I have had a request from our operational pharmacy leaders to report medication event rate as a KPI. While our entire health care system reports serious safety event rates for all events, we have not previously reported a medication event rate. I'm struggling with creating a meaningful numerator and denominator....I'm using total events reported for numerator and have used various denominators such as APD and total dispenses calculating the medication event rate per 10,000 APD or 10,000 dispenses, either as monthly rate or as a 12 month rolling rate.

A nurse requesting potassium w/ lidocaine is a rare occurrence and we have discouraged it's routine use. We have not disallowed it's use.

I'm curious as to what other institutions do for this. Do you restrict it to only certain patients? Do you allow it at all?

Hello,

Hello, my name is Soojin Jun and I am a pharmacist and an ambassador for Patient Safety Movement Foundation. World Patient Safety Day is 9/17/20 and I am looking for organizations that will light up their buildings in orange along with others in the world.

The virtual event is available for RSVP and it is free:
https://patientsafetymovement.org/patient-safety-events/uniteforsafecare...

I was wondering what work has been done by anyone in this group has done work with override reasons especially in regard to ISMP guidelines for ADCs?

warfarin reversal with Kcentra has been confused with profilnine Factor IX product instead-does anyone have experience with this? and what education or medication safety strategies have you applied or implemented?
thanks in advance
jbrady@svmh.com

Recently had a patient requiring high dose/high rate insulin drip. We currently prepare 100 units/100 mL and 500 units/500 mL. Does anyone make concentrated insulin infusions? What is the Upper Hard Limit on your smart pump?

Has any institution eliminated return bins from your ADC machines (we use Pyxis) and had all unused medications either tubed down to pharmacy or discarded as pharmaceutical waste? All controlled substances would be wasted with a witness; controlled substance waste would be tracked through diversion monitoring with Bluesight.

Looking to hear your experiences, what drove this decision, and how you feel about it since. Would you make the same decision again? Pros/cons.

TIA

obesity dosing with heparin infusion has required creative strategies such as hanging two 50 unit/ml premixed bags with total rate above 4000unit/hr (hard max in alaris). does anyone have experience with challenging high doses to reach therapeutic goal? do you alter the guardrails to allow nursing to turn up rate from one bag? or use two bags? thanks in advance
jbrady@svmh.com

TJC recommends pharmacy address anticoagulation in perioperative setting, can anyone share their approach or protocol? thanks in advance
jbrady@svmh.com