We are standardizing our RCA process across our health system. Initially we are requiring all sites complete an RCA for SREs (at a minimum). Eventually I'd love to expand this of course.

As you are probably aware the SRE definition for medication-related events is pretty generic. It is difficult to define "serious injury". Also, I would like to include events where a lack of monitoring led to serious injury, even though it is not technically covered by the examples given.

Has anyone developed or implemented a way to make the age of a medication on the history (when it was last entered or updated) visible to clinicians (MDs, RPhs, RNs, NPs, PAs, CPhTs)?

If so, has anyone incorporated alerting to the prescriber on reconciliation based on the age of the history being reconciled?

Since we are an EPIC shop, any insight or experience with a "Med Rec Module" for EPIC would also be most appreciated.

Regards,

Michael Van Ornum

At my organization, IV push paralytics are administered by nurses in a couple of defined situations, RSI and suppression of shivering in hypothermia patients. We have heard that Joint Commission has cited facilities that allow IVP administration of paralytics by nurses. Has your organization experienced regulatory challenges related to IVP paralytics? Do you have policy that limits who can administer a paralytic?

Hello all-

I have a question regarding how sites are ensuring safety with propofol.

1. Do you limit where it can be used?
2. Do you restrict access in the ADC to prevent diversion?

What else have you guys put into place to prevent errors and/or harm.

Natalie Zilban
Medication Safety Officer
Memorial Healthcare System
Hollywood, FL

For pediatrics we occasionally need tiny doses such as 0.25 units of rapid acting insulin. Since we cannot draw up using an insulin syringe, we are evaluating the process of diluting insulin with the sterile diluent from the manufacturer. Something we have encountered is how to best order and discuss the dose, once diluted. In pharmacy we tend to think of 0.25 units as 0.01 mL (of 25 units/mL diluted insulin). When our Endocrinology team is reviewing with patients, they tend to refer to this same dose as “1 unit of diluted insulin” to visualize the marking on the insulin syringe.

Following up on a medication error where a patient simultaneously took xarelto 15 mg twice daily and 20 mg daily, intended to start 21 days later, and presented to our facility with a serious bleed.

I discovered a workflow in our IR suite with heparin infusions that I am concerned with. The IR staff is priming a bag of diluted heparin through the pump, placing a needle on the end of the tubing, and injecting that needle back into the port of the bag. Then they run the pump at 999ml/hour and this set up is replaced every 24 hours. This provides them with a air free set up in the case of an emergent stroke.
Staff in the area state this is the only way they can guarantee an air free set up. I'm curious to see what other practices are out there.
Thanks -

Our practice has been to use 500ml bags for pediatric patients in the past which I presume it goes back to the days prior to infusion pumps, and that it was to decrease the risk if a dial-a-flow was left wide open somehow. Just wanted to see what others are doing. Does anyone have a policy on this they can share. Also, what is the age cutoff if you are doing this practice?

Hi All,

We are working on consolidation and development of an overarching insulin policy to address use in the hospital setting.

Do you have an overarching insulin policy? If so could you share?
If more than one policy, what do different policies address?

Thanks!

Can anyone share their experience with Baxter IV pumps?
We currently have Alaris and are interested in Baxter's Spectrum IQ pump.

I appreciate any information you can share,
Stacie Ethington
Nebraska Medicine