Hello MSOS,
My institution currently utilizes an electronic incident reporting system, Clarity, to capture medication related errors in the facility. But as you realize self-reporting is only the tip of the iceberg. We are trying to come up with other methods to increase reporting of medication events (and/or adverse events). So my question to the group is two-fold. Are there are other methods you utilize to improve reporting and identification of medication related events? And how do you encourage staff to report events? Thanks so much for your assistance.

The Prismaflex set that we use for our CRRT therapies has a heparin syringe pump attachment, requiring heparin to be prepared in a syringe (20mL size)and sent to the nurse, which poses the obvious risk of mixup with many other products sent in 20mL syringes.
Would anyone share how they prepare/send their heparins for CRRT?
Thank you!
Susan

In your organizations, could you please describe your approach to ensuring that appropriate patient monitoring takes place to support the safe use of a medication at the point of medication administration (i.e. at baseline, during admin, following admin)? This could include monitoring related to an IV drug known to have hypersensitivity reactions at the time of infusion OR could include monitoring following an oral antihypertensive.

Protamine has a black box warning that describes serious reactions (including cardiovascular collapse) to certain patients especially those known to be of higher risk (such as use of protamine-containing drugs including NPH insulin, allergy to fish, previous vasectomy, etc.).
• In light of this warning, do you have a protocol in place to note if the patient is at a higher risk for a reaction before procedures?
• Are you giving test doses of 5 mg to patients? If so, has this helped to prevent serious reactions?

For those that use the Alaris syringe pumps....Do you keep the near end of infusion alarm on or off? Our nurses want to have them turned off and we want to see what other institutions are doing.

Thanks,

Randi

Randi Trope
Pediatric Medication Safety Officer
Cohen Children's Medical Center

How do you store multiple use meds for patients on contact isolation (i.e. inhalers, creams, eye drops, etc)? Do you keep them in the patients room or return them to Pyxis? If you keep them in the patient room where do you store them in the room?

Thanks,

Randi

Hello,

Our hospital is considering moving to the Aerogen system for continuous nebulized medications (epoprostenol and albuterol) because it offers a non-luer compatible syringe and tubing set as well as a blue colored plunger and tubing to hopefully prevent wrong route errors. We also plan to use a different brand of syringe pump than we use for IV medications per ISMP recommendations.

Do you dispense cyclosporine PO solution in syringes? If so do you have a reference that states stability? Specifically looking for Gengraf brand.

Hello,

I am collecting information about the different ways that pharmacies dispense BCG.

How does your pharmacy prepare and dispense BCG?

ie. How many preparations of BCG do you do per week? Who prepares the product? What type of hood, if any do you use? What kind of handling precautions do you have in place? How do you operationalize this?

Thanks!

Bridget Gegorski
Bridget.Gegorski@uhhospitals.org

Dear all,

I am wondering if anyone has a specific policy in place at their institution which addresses opening dofetilide (Tikosyn) capsules for oral administration. It seems to be a bit of a gray area. ISMP has not addressed this to date and the manufacturer offers no clear guidance.

Thanks in advance for your response!
Ted