My organization (UW Medicine) is soon going live with Alaris-Epic smart pump interoperability and we have been working through the concern raised in a recent ISMP Acute Care Safety Alert newsletter from 3/13/25. In brief, the issue was that a nurse mistakenly associated a medication-containing bag (amiodarone mixed in D5W) to an order for D5W because they scanned the manufacturer's barcode on the D5W bag and not the patient-specific label applied by the pharmacy. This resulted in the amiodarone infusing at the prescribed rate of D5W (much faster than intended).

Hi everyone,

We are interested in exploring options for pharmacy user-specific dashboards to help track and measure pharmacist compliance with various clinical and operational activities. I’m reaching out to ask if anyone has been successful at doing this and if you would be willing to share examples of how you’re doing this at your institution.

Specifically, we’re interested in dashboards that capture metrics like:

Hello all,

Do you supply all oral neonate liquids in patient specific doses or would you ever supply a unit dose cup/syringe and RN has to push down to the specific dose or draw up what is needed?

Thank you!
Diane Simko

Our infection control has identified some opportunities in documenting tubing changes. Right now in EPIC, this flowsheet row is in the IV assessment flowsheet, and only allows entry of a date and time, and no comments for which medication.

Looking to see if anyone has optimized this workflow. We are looking for ways to possibly link a flowsheet row to the MAR. Any ideas on how to make the documentation easier for nurses would be appreciated.

Thank you,

Curious if anyone is using the "bolus from bag" feature with their smart pumps for heparin infusions in adult or pediatric patients?

What advantages and disadvantages do you see?

Thanks,
Walton Gibbons
Medication Safety Officer
ECU Health

I'm evaluating workflow for enriching hemodialysis solution with sodium phosphate additive. This is somewhat of an unconventional workflow from pharmacy perspective, so trying to ensure safety of this process. There are reports in literature of hemodialysis solution being enriched with fleets enema or sodium phos 3mmol/mL injection added to final solution. Brief overview of practice is found here: https://doi.org/10.5301/ijao.5000453

Hello all,

For anyone who has the anti-amyloid monoclonal antibodies (Kisunla, Leqembi) on formulary - what have you put in your EHR regarding warnings for ARIA when patients present with stroke-like symptoms? When and how do the warnings fire? Thanks so much!

Checking to see if anyone has use the mini-bag system with Zerbaxa. We are currently making under hood.

Does anybody have refrigerators in surgical rooms? We are looking at adding refrigerators to our Pyxis and just not certain this would be safe. If not, any specific regulations this would be breaking?

There are currently many treatment programs that call for the use of cutting Suboxone film to achieve a 1/2 or even 1/4 sized dose of the film. I am looking for standard instructions that can be provided to nursing that allow for consistent dosing of these partial doses.