Situation: Over the past 8-12 weeks, the pharmacy team at our 400+ bed hospital has seen an increase in unexpected or unexplained heparin anti-Xa levels whereby patients may be therapeutic and then have sudden unexplained undetectable results, or sustained sub-therapeutic levels. It seems that more patients are requiring much higher doses to achieve therapeutic anti Xa results; and patients are taking longer to achieve therapeutic anti-Xa levels.

Please note we have not undertaken a formal study but our observations seem to suggest something is different with heparin.

Good afternoon,
We are still working on the Standardize for safety guidelines in regards to changing to weight based dosing (per ISMP and ASHP recommendations www.ismp.org/ext/446) for levophed (and epinephrine and phenylephrine).

I wanted to see if other sites are still using rate based dosing in mcg/min for levophed:
-What is your max rate in mcg/min?
-I'm curious if there was a particular rationale for not going to weight based dosing?

any feedback helps
Thank you!
Happy New Year Everyone!!

Hello everyone,

Our organization is actively evaluating our processes around smart pump events in an effort to improve our standardized response.

In your hospital/system/organizations, who is responsible for reviewing both the error and event logs from the pump and communicating out that information after a adverse event that involved a smart pump?

For context, our system utilizes Alaris pumps and currently has teams from Clinical Informatics, Clinical Engineering, and Medication Safety all involved after an event.

Thank you for your insight!

Is anyone is tracking medication-related metrics for staffing shortages? Barcode scans, overrides, late meds, etc?

Hi everyone,

Hi,

We've seen a noticeable increase in reactions to IVIG, from patients who have previously tolerated it. We seem to have identified one lot number that has been in common for all but one of them. We've contacted the manufacturer about it, but I was curious if anyone else has gotten reports of similar increases?

Thanks,
Kara Thornton
UVA Health
kara@virginia.edu

We are re-evaluating options for continuous fentanyl infusions. Would you mind sharing your preferred fentanyl concentration in ICU ventilated patients? How do you deliver the fentanyl infusion, e.g. PcA pump, LVP pump, other? Thank you for sharing!

What does everyone have in place for PCA risk mitigation strategies. We currently use Alaris PCA pumps which utilize a typical luer lock syringe along with Epic as our EMR. We recently had an event involving PCAs and are looking to see what other institutions do. We utilize the double check function in Epic but in this situation the nurse did not know what a PCA is and thus was unaware of the double check requirement and since it is a luer lock was able to connect the PCA syringe to the patient's IV line.

Hello, we are interested in how different facilities handle 5% sodium chloride bags used during LDL apheresis from a medication safety standpoint. We recently became aware these were being stocked in our Cath lab when they went on backorder and are wondering what strategies others have put in place to prevent mix-ups with isotonic saline or other fluid infusion bags.

Thank you!
Lauren Gashlin

Strong Memorial Hospital
Rochester, NY

Good morning colleagues and friends,

We are anticipating TJC in the next few weeks and I was wondering if anyone already had their triannual TJC visit recently. I am interested in learning about what were the surveyors focus points during their visits.

Thank you in advance for all your help.

Sincerely,
Mohamed Sarg