Hi all,

Just wondering if anyone has a process in place to prevent incorrect weight entries?

We are an Epic based site and recently had an error where a patient weighed 96lbs (44kg) and this was accidentally entered as 96kg, resulting in high vancomycin loading dose leading to SCr of ~4 and nearly starting HD. Incorrect weights have led to a few errors in the past as well.

I know there was an old post a few years back, but just wondering if anything new has been tried since.

Thanks!

Hello,

Does anyone put high alert labels on medications in the crash cart? A Joint Commission surveyor cited one of our ambulatory clinics for not having medications in the crash cart labeled. This is something I have never done and is not currently done within our system. Trying to see if this is surveyor specific or if we're out in left field somewhere. Appreciate any thoughts.

Carol

We are working to update the ISMP FMEA template forms. Right now, we are focusing on FMEA when new drugs are being added to formulary. Does anyone do this in practice right now? If so, do you mind sharing the tools with me so we can get a better sense of what may be happening currently?
Thanks!!
Merissa
ISMP Fellow

Hello,

For those using barcode scanning technology for medication order preparation and verification during dispensing (e.g., Dispense Prep and Dispense Check in Epic, DoseEdge by Baxter):
1) What is/are your adherence targets (e.g., 85%? 95% adherence)?
1a) Is/are your target(s) for preparation and/or verification?
2) How did you determine those targets?
3) What are barriers to achieving the targets?

Thanks in advance!

RE: MTX Best Practice - Require a hard stop verification of an appropriate oncologic indication for all daily oral methotrexate orders

Our organization uses EPIC. Has anyone built in their ordering system a hard stop that requires the user to input an indication for daily MTX orders and are willing to share your build and/or learnings?

Thank you in advance!
Rachelle Albay, PharmD
Project Manager, Pharmacy Quality and Medication Safety

We are a small pediatric hospital in NY and having issues with programming standard concentrations with Alaris. I was wondering if someone is willing to help us out, please.

We are trying to program standard concentrations like gentamicin 4mg/mL and Cefepime 40mg/mL in Alaris but according to Alaris the only way to program these weight-based pediatric entries is to use __ __ blank entries with limits programmed in the background.

Please share if you know any standard definition for acute/chronic definition from medication perspective. I understand there is acute and chronic definition of diseases perspective. Thanks in advance

Does anyone know of any EPIC functionalities, or that are compatible with EPIC that alerts users when new labs/PK levels/cultures are posted?

We recently had a safety event where RN hung a patient's next vanco bag when the trough was 29. We do have a MAR comment that instructs to hang the next bag but notify pharmacy if level > 20, but this got missed and the pharmacist may also not see it right away. Just wondering if anyone has practices of actively being alerted of labs at their facilities. Thank you!

Anyone have a written SOP and/or Policy relating to storing leeches in the Pharmacy with or among drugs that they're willing to share.

There doesn't seem to be much in the literature limiting "or" recommending it be stored or "not stored" in the same refrigerators as medications.

Just one of those low frequency issues! ( Use of leeches - maybe "once every year or two").

Thanks,
DiAnthia