Following up on a medication error where a patient simultaneously took xarelto 15 mg twice daily and 20 mg daily, intended to start 21 days later, and presented to our facility with a serious bleed.

I discovered a workflow in our IR suite with heparin infusions that I am concerned with. The IR staff is priming a bag of diluted heparin through the pump, placing a needle on the end of the tubing, and injecting that needle back into the port of the bag. Then they run the pump at 999ml/hour and this set up is replaced every 24 hours. This provides them with a air free set up in the case of an emergent stroke.
Staff in the area state this is the only way they can guarantee an air free set up. I'm curious to see what other practices are out there.
Thanks -

Our practice has been to use 500ml bags for pediatric patients in the past which I presume it goes back to the days prior to infusion pumps, and that it was to decrease the risk if a dial-a-flow was left wide open somehow. Just wanted to see what others are doing. Does anyone have a policy on this they can share. Also, what is the age cutoff if you are doing this practice?

Hi All,

We are working on consolidation and development of an overarching insulin policy to address use in the hospital setting.

Do you have an overarching insulin policy? If so could you share?
If more than one policy, what do different policies address?

Thanks!

Can anyone share their experience with Baxter IV pumps?
We currently have Alaris and are interested in Baxter's Spectrum IQ pump.

I appreciate any information you can share,
Stacie Ethington
Nebraska Medicine

I recently found that our facility has an admission policy saying that any patient given tenecteplase or alteplase needs to stay in the ICU for 12hrs and 24 hrs respectively. I can't find any data that those time periods are required. Alteplase does have specific monitoring parameters for 24 hrs but nothing on ICU length of stay. What do others have for guidelines for ICU length of stay if given these? I'm also curious if others are requiring neuro checks x 24 hrs for these medications for all indications, except line clots?

Our institution recently switched to BD/Alaris for most infusions-

We are running into some barriers with the PCA scanning process. All new PCA syringes are scanned via EPIC BCMA process, but we also find that RNs scan the physical syringe/label when assuming care of the infusion from the prior RN.

Because the PCA is enclosed behind the locked, clear plastic window, RNs are not able to scan the physical syringe or label without first obtaining the key and opening the PCA door. This poses a barrier in their workflow.

At your institution:

Hi everyone,

As a health system expands, the layers of medication safety expand as well. For our health system, a newly developed System P&T overseeing both ambulatory and inpatient settings has requested review of medication errors generated through our internal incident reporting software.

My questions for the group:
1. Are any of you currently sharing medication error data/alerts at the P&T level?
2. If yes, what sort of information is shared (e.g. internal data, ISMP alerts, recall information, etc.)?

Thank you,

Recently nursing was concerned with the use of puralube for patients who are receiving oxygen (due to the flammable nature of the ointment). We changed the ventilator order set to reflect artificial tears instead.

Our hypothermia set however still contains the ophthalmic ointment for patients receiving paralytics. I cannot find a non-petrolatum based ophthalmic ointment.

Please share the product that you utilize in this situation.
Thank you in advance for your feedback!

Would anyone be willing to share their template for their organizational medication safety strategic plan. I am tasked with putting one together for the next year and would like some examples instead of reinventing the wheel!

Thank you in advance!