s/b: pt is 12 month old, in ER for bite. pt required tetanus/diptheria shot as part of care. pt was ordered a tdap order which is for peds 7years old and older instead of DTaP

curious what forced functions facilities have utilized to better identify the correct vaccine. we currently have epic

Hello everyone,

What are your practices around patients coming in on a patch? If the provider orders for it to be continued inpatient, do you leave the patch on and apply the next patch at the next due time? Or do you automatically switch to your own patch without waiting for the next due time?

Thanks!
-Saduf

Hello everyone,

Our institution has encountered several reported errors related to the programming of CADD pumps. Because this is a low-frequency but high-risk workflow, nurses often feel unsure or unfamiliar with how to properly program the pumps.

I’m reaching out to see if other health systems have implemented any specific safeguards or best practices to support safe administration and reduce the risk of error. Any insights, tools, or workflows you’ve found effective would be greatly appreciated.

Thank you!
Dominique

Hi all, we have seen an anecdotal (at this point) increase in post-partum hemorrhage over the last week, even in patients that have received usual amount of oxytocin. This has befuddled the medical director, and she is curious if there is a potential issue with the product we are using. Has anyone else using 503(b) oxytocin experienced anything similar recently?

Thanks,

Kara Thornton

I am reaching out because our system is currently updating our policy around labelling medications in the periop space. With the change in NPSG 03.04.01 that now (since 2024) requires expiration date and time on the medication label unless it is a short procedure as defined by the organization, I wanted to reach out to see how your facilities are handling this change in their policies?

Did you define what a short procedure is? How did you address USP <797> immediate use BUD of 4 hours in your policy?

Hello,

What type of expiration date do you assign to 0.9% NS 1000 mL stored in the refrigerator (2-8 C) for Malignant Hyperthermia emergency use? I know it varies based on brand/type (B.Braun, Baxter, Excel), extended stability data shows it could be good beyond 30 days. Curious to know what your facility is doing.

Thank You,

Samir Jani

Good afternoon MSOS members,

I would like to know if you can share any procedures, workflows, and templates related to your organization's EHR medication build, testing, and validation processes. Thank you in advance!

Hello colleagues,

After switching from Kcentra to Balfaxar, IV staff are reporting that it takes much longer (>5 minutes) to reconstitute Balfaxar (even when stored at room temperature). Curious if other sites have noticed this and have found any mitigation strategies (i.e. constant gentle swirling)?

Thank you,
Megan Fragale, PharmD, MS, BCPS
Medication Safety Officer
Skagit Regional Health

Curious if anyone has developed any sort of site medication safety rounding template or checklist. Our organization has 9 inpatient facilities as well as numerous clinics. I would like to start a rounding cadence with our sites and am interested in how others are approaching this.

We’re currently evaluating how to handle the pyridoxine IV shortage at our facility (over 500 beds). Part of our team is considering implementing a hard stop using LMA (an alternative mechanism in EPIC) that would prevent the order from being placed entirely. The intent is to have the provider call the pharmacy directly to discuss the request. This would be a hard stop without an alternative built into the system.

We’re trying to assess if this is the best approach or if there are more effective strategies. I’d love to hear how other facilities are managing this: