We are looking for examples of a patient friendly medication reconciliation report that could be used after admission to communicate clearly with our patients (actually parents, we are peds) each medication we have on their Prior to Admission med list and what was done with each medication on that list.

Does your process for preparation and dispensing of vinca alkaloids differ from other chemotherapies? If so, how does it differ? Any input is greatly appreciated.

What expiration time does staff put on medication syringes that may be drawn up in a procedural area? This does not include compounded syringes--this is for single drug in syringe drawn up in prep for a procedure. Our policy states expiration date and time must be on the label if medication is not immediately administered. Thanks, Mary

What expiration time does staff put on medication syringes that may be drawn up in a procedural area? This does not include compounded syringes--this is for single drug in syringe drawn up in prep for a procedure. Our policy states expiration date and time must be on the label if medication is not immediately administered. Thanks, Mary

Hi all,

I am wondering, for those who use both a heparin by anti Xa nomogram and a heparin by aPTT who manages which protocol? Here we currently have nursing driven anti-Xa protocol and pharmacist driven aPTT protocol. Mix-ups occur and looking to improve our process. Thanks!

Hello everyone!

Does anyone have processes in place to mitigate transcription errors? We are an Epic based system and often times ERXs are being updated or we are constantly having to swap orders due to shortages. Therefore transcribing or swapping orders is not uncommon. Does anyone have a standardized double check process in place for when high risk medications are being transcribed? We've had instances where administration instructions were forgotten on titratable drips or dosage units were mixed up (weight based vs non weight based), etc.

Based off of our last few AHRQ Culture of Safety surveys and the intense view of medication errors during transitions of care, we have been focused over the last several years on finding a handoff tool that could be used within Pharmacy. Many safety organizations have focused on communications between clinicians at transitions (including shift change).

While the I-PASS has shown so much promise and extremely great results for providers and nurses, this does not seem to translate well to Pharmacy.

How do you hardwire handoffs in your area? Specifically:

We are working with our nursing partners to optimize the process for concealing PHI on labels when used medications are discarded. Beyond redacting this information with a black security marker, have any institutions implemented other measures, such as privacy stickers, stamps, or self-shred / perforated labels? If so, what are you using, and how is it working?

Thank you,
Heather Erwin
Barnes-Jewish Hospital
St. Louis, MO

ISMP would like to know if the ongoing shortage of parenteral nutrition (PN) components or supplies has resulted in medication errors or close call events.

We would appreciate if you could share your experiences via the ISMP Medication Errors Reporting program: https://www.ismp.org/report-medication-error

Thank you!

Wondering what others are doing to incorporate medication safety into your PGY-2 program? We are in the process of increasing our PGY-2 residents and wanted to develop a more formalized approach with med safety. In the past, the PGY-2 resident has reviewed and trended critical care events then worked to develop an improvement process and have worked with an individual unit to identify and develop an improvement process. We would like to get the residents involved while keeping focus on their specialty area. Thank you for your time.

Carol