Dear all:
In King Faisal Specialist Hospital & research Center We where surveyed by the Joint Commission International (JCI) couple of months back, one of their findings was related to the labeling of high alert medications in the code boxes (crash carts) with a High Alert Stickers/ labels.
Currently we do not mandate labeling the high alert medications in the crash carts with a High Alert sticker/ label, knowing that almost all the medications in the crash cart are high alert and the whole code situation is a high risk critical situation.
My question:

Hi all -

Does anyone prohibit verbal orders for certain medications? If so, what meds?

Thanks,
Liz

Hi all,

My health system is looking for ideas to optimize our risk reduction strategies for EPINEPHrine administration errors for anaphylaxis in the acute and ambulatory settings.

1. Are you using autoinjectors?
2. Are you using "kits" with ampules or vials?

Please provide details on how you've managed either strategy.

Thanks in advance,

Ambra

​There is a shortage of tubing sets for the Baxa EM2400 TPN compounder with no release date in sight (#173 & 174). What kind of mitigation strategies are facilities using? We plan on using each tubing set for 48 hours to preserve our supplies. This will increase the risk of infection, but I feel it is outweighed by the risk of error that would be caused by manually drawing up TPN ingredients. Thoughts??

Are there hospitals who made the decision to Not carry Insulin U-500 to avoid errors with its dosing?
What do you use it its place when patients get admitted?
thank you!
Susan

Hi all,
Our department is reviewing our IV processes for efficiency and waste reduction.
We are not a 24/7 operation and currently run 1 24hr fill list a day for our in-patient pharmacy-prepared IV meds.
We utilize Horizon's Meds Manager as our PIS.

We are investigating running a 2nd IV fill with the goal of reducing the number of IVs we process for patient's who get discharged within that 24hr period. This would reduce the IV room workload as well as reduce medication waste.

Posting on behalf of Stephanie O’Brien, PGY1 Resident:

Hello,

For my research project this year I identified a liquid medication dosing error in our neonatal intensive care unit that is not detected by our electronic health record. Physicians enter a mg/kg dose into the EHR which automatically calculates a mL dose based on the patient's weight and the drug concentration. The EHR does NOT alert the physician if the mL dose is unmeasurable so we are seeing several instances where patients are being prescribed unmeasurable doses.

When you dispense patient specific insulin vials or pens, does your label display the dose?
Do you re-label the vial or Pen if the dose changes?

Thank You,
Cathy Goetz, Pharmacist
Medication Safety Officer
St. Luke's Hospital

Regarding pre-made IV products that have overwraps stating that product should be kept in overwrap until time of use – how do you dispense these products?

We decided to clean our IV room and Chemotherapy room instead of utilizing EVS. Is anyone willing to share SOPs that they had to develop for cleaning, training, assessment of staff?

Thank you!