We have recognized for a long time that in patients with enteral tubes, often times the orders are not updated to specify "per enteral tube" but remain as "po". The pharmacy team verifying orders do not know that meds are being given via tube and thus are often not able to identify problems proactively. We recently had a serious safety event related to Flomax being opened and placed into a G-tube, which resulted in a clogged tube and necessitating replacement of the tube twice, the second time under sedation (thus the severity rating of the event).

We have recognized for a long time that in patients with enteral tubes, often times the orders are not updated to specify "per enteral tube" but remain as "po". The pharmacy team verifying orders do not know that meds are being given via tube and thus are often not able to identify problems proactively. We recently had a serious safety event related to Flomax being opened and placed into a G-tube, which resulted in a clogged tube and necessitating replacement of the tube twice, the second time under sedation (thus the severity rating of the event).

Good afternoon,
Wanting to pick the brain of this group for how you are all achieving ISMP Best Practice #16 part C "Monitor ADC overrides and verify appropriateness, transcription of orders, and documentation of administration."

We perform an annual review of our override list and keep it targeted towards only medications needed in an emergent situation. We also have really honed in on reducing the numbers of unlinked override pulls and saw great improvement in those numbers.

Hello,
I was looking to get an idea of how many facilities that use Epic also use the One Step Med process for anesthesia, codes, etc.? Could you please comment on if you use the One Step Med process? Thanks.

Hi All !

How many high alert medications are on your policy for high alert medications ?
How many of those require double checks by nursing ?

I know this is an age old process and topic ! thank you for any information !

We are trying to implement a "Good Catch" award program and was looking for any suggestions, recommendations, ideas, etc from other organizations. Thank you

Wondering how others dispense chemotherapy with a SUBQ/IM/IT route in regards to CSTD. I am taking over from another team member who is no longer with our organization and a couple of years ago it was decided to dispense the syringe with the PhaSeal Optima injector still attached and then that is removed and the needle attached immediately prior to administration. I am now getting questions from nursing on this and I don't know why that decision was made a couple years ago in the first places so just curious as what other institutions do. Thanks!

My institution is starting an open heart program and I am working on the safe storage and dispensing of the cardioplegics and reperfusate. We will have one OR room and a Pyxis specifically for this room. How do others store their cardioplegics inside and outside of the pharmacy? For the Pyxis thinking of devoted tower door(s) where only these will be stored with labeling on the door. Thanks!

Is anyone supplying naloxone to the morgue staff? We have had a request to provide to the morgue in case of exposure to unknown substances (topically or inhalation). If this is being provided were team members educated on use and who monitors expiration dates? Thank you.

Hi All,

A question was raised at our institution regarding best practices for flush and maintenance fluid compatibility with IV Bactrim. I am hoping to learn more about standard practices across the country with regards to this specific medication combination as the compatibility data is dependent upon concentration and time in-line.