Hi everyone-
We have had three patients experience anaphylaxis and subsequent cardiac arrest after receiving vancomycin at one of our facilities. Two of the patients received the same LOT and exp. I have submitted a manufacturer and MedWatch report, and we are sending drug off for testing, but I wanted to see if anyone else has experienced something similar. I know anaphylaxis after vanc is possible, but rare, and its alarming that we have had three events somewhat close together.

Hello all

We are struggling with replacement items - any using Cardinal have a good option they recommend?

Thanks in advance
Amy

HI All

I am hoping someone can share a medication safety officer job description with me?

Thank you!
Katie

Hello safety colleagues! Hoping to hear insights from other sites live on pump/EHR integration regarding products that have a variable concentration. Examples of variable concentration products would be "factor products" such as Kcentra or products such as alpha-1 proteinase inhibitor.

1. Do you have any variable concentration products "in scope" with pump integration?
2. If yes can you share tips or would you be willing to connect?

If your facility has a monoplace hyperbaric chamber what IV pump are you using? We are finding limited options and the most commonly used, the Zyno pump, does not have a drug library, which is against our policy.

Our infusion pump system now offers multiple Single Bolus Air-In-Line (AIL) Alarm Settings. At the lowest setting, it contributes to an enormous number of alerts. I understand that there are various causes to these alerts (e.g., nursing practice, characteristics of infusion, etc) as well as potential interventions; however, is there any guidance around what bubble size is considered clinically significant (or non-significant)? From my brief research on air embolism, it doesn't seem the highest pump setting would be of clinical concern.

Recently ASHRM has posted a Medication Safety Tip Sheet that provides a succinct overview on Medication Errors and Recommendations.
https://www.ashrm.org/system/files/media/file/2025/02/Medication-Safety-...

I would be interested in others thoughts on their definition for Adverse Drug Reactions as "side effects experienced by patients even when there is no error (PSNet 2019, NCCMERP 2015)."

Good afternoon,

For those facilities that have adopted interoperability with BD Alaris, could you share what process you follow to flush secondary medications, small-volume syringe medications, and large-volume syringe medications?

Thanks!
Mel

Hello, what does your organization use to dilute epinephrine in emergency time sensitive situations (eg as the drip is being brought to the patient)? There has been discussion around checking the availability of sterile flushes for this purpose.

Hey Everyone!

Our NICU is experiencing issues with SMOFlipids (potentially intralipid as well, they are just calling out SMOF as this is the primary lipid we use in our premature neonates) backing up, specifically when being administered via 1.4F PICC lines.

1.If you use SMOFlipids - what filter are you using, and have you experienced clogged filters or other issues with the infusion (particularly with extremely low rates)?