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ISMP has introduced a new tool to help hospitals, long-term care facilities, and certain outpatient facilities evaluate their best practices related to high-alert medications, identify opportunities for improvement, and track their experiences over time. The ISMP Medication Safety Self Assessment® for High-Alert Medications focuses on general high-alert medications and 11 specific medication categories--including opioids, insulin, neuromuscular blocking agents, chemotherapy, and moderate and minimal sedation. Participants who submit assessment findings to ISMP anonymously via a secure internet portal by December 15, 2017 will be able to obtain their weighted scores so they can compare themselves to demographically similar organizations. Participation also can help organizations meet requirements for managing high-alert medications from regulatory and accrediting agencies, such as the Centers for Medicare & Medicaid Services and The Joint Commission. To access the self assessment workbook, go to: http://www.ismp.org/selfassessments/SAHAM.
Opioids are still among the most frequent high-alert medications to cause patient harm, and anesthesia providers are in a key position to support improved understanding of the risks associated with the use of opioids. An ISMP symposium on opioid safety is being held at the American Society of Anesthesiologists (ASA) meeting on October 22, 2017 in Boston, MA. Please encourage your anesthesiology department to attend--there will be discussion about current opioid medication safety challenges and the potential leadership role for anesthesiologists in error prevention. For more information or to register, go to: http://surveys.ismp.org/s3/freseniuskabi-ANES17
At the recently held MSOS Member Meeting during the ASHP Medication Safety Collaborative in Minneapolis on June 4, 2017, a member shared an occurrence that happened in their facility. The member believed that a defect in BD’s (Pyxis) MedStation ES software resulted in the misinterpretation of an order frequency intended to be every Monday, Wednesday and Friday as every day that was associated with a patient incident. David Swenson, Vice President, Clinical Strategy, Medical Affairs, Medication Management Systems at BD attended that meeting and publicly volunteered to investigate the report. David shared his investigation For the full message with an excerpt of his findings, please click on the title above.
For years, insulin has been shown to be associated with more medication error-related harm than any other drug. The new ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults are designed to help healthcare practitioners prevent errors and improve outcomes for patients with diabetes. The guidelines, based on a multidisciplinary consensus conference of experts, provide recommendations for avoiding at-risk behaviors involving subcutaneous insulin across the entire continuum of care, including prescribing, preparation and administration, monitoring, and patient education. The document also addresses evolving practices, devices, and technology that aim to enhance the safety of insulin use, such as with concentrated insulin and insulin pen devices. For a copy, visit: https://www.ismp.org/Tools/guidelines/default.asp