Hello, my institution is evaluating whether to remove the total dose from our outpatient prescription labels and/or after visit summaries (AVS), and instead only include the number of tablets/milliliters/etc the patient should take. The concern is that patients may misread "5 mg" as "5 tablets" and take the wrong dose, but we also have some concerns with not communicating the total dose to the patient.

Our current formatting for prescription labels and AVS is the same: Take one tablet (5 mg) by mouth daily.

We are considering changing to: Take one tablet by mouth daily.

Hi Everyone
There is currently quite a bit of information on here regarding dispensing of low doses of enoxaparin (< 10 mg) for pediatric patients. For inpatients we currently dispense enoxaparin doses < 10mg utilizing the 20 mg/mL concentration using a fixed needle 0.5 mL TB syringe. When these patients discharge home and need enoxaparin it seems we are sending them home with the 100 mg/mL enoxaparin vials and teaching parents to use insulin syringes for doses < 10 mg.

What are other institutions dosing when patients go home on low dose enoxaparin (< 10 mg)?

We continue to have reports of IV calcium and IV phosphate being ran in the same line with some precipitation noted. We have instructions on both orders indicating to avoid running theses two in the same line and have clinical advisories at the pump as well. Are there any other strategies people have used to try and help prevent this from happening? In a couple cases the IV calcium and IV phosphate had the same administration due time. Is it an expectation that pharmacists are evaluating this upon verifcation and retiming if needed?

Hi everyone, as we all are MSOS members. And we all are working well in different places. My concern today is if someone can guide me as to how we can improve the quality and reduce medication errors. If anyone has worked on any program in his/her hospital till now then please share it here.

PRAVEEN KUMAR
CAPITOL HOSPITAL , JALANDHAR PUNJAB INIDA
7015551545
MSO, CLINICAL PHARMACOLOGIST

Reflecting on a look-alike error we had with dexamethasone and ketorolac vials that are nearly identical from the back and top, I had a radical idea that I would like to share with everyone.

Wouldn't it be great if all medication vial caps were plain white?

We all know that vial cap color is an unreliable means to identify a medication. There are more injectable drugs than there are colors, and there is no standardization across manufacturers for the choice of color. Despite this obvious fact, many people still do rely on vial cap color for identification.

At my facility, we had three incidences (three different patients) where Rocuronium was not paralyzing patients as intended (i.e. anesthesia has had to use twice the dose of Rocuronium from manufacturer below as opposed to the standard dose from other manufacturer).

I have already submitted a case with the manufacturer, and in the interim, we have sequestered the lot and replaced with another manufacturer.

Manufacturer: Piramal Critical Care
Lot: 24410013

Just wanted to see if any one else has received similar feedback from using this manufacturer?

Hi,
What are other centers planning with the news that Lilly will be discontinuing Humulin R 10mL vials by April 2026? We currently use this for our production of infusions, diluted doses for neonates, as well as direct IV for hyperkalemia treatment. Myxredlin will be an option for our infusions but comes as 1 unit/mL but the container may not be able to be used for dilutions or direct IV doses and the company advises against it.
Thank you,
Terrence Davidson
Medication Safety Pharmacist
Saskatoon Saskatchewan Canada

Our site is facing an impending shortage of PCA (Patient-Controlled Analgesia) vials and will not be able to safely transition to Alaris PCA pumps until 2026 due to supply and implementation constraints.

In the short term, we are actively exploring alternative options to manage pain safely and effectively while minimizing disruptions to patient care. Specifically, we are:

Does anyone have recommendations, protocols, or successful strategies they've used during PCA vial shortages? We are especially interested in:

Hey Everyone!

I'm just wondering if anyone has tips or recommendations on safely keeping both 10 mg/mL and 100 mg/mL ketamine in the same Pyxis. We've encountered a few emergency situations where IM or intranasal ketamine (100 mg/mL) was needed, but most of our units currently only stock the 10 mg/mL concentration due to concerns about the significant concentration difference. Both concentrations are currently set as overridable in the Pyxis profile. Any recommendations on how to manage this safely would be greatly appreciated. Thanks in advance!

Rachael

We are reviewing the practice of drawing more than a single dose into a syringe. This has been discussed by ISMP over the years (February 2016 Volume 14 Issue 2) and is a future question in the IV push guidelines (Under what circumstances is it safe to draw up more than one dose or use a single syringe that contains more than