MSOS Discussion Board

HIgh Alert Medication labelling in the code box/ crash carts

Salma Al-Khani's picture

Forums: 

Dear all:
In King Faisal Specialist Hospital & research Center We where surveyed by the Joint Commission International (JCI) couple of months back, one of their findings was related to the labeling of high alert medications in the code boxes (crash carts) with a High Alert Stickers/ labels.
Currently we do not mandate labeling the high alert medications in the crash carts with a High Alert sticker/ label, knowing that almost all the medications in the crash cart are high alert and the whole code situation is a high risk critical situation.
My question:

EPINEPHrine Administration for Anaphylaxis

Ambra Hannah's picture

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Hi all,

My health system is looking for ideas to optimize our risk reduction strategies for EPINEPHrine administration errors for anaphylaxis in the acute and ambulatory settings.

1. Are you using autoinjectors?
2. Are you using "kits" with ampules or vials?

Please provide details on how you've managed either strategy.

Thanks in advance,

Ambra

Baxa TPN Compounder tubing set shortage

Karen Thompson's picture

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​There is a shortage of tubing sets for the Baxa EM2400 TPN compounder with no release date in sight (#173 & 174). What kind of mitigation strategies are facilities using? We plan on using each tubing set for 48 hours to preserve our supplies. This will increase the risk of infection, but I feel it is outweighed by the risk of error that would be caused by manually drawing up TPN ingredients. Thoughts??

for facilities using Horizon's Meds Manager - IV fills

Charlene Haluk-McMahon's picture

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Hi all,
Our department is reviewing our IV processes for efficiency and waste reduction.
We are not a 24/7 operation and currently run 1 24hr fill list a day for our in-patient pharmacy-prepared IV meds.
We utilize Horizon's Meds Manager as our PIS.

We are investigating running a 2nd IV fill with the goal of reducing the number of IVs we process for patient's who get discharged within that 24hr period. This would reduce the IV room workload as well as reduce medication waste.

EHR Solution? - Unmeasurable Peds Liquid Doses

Liz Hess's picture

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Posting on behalf of Stephanie O’Brien, PGY1 Resident:

Hello,

For my research project this year I identified a liquid medication dosing error in our neonatal intensive care unit that is not detected by our electronic health record. Physicians enter a mg/kg dose into the EHR which automatically calculates a mL dose based on the patient's weight and the drug concentration. The EHR does NOT alert the physician if the mL dose is unmeasurable so we are seeing several instances where patients are being prescribed unmeasurable doses.

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