My organization is transitioning to EnFit, and I would appreciate any information on the following:
1. Did you transition ALL of your oral and enteral medication doses to syringes w/a the unique enteral connector?
2. For meds dispensed in syringes w/the enteral connector, are you using clear enteral syringes w/the purple plunger, or enteral amber syringes?
3. Did your organization research which oral liquids require protection from light to inform #2, and if so, can you share your resource for that?

I wanted to let members know about two ISMP pharmacists who have retired or will be retiring soon, Darryl Rich and Matt Fricker.

Does anyone have a second victim support group/program at your institution. Do you have a policy outlining how this program functions? If so, are you willing to share.
Our program has been active for 3 years now. We are trying to write our policy.

Thanks, Vic

Does anyone require pharmacist double checking of high alert medicated infusions, such as vasopressor infusions? How do staff know which meds require double signature - are the labels different from other meds? How is it handled if a second pharmacist is not available to check? If anyone has a policy or any guidance on how to operationalize this I would appreciate it.

Wondering if anyone is willing to share their Impella protocol, specifically for those on Heparin for another reason (i.e. A.Fib/ DVT/ ACS etc)and the monitoring changes because of it. Thanks.

Are you using an albuterol inhaler for multiple patients with a patient specific aero chamber that has a 1-way valve to avoid contamination of the inhaler? If yes, how do you clean the inhaler between patient use?
Thank you,

During my presentation last Thursday for the member briefing I mentioned an issue with look-alike succinylcholine and phenylephrine syringes from Nephron, which has a 503b outsourcing operation. There had been an incident reported to ISMP where anesthesia personnel gave a hypotensive patient succinylcholine instead of the phenylephrine. The syringes can be seen in the member briefing slides posted on this website. We are happy to note that Nephron has revised the labels and these are attached. Mike

Hello,

Does anyone have products in their hospital that are available in syringes with colored plunger rods?

Does anyone purchase empty syringes with colored plunger rods for their own compounding? If so, what are you using them for? (e.g., OR medications, crash carts, RSI Kits)

Does anyone think using colored plungers would be helpful in differentiating medications? If so, which medications would it be useful for?

Appreciate your responses to following questions related to profiling of automated dispensing cabinets (ADCs) in the Emergency Department:

1. Are the ADCs in the your Emergency Department profiled or are nurses able to remove any stocked medication for any patient?

2. If yes, what is your order review workflow--are all orders prospectively reviewed by a pharmacist, or do some orders "autoverify"?

Appreciate your responses and any feedback you have on this issue!

Don McKaig, RPh
Medication Safety Specialist
Lifespan, Providence RI

Hello all,

I have a Patient Safety Question.

We are planning to administer a Patient Safety Culture Survey, and need some guidance on how to get started. We participated in a pilot study last year, but we will self administer this year.

If anyone has any information, my email address is: cmontgomery@deltaregional.com

Thanks!