements of Performance:

Hi everyone -

Recently have had various reports of tacrolimus administered for sublingual administration being administered orally. The two routes are not always equivalent doses which may cause issues with immunosuppression management. Reaching out to see if anyone has tackled this issue in their EMR with success.

Thanks

Hello, I am looking for some input as to how other hospitals handle the instance when a pt is going through withdrawl and methadone is needed and either the pt is not in a methadone treatment center or the dose is unable to be verified due to off hours ( weekend/ evening). Do you allow one time dose ? Is there a restriction on who can order ? I am not talking about detox, just talking about treating the withdraw symptoms.

Any input is greatly appreciated.