MSOS Discussion Board

MM.05.01.11 EP 4

Stacie Ethington's picture

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Good afternoon,
I am wondering if you can share your thoughts on this Joint Commission requirement: "Medications are dispensed in the most ready-to-administer forms commercially available and, if feasible, in unit doses that have been repackaged by the pharmacy or licensed repackager."

High Alert Designation on EMR Labels for Health-Systems

Lara Ellinger's picture

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Hi All,

Can those of you who work at health-systems with multiple inpatient sites on one instance of Epic share your approach to High Alert medications? Specifically,

1) Do you have one shared list or does each site have their own?
2) Do you leverage your EMR-generated labels to designate those meds that are High Alert? How does this work if you have one list?

Bag/container for personnel to carry medications

Julie A DAmbrosi's picture

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Adult Medical Emergency pharmacists at YNHH are going to start a pilot to bring tenecteplase kits to codes soon. They will obtain the drug kit at the beginning of their shift and if not used return it to inventory by the end of their shifts

How are other organizations supporting the carrying of medications on personnel so that one is maintaining drug security, but also ensuring maintenance of proper storage conditions? In other words, how have you addressed the concern for lab coat pocket or fanny pack use and adjacent body temperature?

Vesicant/Irritant Potential

Emily Messing's picture

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Our institution is looking to develop a process for regularly reviewing agents for vesicant or irritant potential when it is 1) FDA approved and 2) reported to FDA post market as having vesicant/irritant potential. Does your hospital have a committee or task force that manages/reviews this? Are there any specific resources that you use when reviewing this information? Any other information you can provide about your process would be greatly appreciated. Thank you!

Independent Double Check Lists

Carley Castelein's picture

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Hi,
Our organization is going through an analysis of independent double checks to make sure they are judiciously used. I had a couple questions for the group:

1. What are the objective criteria you use to determine if a medication requires IDC at administration?

2. Are there instances when an IDC is performed but not documented?

3. In the meds you require IDC, is there a carve out for in emergent situations "it is not required if delay in care could cause harm to the patient in an emergent situation" (or something similar)?

Turbid Ferrous Sulfate Solution

Perry Shafner's picture

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One of our pharmacists noticed turbidity in a ferrous sulfate solution stock bottle that had been opened less than a month ago. We are unsure if this is due to contamination from mishandling by our staff or if there is a problem with the product itself.

Please share if you have experienced a similar issue.

Product details:
Ferrous sulfate solution
15 mg of elemental iron per ml
Patrin Pharma
NDC: 39328-557-50
Lot: M1054
Exp: 12/24

Thanks,
Perry Shafner
pshafner@gbmc.org

Pneumatic Tube Use for Controlled Substances

DiAnthia Patrick's picture

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WE recently went through a pneumatic tube system upgrade. The new system has functionality to allow secure transport of medications (like controlled substances) if we so desire. We have not turned the functionality on yet as we're still having some inconsistency with the tube system going down more regularly than we'd like.

Does anyone have a tube system where this functionality is turned on? If so, what happens if the tube system goes down while a CS is inside the system and has not reached the destination yet.

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