Hello -

Recognizing that 'medication error rates' captured by voluntary incident reports is the least effective and least reliable determinant of true error rates / benchmarking....

I wondered if other institutions have developed executive-level (or really any level) benchmarks / dashboards / metrics which they follow in their health system to track performance improvement within medication safety and safety realms?

I would be particularly interested if anyone has develop these measures in the outpatient / ambulatory spaces as well.

Hey safety gurus!

Wanted to know if anyone has any input/guidance regarding having a default age/DOB for the pediatric unknown patient (e.g., trauma patient) in order to get the patient registered and allow orders to be entered. EPIC is our EMR and most things (alerts, normal ranges, etc) are based on age and weight. We are trying to find a way to choose a default age/DOB that allows us to get the patient registered and orders entered, while maintaining our medication and lab safeguards.

Thanks in advance for any help that you can provide.

-Jameika

How do you dispense remifentanil for use by anesthesia?
Do you draw up syringes for them?
Dispense vials and they draw up?
Purchase premade syringes for their use?

Thank you,
Ann

Our opioid stewardship team is trying to determine the best way to meet the Joint Commission Pain Management Standard for identifying high risk patient's. We would like to flag patient's who are considered high risk for opioid related harm via Epic. Has anyone successfully implemented this at your institution. How are you meeting this standard and identifying high risk patients?

In the ED Zofran is often given quickly and early (from or in triage). Do you have any systems in place to ensure that patients with congenital prolonged QTc do not get it? We are seeing that those that prescribe it in the ED are usually NP's and residents that may not realize the connection yet.

Therefore looking to see what, if any, measures you have in place to prevent it's prescribing.

Hello.

I'm wondering what occurs at your organization when a vascular access device infiltrates/extravasates. If the agent that infiltrated/extravasated has an antidote, do you always use it or is it based on severity of the event?

I appreciate your guidance,
Stacie Ethington
Nebraska Medicine

HI All,
I really enjoyed the "Great Safety Debate" at the ASHP Annual meeting. As part of the follow up to the drug testing debate, I have begun to look at what pharmacies or hospitals have done for fatigue management/ alertness in a structured way. I had a recent discussion with a vendor that was mentioned at the debate and I think my coworkers were a bit surprised how pharmacies are staffed in the real world with call ins, doubles, 7 on 7 off midnights, etc. (often in violation of fatigue management principles).

We discovered a concerning nursing flushing practice that is occurring in our clinical research unit. After an IV investigational medication has been administered, the nurses are drawing up 30 mL of fluid (usually 0.9% NS) and injecting it into the empty bag. They then run the 30 mL at the infusion rate the drug was run at. They do this to ensure the entire dose of investigational drug is delivered, and state this is common practice across the country. We have safety, sterility, and documentation concerns and are wondering if this is actually done elsewhere.

Thanks,

We have a lot of single dose vials that we reuse during 6 hours window that is allowed per USP 797, since we serve pediatric patients, we usually do not use the whole vial per one patient.

I was wondering how other hospitals store vials in ISO 5 environment, since we might epinephrine vial and dexamethasone that look almost identical. Outside of ISO 5 environment we have more space, so we can segregate epinephrine vial away from dexamethasone. What about narcotics, since they have to be locked? How can we store open vials of narcotics safely in ISO 5 environment?

We have a lot of single dose vials that we reuse during 6 hours window that is allowed per USP 797, since we serve pediatric patients, we usually do not use the whole vial per one patient.

I was wondering how other hospitals store vials in ISO 5 environment, since we might epinephrine vial and dexamethasone that look almost identical. Outside of ISO 5 environment we have more space, so we can segregate epinephrine vial away from dexamethasone. What about narcotics, since they have to be locked? How can we store open vials of narcotics safely in ISO 5 environment?