Hi everyone,

As a health system expands, the layers of medication safety expand as well. For our health system, a newly developed System P&T overseeing both ambulatory and inpatient settings has requested review of medication errors generated through our internal incident reporting software.

My questions for the group:
1. Are any of you currently sharing medication error data/alerts at the P&T level?
2. If yes, what sort of information is shared (e.g. internal data, ISMP alerts, recall information, etc.)?

Thank you,

Recently nursing was concerned with the use of puralube for patients who are receiving oxygen (due to the flammable nature of the ointment). We changed the ventilator order set to reflect artificial tears instead.

Our hypothermia set however still contains the ophthalmic ointment for patients receiving paralytics. I cannot find a non-petrolatum based ophthalmic ointment.

Please share the product that you utilize in this situation.
Thank you in advance for your feedback!

Would anyone be willing to share their template for their organizational medication safety strategic plan. I am tasked with putting one together for the next year and would like some examples instead of reinventing the wheel!

Thank you in advance!

Would anyone be willing to share a template that they use for their Organizational Medication Safety Strategic Plan? I am tasked to put one together for my organization and wanted to see if others had some good examples to work from.

Thank you in advance!

We are in the midst of evaluating our process of what & how suppositories are supplied to nursing by pharmacy for our pediatric patients.

does your institution have a policy/procedure on how partial suppositories are supplied to patients (do RN's cut vs prepared by pharmacy)?

do you allow more than one suppository to be given to meet ordered dose (i.e. supp is 40 mg, dose is 80 mg- allow 2 supp to be given)?

what type of glycerin and acetaminaphen suppositories do you use- liquid or solid?

Thanks!
Lindsey

Hello,

When a patch (such as clonidine) is held due to parameters, is there a process at your institution to monitor the patient and check when the patch should be given again? For example, since clonidine is given every 7 days, if it's marked as held and there's no follow up, the patient would miss an entire week of clonidine. Do nurses at your institution typically page the provider to inform, recheck again in an hour, hand off to the next shift, recheck again in a day...?

Thank you!

Does anyone have a good process for providing patient education related to Sugammadex?
An additional nonhormonal contraceptive (eg, condom, spermicide) should be used for 7 days after a dose of sugammadex in women using oral or non-oral hormonal contraception.

Who is responsible for identifying and educating patients - nursing, pharmacy, anesthesia? What does the education consist of?

our high alert policy is currently under review. RNs are not required to perform independent double check on subcutaneous administration of heparin per our current policy. We are considering if we should maintain this practice or change it to require a co-signer. What are you currently doing at your respective hospitals. Are all forms of heparin, irrespective of the route co-signed by another RN or only the IVs and the drips? Thanks for your input

What does your facility do in terms of risk mitigation for 23.4% concentrated sodium chloride? Currently pharmacy draws up and puts into an empty ViaFlex and sends up a high alert double check form with it. A new PA mentioned other facilities administered it IVP (rather than via an IVPB) and having a special 'box' in the ICU Pyxis containing the medication so I wanted to see what other facilities do. Thank you!

Due to some IV therapy errors we have had we are reviewing our practices surrounding hanging new bags. One of the topics we are debating over is whether there are recommendations regarding line labeling. Is anyone aware of guidance from any professional organizations on line labeling?

I'd also love to hear any personal opinions or experiences others have on this topic. Does it facilitate line tracing or does it cause unintended bias with line tracing?

Thanks!