In Current State we have removed the use of a Buretrol system from the majority of our locations (except for anesthesia/OR workflows). Our Emergency Department is still using a buretrol system to administer intermittent medications that require a patient specific dose from a ready to administer bag. Have you successfully removed the use of a buretrol system? If you still use a Buretrol system -- what are the use case/purposes (dilution?, partial doses from a RTA?).

Hello,
We are looking at updating our High Alert Policy and just wondering what alerts other Hospitals use on their high alert medications. (i.e. stickers, ADC pop-ups, EMR alerts etc. ) Do you feel like alerting helps to reduce errors ? Thank You!

Jen

Hi all,
The new TJC standards do not include MM.01.02.01, which required a LASA list and annual review. MM.04.01.01 EP2 is moved to 14.01.01 EP3, so we still have the requirement for a policy that defines "precautions for ordering medications with look-alike or sound-alike names."
Reviewing LASA errors and maintaining the list is helpful for ensuring those precautions are in place so I'm hesitant to change policy, though it would be nice to lighten the timeliness burden of the reviews. Is anyone considering policy adjustments in light of the standard change?

We are all aware of ISMP's targeted safety best practice 6 to avoid glacial acetic acid, which has been archived since 2020. Attached is the NAN alert from 2013.

I always thought we had this best practice squared away, since we don't use glacial acetic acid. However, I realized that our OR uses acetic acid 4%, which we obtain for them from a chemical supply company, since our wholesaler only has the 0.25% product.

We are currently unable to get racemic epinephrine and may need to start switching to nebulized epinephrine. If you have implemented this before, what strategies did you use to ensure safety and decrease risk of wrong route administration. Thanks!

Hello all.

Per our High Alert policy, a dedicated IV pump is required when a high alert medication & concurrent continuous therapy (e.g. cardiac infusion) is needed.

Hi all,

We are embarking on a project to implement Epic's manual MAR hold feature. I was interested in learning from others who already have manual MAR hold implemented in Epic.

Specifically:

1. Any existing policies/procedures that could be shared?
2. Do you include/exclude certain medications/classes of medications?
3. What safety events have commonly occurred? Any specific challenges?
4. Lastly, was there any specific education/training provided to providers, nursing, and/or pharmacy re: manual MAR hold?

Thank you!

Within the past year our hospital burn ICU has started using a combined inhalation injury order set incorporating nebulized heparin with nebulized N-acetylcysteine (NAC) and albuterol-ipratropium for the treatment of inhalation injury related complications. Our practice is for RT to mix two 5000 unit/1 mL vials with 1 mL of NaCl and administer nebulized via the vent. We've had a couple instances where nurses pull the heparin and administer it subcutaneous since it is the same product used for VTE prophylaxis.

Our hospital switched to the Wireless Parasol Fall Prevention system years ago. We are evaluating different options at this time. If you have a system that easy for nurses/therapist to use and are seeing successful fall prevention results with, would you please share the name of the chair alarm system with me? Thank you!! April