Good Morning,

I would like to connect with others that have experience with HRP as their event reporting platform. Were you able to use the reporting forms "out of the box" or did you customize them? Was there anything that you would have done differently? Any input and tips would be greatly appreciated!

We are preparing to transition to the third reporting platform since I have been with this organization, and I have concerns that this negatively impacts our reporting. I would like to help make this transition as easy as possible on our frontline staff.

Good morning,

What strategies are you all employing to capture data around PI.01.01.01 EP5 (Adverse events related to using moderate or deep sedation or anesthesia)?

We historically have treated amiodarone, dopamine, and dobutamine as irritants.
Lexicomp current has them all listed as vesicants.
Per our nursing policy, this would mean very frequent assessments if infused via PIV.
How does your organization treat these infusions?
Thanks,
Stacie Ethington MSN, RN
Nebraska Medicine

Hello All,

Do any of you have any form of REMS policy in place to track the drugs, REMS requirements and provider compliance? If so, would you be willing to share?
For the drugs that require provider registration, how do you confirm this when you get a prescription? Does your system allow for such documentation or is it documented on the hardcopy?

Are there specific indicators: eg. level of harm to patient, drug class involved in event, technologies in use, etc. that your organization or practice utilizes to drive cause analysis like ACA? I am looking to put some framework around the kind of events we should sometimes/always consider for deeper analysis. TIA!

Greetings,
Would anyone be willing to share how their organization currently handles levonorgestrel IUDs in regards to it's hazardous drug status? Do you require full PPE for administration?

Lexicomp states: Hazardous agent (NIOSH 2016 [group 2]).
Use appropriate precautions for receiving, handling, administration, and disposal. Gloves (single) should be worn during receiving, unpacking, and placing in storage. Double gloving and a protective gown are recommended for administration (NIOSH 2016). Assess risk to determine appropriate containment strategy (USP-NF 2017).

We are working to improve safety surrounding anticoagulation prescribing by including a required indication field when inpatient orders are placed. This additional information will help the pharmacist to ensure correct dosing, especially for DOACs.

Trying to gauge if any other institutions have an indication field for documentation when anticoagulants are ordered and if so, if it is required.

Many thanks in advance!

Hi all. I am an ambulatory med safety officer. I am trying to incorporate GEMBA walks into all of our serious safety event reviews. How do other teams approach GEMBA concerns in a totally remote team? Do you look at staffing levels and patient load as well? Any additional items to look at for GEMBA?

Carrie Steiner, Ambulatory Pharmacist Swedish Medical Group, WA

We are in the process of implementing electronic prescribing of chemotherapy orders in our adult inpatient unit. Do the providers or the pharmacists at your institution enter the chemotherapy plans into the EHR? If the pharmacist enters the orders does a second pharmacist double check?
In our pediatric department the providers enter the orders and there is a double check by a second provider prior to going to pharmacy for a double verification. We would like to mimic that workflow in the adult setting but are meeting some resistance.

Hello,

Does anyone have limits set to the amount of potassium allowed per container (potassium in any salt form) or know of any safe practice recommendations that address this?

Thank you,
Mara Miller, PharmD BCPS
Medication Safety Coordinator
Kaweah Health Medical Center Pharmacy
400 W Mineral King
Visalia, CA 93291
T: (559) 624-5652