I was wondering if anyone has done an FMEA on HIGH ALERT MEDICATION? I was wondering if anyone has identified areas of risk and/or corrective actions. Anything you could share would be much appreciated.

Thank you!

Good morning,

A quick question for you all to start your weekend. Have any of your organizations seen an uptick in severe infusion reactions when administering Crofab over the last couple of months? We have preliminary reports of two recent incidents that we are investigating for any commonality.

Thanks,

Kevin

Hi Everyone. For all the hospitals that have converted to ENFit syringes are you having issues with drawing up doses in 1mL and 3mL syringes when you place the ENFit cap on the syringe it pushes the volume dispensed to almost .1- 0.2mL over the dose. we are dispensing a 0.25 mL dose, but when we put the cap it pushes the volume to 0.3 mL. Wondering if other places had the same issue.

Hello all,

The ISMP Action Agenda from 7/15/21 described a situation in which the preferred name of a transgender patient was not visible in the ADC, which caused delay in getting medications in a code situation. This also impacts pediatric hospitals, in which newborn naming conventions use preferred names in lieu of assigning a legal name to the patient.

Preferred names are located within our EHR (Epic) and print on all Epic-generated medication labels, but our ADC (Pyxis ES) does not have this information visible.

Good morning,
What is your process for managing patient's own controlled substances that come in a liquid formulation? Primary concerns are admin of accurate doses especially if dosing changes and diversion
1) Does the pharmacy take custody and draw up doses? What quantity of doses are drawn up in a given time?
2) Do you keep in pyxis? If yes, are doses drawn up in syringes and labeled or kept in original container? How do you keep track of count since liquid?
Tactics to avoid diversion?

Appreciate any feedback you may have. Thank you!

Nurses requesting access to concentrated heparin (1000 unit/ml) prior to patient arrival in order to prime dialysis circuit and eliminate significant lead time required.

What is your hospital's process around this topic? Allow ADC override for concentrated heparin in dialysis unit? Other safety processes in place?

Appreciate any feedback!

Does anyone have hospital, pharmacy or IRB policies or SOPs related to single-patient expanded access programs (formerly compassionate use)? We are wanting to outline our process to assist physicians who need access to a drug (or device) through one of these programs. Looking for examples to assist with writing a new policy.

Thanks in advance for your assistance!
Anjali

Anjali Todd, PharmD
Pharmacist Specialist, Medication Safety
The University of Tennessee Medical Center
Knoxville, TN

Hello,

We have had some challenges with not activating Clinimix prior to dispensing. Have any of you had similar challenge and put in a practice to prevent? Thanks! ---Jeff

Hello everyone! I was hoping to get some feedback regarding your ICU med reconciliation processes.

Currently our ER pharmacists do med rec from 0600-0030, so we have about a 5.5 hour gap in coverage. And of course, sometimes they are pulled away for other clinical activities so not everyone who comes through the ER has their med rec done by a pharmacist.

Good morning everyone -

We are looking at some opportunities for operational efficiency for vancomycin preparation. Curious to see what institutional maximum vancomycin concentration and rate of infusions have been established for others. We are mainly looking at some of the information in tertiary sources & PIs that note 5mg/mL concentrations as recommended but reference for up to 10mg/mL with the disclaimer for the potential for increased rate of infusion reactions.

Thanks