About a year ago when the Versed/vecuronium issue was being discussed, one of the pie-in-the-sky ideas that was batted around was a DO NOT LOAD list for our ADCs. However at that time, it would be a manual list and not something that could be hardwired into ADC "brains". Now that it has been a year-ish, has anyone found anything like this that would not be a manual process?

We use Omnicell, and have restricted the addition of medications to machines to a core team. This obviously helps, but desire to go a bit further than human vigilance on this if possible.

Thoughts?

ISMP received a report recently about confusion between Activase (alteplase 50 mg and 100 mg) and Cathflo Activase (alteplase 2 mg). We previously published recommendations (in 2008) to: communicate the purpose of the drug, communicate complete orders (i.e., dose, route, administration directions), use disease-specific ordersets in non-emergent situations, and avoid the abbreviation “tPA”.

Just curious, but what additional strategies is your institution using to avoid medication errors with these two products?

Thanks!

Mike

Hello!

As you are likely aware, there have been safety concerns reported with the packaging of Recothrom [as it comes in a box containing supplies for medication preparation including a 5-mL sterile empty syringe (luer-tip)]. (reference links below)

Wondering if you might be able to speak to the process around dispensing, preparation and use of recombinant topical thrombin (Recothrom) in your organizations.

Hello!

As you are likely aware, there have been safety concerns reported with the packaging of Recothrom [as it comes in a box containing supplies for medication preparation including a 5-mL sterile empty syringe (luer-tip)]. (reference links below)

Wondering if you might be able to speak to the process around dispensing, preparation and use of recombinant topical thrombin (Recothrom) in your organizations.

Does your facility carry both preservative-free and preservative-containing vitamin K injection for neonates, and what is your rationale for what you carry? ​If your facility carries only preservative-containing neonatal vitamin K, and family refuses, what is the procedure for handling the situation? Does your facility have a protocol/procedure in place for accepting labeled, unaltered Vitamin K injection for single use that the family has brought in from an outpatient pharmacy?

Thank you!

Our Med Management Committee would like our inpatient pharmacy to standardize use of auxiliary labels and develop a SOP for use. Wondering if anyone would be willing to share a list of which auxiliary labels you use and/or SOP/info on who is responsible for labeling, when in process they're put on, are they put on the patient label or the actual bottle, who approves the use of new labels, how to ensure and monitor for consistent use, etc. Thanks! Joanie

Hi!

Nymalize is super expensive, but an oral solution is safer for our patients who cannot swallow nimodipine capsules. We also don't want to put our nurses and pharmacy staff at risk for withdrawing liquid contents from a capsule. Can anyone who is NOT purchasing Nymalize share their processes/policies?

For those who purchase Nymalize, can you share how you sold your point?

Thank you so much,
Farzana

We are a small hospital without 24/7 pharmacy services. While our orders are verified by remote pharmacists; we would like to know how others handle double check/verification of IVPB or IV Infusions prepared by nursing after hours? During pharmacy hours, we prepare and send almost all compounded items, with the patient specific pharmacy label barcode used for BMV. We require a 2nd RN to verify drug prepared, patient etc since the patient specific label is not available when the pharmacy is closed.
Thanks!
Kathleen Black, Pharm.D.
Medication Safety Lead

Hello,

In reference to ISMP article (March 8, 2018 Volume 23 Issue 5) regarding ethyl chloride, what safety precautions do you have in your organization? Do you store this as floor stock? Is it stored in a flammable safety cabinet? Thanks!

---Jeff

Hi everyone -

I wanted to let the group know that my position (Executive Director, Medication Safety) is open at WellStar, as I have taken a medication safety position with Kaiser Permanente. WellStar is in the metro Atlanta area and is the largest healthcare system in the state. The application link is below; if it doesn't go straight to the position you can search "medication safety" and it will appear. If you would like to speak with me about the position, I'm happy to do so. Thank you!