I was the Medication Safety Officer at the largest hospital in our system, and I was the only medication safety officer in our system. We just went through structure changes, and I am now over medication safety at all of our hospitals.
I'm trying to get ideas on how best to tackle communication, process improvement, etc.

I was hoping to get some feedback regarding the structure of medication safety programs at other Health Systems with multiple hospitals. If you have any insight into this, I would greatly appreciate it!

Issue: Pre-spiked IVF on units

Question: What is the accepted practice in your institution? If you do allow pre-spiking of IVF, what expiration dating do you provide. Are there units that are exceptions (OR/Trauma/ED)?

Concerns: Infection control and pharmacy looking at pre-spiked IVF with respect to 2016 APIC position paper and USP 797 guidelines identifying that pre-spiked IVF be given 1 hour expiration (recommendation). This is taken from the position that an IVF bag is similar to a Single dose container.

Hi All,

We are considering "unlinking" our drug allergy alert for sulfa medications from sulfa- derivative diuretics (e.g. Furosemide) to decrease the number of alerts. The alert would then only fire for a patient with a documented sulfa allergy and sulfa antibiotic order. It would NOT fire a patient with a sulfa with a documented sulfa allergy and an order for a sulfa-derivative diuretic.

We have never previously allowed heparin drips or hypertonic saline to be stocked on ADC's but I am being pushed to change that. Does anyone out there allow these on ADC's and if so have you had any safety events as a result of this? Thanks,

Cortney Swiggart
Med Safety Officer

I was tasked to reach out to this group to see if there is any type of benchmarking for medication errors within healthcare.
I realize our goal is to prevent/reduce the severity however I would love for the number to be zero!
My guess is that it will vary by organization and human factors.
Any insight is always helpful.
Thank you
Marilyn Hargett

I was tasked to reach out to this group to see if there is any type of benchmarking for medication errors within healthcare.
I realize our goal is to prevent/reduce the severity however I would love for the number to be zero!
My guess is that it will vary by organization and human factors.
Any insight is always helpful.
Thank you
Marilyn Hargett

Hello,
I am inquiring about how other organizations handle medications for intra op orders. Are all the meds (such as ATB, ATB for irrigation, cardiac drips) available in the OR for anesthesiologist to pick from a pyxis machine or department stock therefore not utilizing a pharmacist? If pharmacy dispenses, is there an order sent to pharmacy? Is the preference card for a case utilized as the order for pharmacy?
Your input would be greatly appreciated.
Thank you
Marilyn Hargett

For the medication use process involving chemotherapy infusions, what is best practice? We are reviewing our current process and I wish to know what other pharmacies are doing for inpatient and outpatient chemotherapy infusions. We have CPOE & BCMA as part of the process. Do you have two pharmacists independently verify the order prior to compounding? Does the person preparing infusion select the medication? Do you have a checklist? Do you utilize IV workflow software? Do you have two people verify compounded product prior to administration?

For those of you who have BCMA at your facility, does your Cath Lab and/or procedural areas also use BCMA? We're getting reports that it impedes workflow and directs attention away from the patient during critical moments. Curious if others have had issues with this as well. Thanks,

Cortney Swiggart
Med Safety Officer

We have an order set for insulin that contains orders for hypoglycemia treatment and also an order for D10 for hypoglycemia prevention. If the patient receives NPH insulin and continuous tube feeds are later stopped, the nurse is to hang D10 at the same rate as the feeding rate. The D10 order may be placed days before the tube feeds are stopped for procedure or other reason. Our nurses are not hanging the D10 in all cases and we see 1-2 safety events each month for hypoglycemia due to this.