Hello,
At out institution, we are revisiting this topic and updating our policies...

Would you mind sharing a policy/guideline related to:

1) Antineoplastic agents for non-oncology indications? (eg methotrexate, IV/PO cyclophosphamide)

2) Biologic agents given for non-oncology indications? (eg rituximab, infliximab)

3) Do you require informed consent for either 1 or 2? If so, do you require re-consenting each year?

Thank you,
Tanya

Greetings!

Does anyone use insulin pens for inpatient administration? If so, what is your administration process? Storage? On unit? In patient room? How is the pen itself labeled? Labeled with patient information bar code or are you just scanning the pen itself at administration? Any information you provide would be much appreciated. Thanks in advance.

Hi, I'm curious what people think about the use of auxiliary labels on final dispensed products... i.e. when techs or RPhs place "High Alert Medication" or "Continuous Infusion" or "For RT Use only" labels on the products. This can definitely bring attention to safety concerns, but what happens when people forget? Could this actually increase risk if nurses rely on these labels to identify risks? What are some ways to make this practice more consistent? Considering if/how this should be addressed in our high alert policy. Thanks!

Does your institution use sterile water for irrigation for reconstitution of non-sterile compounds? Labeling specifies single use only. Is there any supporting evidence for assigning a specific BUD after it has been opened for the purpose of non-sterile compounding?

Is anyone aware of CMS or JC issues with lab control reagents stored in medication refrigerators?
Thanks,

Hi all,

I know this question has been asked in various forms many times, but I couldn't find exactly the answer I was looking for.

We just recently removed the "Continue All" button in EPIC for medication reconciliation because we felt this to be a blanket order by CMS and Joint Commission. However, now that we have been live for a couple of weeks with the change we are getting medical staff push back and it is coming back to committees to reconsider whether this button should be available to them or not. We recently had a MOCK survey and the surveyor said the expectation is for the provider to go through each medication order line by line.

While I am aware the Pharmacy workflow manager systems are controversial, does anyone have experience with using these for non-sterile compounding? We currently use DoseEdge for our sterile compounding across most of our hospital system (not critical access at this time). Have there been other approaches to both increase the safety and completeness of documentation?

Thank you for your response.

Looking at USP 800, what is your hospital's procedure for handling hazardous drugs that need crushing? Do you allow crushing? Does Pharmacy do it? Do you make a solution/suspension out of it for administration?
Thank you

Andrea Gimpel-Blanchard, PharmD
Director of Pharmacy
MaineGeneral Medical Center
35 Medical Center Parkway
Augusta, ME 04330
Phone: (207) 626-4133
Fax: (207) 626-4133
Pager: (207) 580-8001

Hi Everyone,

We are evaluating our independent double check policy after our transition to Epic and want to learn what other places are doing.

At your institution, are nurses required to conduct an independent double check for high- alert medications?

If yes, is there a system prompt in the EMR for the nurse to conduct an independent double check?

If you are at an Epic institution, do you use dual sign functionality or the independent double check MAR action? Any Epic tips for implementing Nursing independent double checks would be appreciated.