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.

When you dispense patient specific insulin vials or pens, does your label display the dose?
Do you re-label the vial or Pen if the dose changes?

Thank You,
Cathy Goetz, Pharmacist
Medication Safety Officer
St. Luke's Hospital

Regarding pre-made IV products that have overwraps stating that product should be kept in overwrap until time of use – how do you dispense these products?

We decided to clean our IV room and Chemotherapy room instead of utilizing EVS. Is anyone willing to share SOPs that they had to develop for cleaning, training, assessment of staff?

Thank you!

In effort to ensure that our start up TPNs for NICU babies have appropriate BUD, we were wondering what BUDs are used by other pediatric institutions.

Thank you!

Has anyone developed in Regular Insulin Hyperkalemia Treatment kit to facilitate IV push correct dose/route for IV push treatment to prevent errors.

1. IF YES, is it working well?
2. IF NO, what other solutions are you using to prevent wrong dose wrong route errors? Are they working?

Thanks very much,
Vic

Hi all,

The ASHP medication safety SAG is interested in learning about different health systems' EHR governance structures and coordination of changes to systems.

Please find attached a document requesting information about your health system's clinical decision support governance structure. Thank you in advance for taking the time to complete this survey!

For those using Baxter SIGMA pumps, when using a non-DEHP tubing set, have you encountered issues with incomplete infusions (apparent overfill) based on the following:
"When evaluated over a one-hour period, the Flow rate accuracy will range ±10% from the expected volume" (source: http://sigmapumps.com/pdfs/compatible-iv-sets.pdf)

If yes, what steps have you taken to address these issues?

Is anyone performing these procedures able to share their policy with me? We have interventional pain specialists that would like the ability to offer this treatment to potential candidates, so we are in the process of operationalizing (order sets, education, policy, etc.). Any information anyone could share would be greatly appreciated!

Hello,
Our ER is looking to store Tylenol in triage outside ER for a pain management in triage protocol. Has any institution implemented something similar?