Recent injury report of a nurse cut when plastic flange broke when administering the dose during a code. On follow up, I was advised that several other syringes have done the same thing. We have placed a formal report with the company but I wanted to reach out to this group to look for any similar occurences. Staff do describe it taking a lot of pressure to administer the medication

Any feedback is appreciated

Julie Caler
MSO Western Maryland Health System

Dear all:
I know this is not the first time to bring this question, but I tried to search for it in the forum topics and could not find it.
In our hospital I am working to establish a medication safety team/unit, currently I am writing the business case or proposal for it. I am planning to include the number of big hospitals similar to our hospital (Tertiary care leading teaching hospital with around 1100 beds) that have a structured medication safety program/ team / unit with a full time FTEs in the document.

My hospital system over the past 6 months has had increased attention around dangerous medications possibly found in the community and their risk to health care providers (Carfentanil, other synthetic medications that can cause overdose from touch exposure). This issue has been combined with a more recent issue of illicit medications that are being packaged to look identical to prescription medications (Example: Heroin being pressed to look like Percocet).

Hello,
We recently had a 15 kg adult patient being cared for in our ICU and due to her low weight multiple dosing errors occurred.

Does anyone have any suggestions for how we can flag for this unique patient population or develop a trigger to the pharmacist to alert him/her to review the medication against the weight?

Best,
Rachel

During a recent mock surveyor it was brought up that our institution does not have a "carry policy" or built into another policy verbiage addressing stability/temperature monitoring of medications within fanny packs. I was wondering if anyone has anything specific to this and how you are executing it.

Thanks in advance

What are other facilities doing in regards to epinephrine IV infusion compounding since the IMS brand of epinephrine 1 mg/ml, 30 ml for IV dilution has been discontinued by the manufacturer?

Currently, the only large vial of epinephrine available is the Adrenalin 1 mg/ml, 30 ml vial by PAR and it is very specifically listed for Intramuscular or Subcutaneous Use only. The FDA has not approved for IV infusions and the company cannot provide any off-label use for IV infusion as well.

Our pharmacy compounding suite is undergoing a renovation starting mid-July, including our sterile hazardous compounding room. For any chemotherapy needed our Cancer Center across the street will compound it for us (we do a low inpatient volume). The one scenario that we don't know what to do with is methotrexate for ectopic pregnancy since this could happen overnight when our Cancer Center is closed. Any one have any contingency plans for something like this?

Do you allow nursing to crush one time doses of hazardous medications on the floor to administer via g-tube or do you require pharmacy to crush in a controlled environment per USP 800?

If you allow nursing to crush on the floor, what device do you use for crushing and what additional PPE requirements do you have for them?

We are struggling to determine if pharmacy needs to take over crushing activities for hazardous medications (non-antineoplastics and reproductive risk).

Thank you,
Madiha

Hi, a question for Epic users,
What is your means of minimizing risk of duplicate dosing of drugs such as vancomycin when the patient receives a pre-op dose in OR, then after procedure returns to floor, then receives another dose based on an active MAR order.
Is the Transfer navigator used appropriately/effectively?
Do you use duplicate dose alerts?
Thank you for your input.
Susan

Greetings,

We have noticed an increase use of monoclonal antibodies (MABs)for non-chemo indications, and when prescribed it has been noticed paperwork or labs are missed.

To safely order MABs for non-chemo indications, how do others utilize the capabilities of their CPOE system? Has this been a concern at any other sites?

Thank you in advance for the responses. It is highly appreciated.

Jessa