In December, ISMP published an article re: adverse glycemic events and critical emergencies. Safe practice recommendations included steps to avoid insulin mix-ups. Historically, we have experienced these errors in our ED and worked to limit the number of insulin products available, with a goal of removing regular insulin vials from the ED and sending patient-specific doses (diluted) for IV administration. Note: we also recently moved to EPIC with some prospective order review in the ED and Pyxis profiling, but there are still some gaps in coverage to be fixed)

Hi all,
I know many of us are still struggling with how to eliminate injectable promethazine (or at least reduce utilization).
Have any of you had success with offering alternatives via an alternative alert for a provider? If so which meds/doses have been well received?

Ondansetron IV/PO, promethazine PO, prochlorperazine IV/IM? others?

If you have an alternative alert do you allow the provider to continue with original order with documentation of a reason (central line, intolerance to other agents, etc?)

Thanks!

Do ambulatory clinics in your organization use barcode medication administration (BCMA)?
If yes, is it used in all clinics or only certain clinics (e.g. PCMH, specialty, etc.)?

Thanks!
Stacie Ethington MSN RN-BC
Med Safety Nurse Specialist

Hello MSOS,

How frequently are you requiring formal and documented medication storage area inspections at your facilities?

Currently our system policy requires monthly documented inspections, but there has been a request to change this to quarterly. The Joint Commission requires inspections to take place periodically, but des not define a timeframe.

Thank you in advance for your response!

We recently observed two patients experience severe and concerning reaction to carfilzomib. Both had tolerated this medication well in the past and were in good health the day of infusion. Lot# 1125072 was used and both patients experienced similar symptoms: nausea, vomiting, changes in mental status, profound weakness, and possible syncopal episode. One patient recovered, the other remains in ICU. Has anyone else seen a similar constellation of symptoms with this medication? Notifications to medwatch and the manufacturer are in process.

What programs are being used for creating the discharge medication list for patients and families that integrates with your EHR system? For those who use oral liquids, how is the medication list presented on the discharge paperwork? For example, in "mL", in "mg", or in "mL=mg"? Thanks! -Melody Sun, CHOC Children's

Dear Friends and Colleagues,

ISMP has published a NAN Alert regarding Medication safety issues with newly authorized Paxlovid and the different dosing for normal renal function vs. impaired renal function (one less tablet).

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.

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!!