Does your organization currently have any High alert medication error KPI ?if yes what is the formula of it and the international benchmark

Does your organization currently have any High alert medication error KPI ?if yes what is the formula of it and the international benchmark ?

Hi all,

I'm a medication safety pharmacist in New Zealand and we have opioid premixed IV bags that we use in patient controlled analgesia and produced by the same company. Due to international colour coding standards that require that colour use for IV opioid products is limited to light blue, we have a situation where our morphine, oxycodone, and fentanyl premixed IV bags look very similar at a glance. We have had several incidents of selection error.

Just curious if anyone is utilizing Xellia vancomycin RTU bags in their hospitals. If so, what strategies do you have in place to ensure that pregnant women are not receiving this product (e.g., orders only allowed for male patients, require negative pregnancy test in women of child-bearing age prior to dispensing, do not stock in ADCs, EHR warnings, etc.)?

Thanks in advance,
Amanda

Have any institutions transitioned to U-500 pens for in-patient use? What safety mechanisms around storage and administration do you have in place?

Thank you!

I know medication reconciliation is an issue that all hospitals are constantly trying to improve upon. I wanted to ask about processes in different hospitals:
1. Do RNs, pharmacists and technicians all have the ability to remove medication off the home medication list and is that part of the standard workflow?
2. For EPIC users, how do you deal with PTA med lists for transfers? Is the PTA list what the patient took at the first hospital? How do you address risk of errors upon discharge with discrepancies from what the patient has at home?

Has anyone made the transition to NRFit?

We would like to move forward with this transition due to recent errors surrounding epidural connections, but the vendor that we use (BBraun) does not have anyone that has made the transition, which is concerning to me.

Thanks!

Hello! Have any facilities found any creative ways to prevent wrong route administration of insulin for treatment of hyperkalemia? We are a rather large health system, and some of the ISMP recommendations (e.g. providing kits, or drawing up patient-specific syringes in pharmacy) are not necessarily feasible to operationalize given our size and resources. I would love to hear what other sites have done to mitigate wrong route errors!!

Thanks,

Jennifer

We recently had a large discussion about how to document an error with regards to the MAR. Some feel that an order should still be written for it so the med can be documented in the MAR. Whereas others (me) feel that writing an order validates the error because it also has to be approved by pharmacy to get it in the MAR.

I have advised my group to document in the notes section of the chart what the error was and to NOT write an order for an erroneously given med/dose.

What is your practice and thoughts?

T

Good afternoon!

For those of you using an IV preparation software (such as DoseEdge), do you prepare blinatumomab through this software? We traditionally have not done so given the complexity of the preparation with the overfill and multiple bag preparation options, but are wondering if anyone has found a way to do so and minimize the potential for error.

At this time we are primarily administering blinatumomab as an investigational agent as part of COG protocols AALL1731 and AALL1821.

Thank you for any insight you are able to provide!