We've had several cases lately where pharmacy staff have drawn up 10x the ordered dose for NICU patients. For example, 0.9 mL of clonidine suspension was drawn up instead of 0.09 mL. In one case, the dose made it to the floor before the nurse caught it.

The label shows the dose (0.9 mcg)in 2 different places, in addition to the concentration 10 mcg/mL and the volume 0.09 mL.

We are trying to increase our compliance with smart pump (alaris) guardrails in pediatrics. After some observations/rounding it seems a recurring issue with using the guardrails for pediatric patients is related to medications that are intended to be given IV push over a few minutes. Examples include opioids, ketorolac, furosemide etc that are obtained from the Omnicell and the patient specific dose drawn up by the RN. The RN then further dilutes the medication and hangs it on the syringe pump (via basic infusion) instead of standing and pushing the medication by hand.

Hello,

We are working to develop a policy/standardized process for medication administration in the perioperative setting specific to anesthesia staff. Would you have a policy, guidance, or any advice to share? If this helps - we are a Cerner shop and do not have BCMA in the OR yet. Much appreciate any guidance or pearls you may be able to share.

Thank you,
Daniel

Hello,

Two part question:
1. Have any of your organization's implemented EHR-Pump integration in your outpatient infusion centers, and if so, how have you dealt with increased chair time?

2. We use Alaris pumps and have yet to convert to short set tubing. If you have adopted short sets, what sold you on this setup? Pros/Cons/lessons learned?

Thank you!

Emi Grant

Our system has TPNs as our last line to be converted from paper-based ordering into CPOE and a visual flowsheet. Do other Cerner hospitals have custom TPNs that are already converted that would be willing to share how this process has been working and learnings?

We utilize Pyxis from BD as our automated dispensing cabinet (ADC) vendor, which includes a feature known as a “Too Close to Remove” alert. This alert functions by warning the end user upon removal of a medication for a patient if a dispense of the same medication within a time frame pre-determined by the organization has already occurred. The time setting is applied to the medication record and cannot be turned off or on for various stations in certain patient care areas (e.g. ORs).

In order to advance our safety culture across a 5 hospital system, we are planning to initiate a structure for medication safety event debrief sessions for shared learning. We are anticipating hosting an event each quarter.

Asking for my team, is anyone currently hosting similar debriefs and would you be willing to share or talk to use about your structure, criteria for selection of events to be shared, and any feedback/insight you've gained during this process?

Hello,

Not directly a med safety topic, but I think some of us are also residency directors or preceptors.

Do any of you currently prime the TPN tubing for your central line patients in an effort to prevent CLABSI?

Our NICU is asking if we could do this on our neonatal TPNs.

We prime the tubing for our chemotherapy, but nothing else currently.

Wondering if any of you have experience in your facilities priming TPN tubing?

In my opinion, if we start this for NICU, we should probably do it for pedi and adult patients as well.

Thoughts?

Thanks -
Chad

We are beginning to notice something that we hope others can help with, as we are weeks to months behind the surges of COVID-19 than others around the country. From the patient perspective, COVID-19 treatment within acute care would be traumatic, especially with not being able to see loved ones (at least in person). Some facilities have been able to set up ward-style units. However, all this can and has led to post-traumatic stress disorder. How could it not. The front-line heroes have PTSD, but imagine from the patient perspective.