Do any of you have an observation based error tracking system in place?

What system do you use?

What types/how many process improvement projects or action items have been identified using observation based error tracking?

How has your organization responded to this type of tracking? (positive vs negative feedback)

How long did it take to implement?

Any insight is greatly appreciated!

Thank you,

Are any facilities using KCL for therapeutic abortion in the OB clinic setting? If so, how have you structured the ordering and dispensing workflow? What safety checks do you have in place.

Best,
Drew

According to The Joint Commission's standard MM.03.01.01, EP 10 "Medications in patient care areas are available in the most ready-to-administer forms commercially available or, if feasible, in unit doses that have been repackaged by the pharmacy or a licensed repackager."

Lorazepam is available in a Carpuject, but requires special equipment, training, and extra storage space.

Does anyone use separate in-line air detectors when a syringe pump is being used (which do not contain air-detectors themselves (Alaris))?

Thanks,

Randi

1. Does your pharmacy dilute fentanyl and or morphine for small doses?

2. To what concentration do you make the dilution?

3. If yes, then do you store these in an automatic dispensing machine such as pyxis or Cerner med station on the floor?

Hi

I need to develop a new position description for a Medication Safety Pharmacist. If you are happy to share one, please email me at patel.ish@gmail.com

Thanks

ish

Hello,
In situations when a medication is being administered using a "smart" infusion pump and the nursing staff who have programmed the pump receive a soft limit alert, does your organization describe in policy/procedure the specific actions to be taken prior to overriding the soft alert?
Thanks
Jen Turple
IWK Health Centre
Halifax, NS Canada

Topical epinephrine bottles look very similarly to injectable epinephrine 30ml vials. What safeguards do you have in place to prevent errors with these medications (e.g. topical drawn up and injected)?

Hi I am looking for any information about your hospital's policy for KVO. I have searched and found no specific data and very few articles. Some data I have seen has rates as high as 50 ml/hr, while most of the list serves say it must be MD order specific.

Hello,

We are considering implementing order questions to guide non-oncology providers through ordering antineoplastics for non-oncology indications (eg. methotrexate for RA) or for continuation of oral chemotherapy. We want to include questions that require some sort of verification step (with patient/family, home pharmacy, or outpatient provider).

Have any of your institutions implemented something like this and would you be willing to share the types of questions?

Many thanks,
Lauren