Our largest number of errors associated with nursing staff have to do with medications not being administered. Does anyone else have an issue with medications not being administered as ordered?
We are looking to do reeducation and want the providers to be notified when (certain) medications are not given. I was hoping to hear how other places tackle this - strict protocol for notifying providers per medication class or some other approach.
Thanks -
Maria Cumpston, PharmD, CPPS
Medication Safety Officer
WVU Medicine

Dear Colleagues:

As you know ISMP has long promoted that intravenous vincristine should only be given after dilution in a minibag and never by syringe. We recently called upon FDA to eliminate syringe administration in product labeling. Syringe administration remains in certain protocols around the world. In particular, syringes are used in infants and children in some locations, which continues to put patients at risk of injection into spinal fluid when mixed up with a drug intended for administration by that route. We are aware of 4 child deaths outside the US since January.

Another question regarding smart pumps:

Does anyone have a chemo drug library set up in their smart pumps? If so, how did you set it up?

We use Alaris pumps (obtained many years ago) and did not originally make a chemo library based on recommendations from the Alaris team. Rationale was that there are too many required concentrations of chemo drugs making building a library prohibitive. As the pumps have become more sophisticated, I am wondering what other institutions are doing in this high risk area.

Hello,

Does anyone have and is willing to share a monograph/algorithm/comparator chart of all available anti-emetics and their efficacy/safety in various populations (oncology, cardiology, pediatrics, etc.). Additionally, does it address use of and alternatives for promethazine as a sedative? I think it would be beneficial if ISMP/MSOS/ASHP? published this information so each institution would not have to do this work independently.

Thanks!
Rosemary

Hello,

We are revamping our smart pump processes and I’d like to know how other hospitals and health-systems function. My questions are below. Thank you in advance!

Hello,

In your institutions, who is responsible for training, establishing procedures and surveillance of smart pumps? Is it nursing, pharmacy, a dedicated interdisciplinary committee?

This would help us to find out how other health care systems have succeeded in assigning the required ressources to support safe use of smart pumps.

We are a complex, public health care system in Québec including 7 short acute care hospitals for a population of 450 000.

Thanks.

Hello all,

Can you please share how your OR incorporates pharmacist and available technology in intraop setting? What processes are still manual/semi-manual? How do you handle narc waste and reconciliation of narcs (ADC vs paper)? What would you like to see happen (ideally)? Does OR pharmacist(if you have one)extends his services to PACU as well.

Thank you for sharing.

I'm curious how other institutions view the role of the MSO for USP 800 compliance requirements (specifically leading the project/program development). I need help to justify to my administration that this work requires a dedicated, knowledgeable person outside of the work I provide as a medication safety officer. Thanks in advance for your help and comments.

Hi all -

We're an Epic organization, and I just found out that the administration documentation process allows batching, where the nurse can scan and document multiple meds in a row, or batch, at one time. You still have to go through each one individually, but it's not the process of armband scan, med barcode scan, administer, then move to the next med. This is contributing to some of our administration events.

Do any other Epic organizations have this same issue, or have you implemented any kind of fix for this?

Thanks,
Elizabeth

Hi all,
Has anyone that has the ability turned on allergy alerts upon BNV scanning? We are toying with the idea but are concerned about alert fatigue and nursing workflow. Any information is helpful.
Thank you,
Lauren