Hello,

Wondering if other sites have a good process for this. For patients that come in on an IUD, how is this being managed from an order rec process? We have had issues where a provider unintentionally ordered a patient's IUD for continuation in-hospital from their home med list, leading to our pharmacy dispensing one but luckily was caught by another pharmacist.

Looking to see how everyone incorporates PGY-1 residents in the med safety process at your institution. Do you do it longitudinally? Do you allow them to help investigate error reports and if so, do you allow them full access or do you de-identify them to keep names of staff confidential? Would appreciate seeing any and all recommendations you may have around this. Thanks in advance!

Hello fellow Med Safety officers.

I am looking to see how other institutions manage duplicate pain medications ordered via different routes, but for the same pain scale to comply with JCAHO's "Med orders are clear & accurate" standard.

For example:
Post-op ortho orders:
Oxy IR 10mg po q4hrs prn severe (7-10) pain
Dilaudid 0.5mg IV q2hrs prn severe (7-10) pain

Hello colleagues,

For those who have nebulized tranexamic acid for hemoptysis, how do you dispense it? Repackage and dispense from pharmacy or allow respiratory therapist to remove a vial from an ADC based on a linked order?

Thank you kindly,
Megan Fragale, PharmD, MS< BCPS
Medication Safety Officer
Skagit Regional Health

Does anyone have any USP 800 practice exceptions surrounding the use of methotrexate in ectopic pregnancy that allows its use for this indication outside of a sterile compounding containment environment? e.g., assessment of risk (AoR) that delineates appropriate storage, handling, disposal that would allow the frontline nursing staff to draw up and administer these onetime intramuscular doses.

Thank you!

Question for retail pharmacy members: We are discussing paperless options to deliver medication guides to the patient. Has anyone in this group switch from printing the FDA medication guide to give to patient to an alternative paperless delivery of the FDA medication guide? Thank you! Lu

Wondering how your facility prepares chemo doses that are dispensed in bags.
1) Do you start with an empty bag and add the diluent and drug to the empty bag?
2) Do you start with a commercially available bag and remove fluid from the bag? Do you remove overfill? Have you had any concerns of doses being prepared inaccurately due to varying amounts of overfill?
3) Does your process vary depending on pediatric vs adult/adult sized patients?

Has anyone been successful with curbing unintentional therapeutic duplications with PRN orders? I know this has been a long-standing issue with TJC. I perused prior discussion on this topic from 2013-2016, and hoping to see if there was something new we could learn from.

All we have had several errors secondary to missing medications and significant delays once replacements are requested. In larger facilities, would you be willing to share process metrics in terms of time required to re-dispense, verify and deliver a medication to the nurse?

Any insight would be helpful.

Thanks,

The anesthesia department at my institution is starting to explore the use of bar code scanning of medications in intra-operative areas (we use EPIC). Are there other institutions that have incorporated this into OR processes, and would you be willing to share your experience implementing this process as well as what the barcoding process actually looks like in the OR suite?