I’m interested in know if/how hospitals are securing their controlled substances being administered as a continuous infusion (e.g. fentanyl, midazolam).

Do you secure the controlled substance infusion bag/syringe when they are hanging on a patient?

If so, do you place the infusion bag/syringe in a locked box?
If so, do use a key lock or combination lock?

Do you use a lockable PCA pump to administer continuous controlled substance infusions?

I’m interested in know if/how hospitals are securing their controlled substances being administered as a continuous infusion (e.g. fentanyl, midazolam).

Do you secure the controlled substance infusion bag/syringe when they are hanging on a patient?

If so, do you place the infusion bag/syringe in a locked box?
If so, do use a key lock or combination lock?

Do you use a lockable PCA pump to administer continuous controlled substance infusions?

Hi All,

We are doing our annual review of our Look Alike/Sound alike policy and list, as required by TJC. We currently post our list at our pyxis machines, but are rethinking the utility of printing and posting it. The original intention was for nurses to be able to reference it day to day and when TJC arrives. We have been cited for having an ‘old list’ posted, even though reviewed and not changed.

The 9/29 issue of the ISMP Medication safety Alert! included an URGENT REQUEST for action regarding confirmed mix-ups between Prolia and Udenyca syringes.

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We are currently looking at implementing hard stops for a select number of drugs. We are keen for other organisations to share any policy/ procedures or a list of drugs for which you have hard stops in your electronic ordering system(s) to help facilitate this. If you have the rationale for the hard stop, that would be appreciated too.

Last month, ISMP surveyed MSOS members on scanning the 2D matrix barcodes on heparin and saline flush syringes. Thank you to all who replied! It was apparent from the results that many organizations are having issues with these barcodes.

We are now working with FDA to investigate the reported difficulties and are looking for 3-4 volunteers from different facilities who use Cerner, Meditech, Epic, or Allscripts, (or other EHRs) to assist with the investigation. Your time commitment would be very minimal and include email communication with perhaps some barcode scan testing.

We are in the process of revising our surgical prophylaxis guidelines and are struggling with management of patients receiving current scheduled therapy (e.g. extended infusion pip/tazo, scheduled vanco) especially when administration times fall outside of the recommended window. There are no clear guidelines from our review.

How has your organization addressed this component?

I'd be happy to compile a response summary.

We've also capped the maximum number of intra-operative re-doses at three.

Thanks!

Andrea

We operate an outpatient pharmacy at a rural hospital and are completing ISMP's Community/Ambulatory Self Assessment. We are assessing questions # 48 and #49 which state:

48. The pharmacy has a formal policy to assess and clarify any unusual doses or uses of medications before dispensing.

49. Pharmacists have a written policy to follow, to easily and effectively resolve conflicts when prescribers do not agree with their expressed concerns about the safety of an order.

Hello,

I'm interested in obtaining information about other hospitals that use neostigmine subcutaneously for the indication of acute colonic pseudo--obstruction.

What administration instructions/monitoring parameters are utilized at your facility.

Thank you,

Matthew Beaulac, PharmD, MS

Our health system is looking to assess the frequency of patient cafe area ADM controlled substance inventories.
Could you please respond to how your institution conducts the following:
1. How often do you physically inventory your patient care area ADM’s controlled substances?
2. Do you inventory all controlled substances in the ADM or only those not accessed since the last physical inventory?

I will share results after a week of responses.

Thanks in advance.