MSOS Discussion Board

FDA Drug Safety Labeling Changes

Jennifer Marie Soto Meyer's picture

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I noted the FDA has recently updated the "Warnings and Precautions" section of the drug labeling for several paralytics to include a new subsection "Risk of Death Due to Medication Errors".

I don't recall seeing this subsection for other medications but perhaps I am mistaken. Has anyone noticed this subsection added to other agents?

Benchmarking / Dashboards / Metrics

Emily K D'Anna's picture

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Hello -

Recognizing that 'medication error rates' captured by voluntary incident reports is the least effective and least reliable determinant of true error rates / benchmarking....

I wondered if other institutions have developed executive-level (or really any level) benchmarks / dashboards / metrics which they follow in their health system to track performance improvement within medication safety and safety realms?

I would be particularly interested if anyone has develop these measures in the outpatient / ambulatory spaces as well.

Default Age/DOB of Unknown Pediatric patient in EMR

Jameika M. Stuckey's picture

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Hey safety gurus!

Wanted to know if anyone has any input/guidance regarding having a default age/DOB for the pediatric unknown patient (e.g., trauma patient) in order to get the patient registered and allow orders to be entered. EPIC is our EMR and most things (alerts, normal ranges, etc) are based on age and weight. We are trying to find a way to choose a default age/DOB that allows us to get the patient registered and orders entered, while maintaining our medication and lab safeguards.

Thanks in advance for any help that you can provide.

-Jameika

Opioid Risk Assessment Tool to identify high risk patients inpatient

Alissa Carter's picture

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Our opioid stewardship team is trying to determine the best way to meet the Joint Commission Pain Management Standard for identifying high risk patient's. We would like to flag patient's who are considered high risk for opioid related harm via Epic. Has anyone successfully implemented this at your institution. How are you meeting this standard and identifying high risk patients?

Zofran with prolonged QTc

Randi Trope's picture

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In the ED Zofran is often given quickly and early (from or in triage). Do you have any systems in place to ensure that patients with congenital prolonged QTc do not get it? We are seeing that those that prescribe it in the ED are usually NP's and residents that may not realize the connection yet.

Therefore looking to see what, if any, measures you have in place to prevent it's prescribing.

Fatigue Management and alertness testing

Mary E. Burkhardt's picture

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HI All,
I really enjoyed the "Great Safety Debate" at the ASHP Annual meeting. As part of the follow up to the drug testing debate, I have begun to look at what pharmacies or hospitals have done for fatigue management/ alertness in a structured way. I had a recent discussion with a vendor that was mentioned at the debate and I think my coworkers were a bit surprised how pharmacies are staffed in the real world with call ins, doubles, 7 on 7 off midnights, etc. (often in violation of fatigue management principles).

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