Has anyone noticed a recent spate of low vancomycin troughs despite adequate dosing? We are seeing a larger number of low troughs are investigating possible reasons. Just reaching out to see if anyone else is seeing something similar.

Randi

Hi,

Curious what data and metrics other Med Safety Officers report out at their Medication Safety Meetings and the frequency of reporting this data. Do you have a set of canned reports that you are willing to share regarding what is specifically looked at?

I know there are the obvious (by drug category, by severity, etc), but wonder if we are missing anything that you find useful and potentially actionable.

Appreciate any insight.

For institutions that use a digital refractometer as part of your Controlled-Substance Monitoring / Diversion Prevention plan, is there a reference that lists the refraction indexes of all injectable controlled substances?

Thank you!

Thrombolysis patients are often treated with heparin and/or tPA through the sheath post procedure. If your organization does thrombolysis, does nursing transduce the sheath post procedure? Is this also true when continuous infusions of heparin/tPA are infusing in the line? Do you have a policy you can share? Any literature to support your decision? I have not been able to find any literature for this specific patient population. Thanks.

At your hospital(s), in what situations are medication orders completely re-written (e.g., medication reconciliation at transitions of care)... in other words, how does your facility define a "patient transfer"?
Do you use a transfer medication order form (medication order set), or a medication reconciliation form?
Who is responsible for writing the transfer orders - the sending prescriber, or the receiving prescriber?
Are there any situations of patient transfer where medication orders are not re-written?

At the ISMP Intensive last week they talked about how unproductive a second nurse independent check is for subcutaneous insulin injections. We do currently use a double check but I am wondering what other facilities are doing. Pretty sure the nursing staff are not actually performing the check the correct way and we have created a policy that is almost impossible for them to follow..... If you are not using a double check, what are you doing to keep the patient safe??

Hello,

Hello everyone,

Hello,

Are there any large, national, pharmacy quality forums or quality programs that exist for Pharmacy? The surgeons have NSQIP (National Surgery Quality Improvement Program) , the Children’s Hospitals have SPS (Solutions for Patient Safety), and there are many other similar groups for other disciplines. I have not heard of anything that exists for institutional pharmacy. Such an organization would allow the pooling of data across many organizations, but also effectively benchmark for individual institutions as part of their quality improvement processes.

I am working to implement the use of locked boxes for narcotic infusions and would appreciate any experience had with:
1. Estimating how many to purchase
2. Determining where they will be stored on campus and how nurses access/request them

Thank you