I am reaching out because our system is currently updating our policy around labelling medications in the periop space. With the change in NPSG 03.04.01 that now (since 2024) requires expiration date and time on the medication label unless it is a short procedure as defined by the organization, I wanted to reach out to see how your facilities are handling this change in their policies?

Did you define what a short procedure is? How did you address USP <797> immediate use BUD of 4 hours in your policy?

Hello,

What type of expiration date do you assign to 0.9% NS 1000 mL stored in the refrigerator (2-8 C) for Malignant Hyperthermia emergency use? I know it varies based on brand/type (B.Braun, Baxter, Excel), extended stability data shows it could be good beyond 30 days. Curious to know what your facility is doing.

Thank You,

Samir Jani

Good afternoon MSOS members,

I would like to know if you can share any procedures, workflows, and templates related to your organization's EHR medication build, testing, and validation processes. Thank you in advance!

Hello colleagues,

After switching from Kcentra to Balfaxar, IV staff are reporting that it takes much longer (>5 minutes) to reconstitute Balfaxar (even when stored at room temperature). Curious if other sites have noticed this and have found any mitigation strategies (i.e. constant gentle swirling)?

Thank you,
Megan Fragale, PharmD, MS, BCPS
Medication Safety Officer
Skagit Regional Health

Curious if anyone has developed any sort of site medication safety rounding template or checklist. Our organization has 9 inpatient facilities as well as numerous clinics. I would like to start a rounding cadence with our sites and am interested in how others are approaching this.

We’re currently evaluating how to handle the pyridoxine IV shortage at our facility (over 500 beds). Part of our team is considering implementing a hard stop using LMA (an alternative mechanism in EPIC) that would prevent the order from being placed entirely. The intent is to have the provider call the pharmacy directly to discuss the request. This would be a hard stop without an alternative built into the system.

We’re trying to assess if this is the best approach or if there are more effective strategies. I’d love to hear how other facilities are managing this:

Have you done/considered turning off the penicillin allergy cross reactivity warning for cefazolin specifically? Have you used any mitigating actions to keep the alert "on" for SJS, TEN and DRESS?

Colleagues,

Do you allow for same day inpatient chemotherapy ordering (or order releasing from treatment plans) and administration -OR- do you endorse a time-based cut off model for oncology therapies?

Thank you,

Megan Fragale, PharmD, MS, BCPS
Medication Safety Officer
Skagit Regional Health

For EPIC hospitals, have you configured/disabled system settings around which units can be used for patient-reported medication in medication reconciliation? Our system currently allows dispensing units to be used during med reconciliation which contributed to recent medication error in which a patient was inadvertently ordered for 7.5 tablets instead of 7.5 mg - beginning with the admission medication reconciliation.

Do you allow docusate to be used for ear wax removal in clinics/hospital settings? If so, do you extract the contents of a capsule or use the commercially available oral liquid? For those who are using the contents of a capsule, what precautions are used to limit the risk of sharps injuries during this process?

Thanks!