Good morning,

We are exploring creating a peer review model (for pharmacists and technicians) to review medication errors that occur in the pharmacy. The intent is to ensure that we maintain a just culture approach and avoid the perception of punitive response to slips/lapses and identify system-based issues that may lead to error. While maintaining accountability for unsafe workarounds, breaches of policy/safeguards, etc.

Is anyone using or had experience with a pharmacy peer review process?

Could anyone share error prevention strategies they have used around addition of trace element components to neo TPNs?

Despite scan on prep and other redundancies, recent mixup due to a workaround.

Any help appreciated -

I have a question regarding Clinimix TPN solutions. Are there any facilities that are still adding electrolytes to the Clinimix bags? There has been discussion amongst our pharmacists at my facility that adding electrolytes would interfere with the pH of the resulting TPN. Then most recently, ER requested KCL 10mEq with Na Phos 15mmol mixed together in an IVPB. There was some question as to the pH of this mixture. Does anyone have a protocol as to adding electrolytes to TPN or even IVPB in general?

Thank you,
Michelle Voss
King's Daughters Health
Madison, IN

Hi,

When using the smart pump drug library at your institution, When you (pharmacist or designee) enters soft/hard mins and max, and/or when you make edits or updates such as adding new medications, who actually verifies the information in the physical pump?

a) pharmacist entering the soft/hard min & max?

b) nurse manager or nurse representative

c) both (pharmacist and nurse)- together or individually?

Thanks!

Ivy

Greetings!

I am wondering if nurses at your institution are required to place a label containing 2 patient identifiers on IV fluid bags removed from automated dispensing cabinets?

We do NOT currently do this and I'm wondering about regulatory compliance with this process.

Thank you
Shelly Morvay, Medication Safety Pharmacist
Nationwide Children's Hospital, Columbus, OH

A new requirement for performance goals has been included into annual evaluations at our institution. Would others care to share what kind of goals are appropriate to the Medication Safety Officer Position? While my primary work in medication safety is to decrease the frequency and severity of medication events, there are so many variables and factors that influence this, from event reporting rates to staff turnover, that I hesitate to pin any individual's performance on this. Thank you in advance.

Does anyone have a good titration policy or tips on how to be compliant with titrations? We were just cited for this by TJC and are looking for ways to improve. We did well with titrating at correct increments and frequency but on sedation drips we didn't have a Riker assessment with each titration rate change. I would appreciate any information you can offer if you successfully made it through a survey without a citation. Thank you

We are re-evaluating our lockout intervals for our PCA's as part of an Opioid Safety group. We currently use 8 minutes for all. Can you tell me your lockout intervals for PCA:
Morphine
Hydromorphone
Fentanyl

Thank you,
Ann Jankiewicz, PharmD, BCPS, FASHP
Medication Safety Officer
Rush University Medical Center
Chicago, IL

Hi Everyone,

I am writing today to ask about your institution's practice when dosing rivaroxaban for Afib. For Afib, there are two labeling recommendations based on CrCl: US and Canadian.

The Canadian labeling recommends avoiding use with CrCl < 30 mL/min. However, the US recommends avoiding use with CrCl < 15 mL/min.

Please let me know what labeling your institution follows when dosing rivaroxaban for Afib in patients with CrCl < 30 mL/min.

Thank you,

We are seeing an increasing population of dementia patients that we are having to care for long term as we cannot find placement post their acute care stay. Many of these patients remove their arm bands as soon as staff puts them on(or leg bands which we have tried).