We did a brief article in today's ISMP newsletter related to the recent tragic error in Oregon where a neuromuscular blocker was prepared in a bag labeled fosphenytoin.

http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=97

The Strategies Worth Sharing session is scheduled for Wednesday, June 10, 2015 from 8 -10 am at the 2015 Medication Safety Collaborative. Notice that this session used to be called “Best Practices” but has been renamed to avoid confusion with the ASHP award program called Best Practices.

What is the process you use for notification of nursing that a medication has been prepared and delivered to the floor/Pyxis machine? We are not yet at BCMA so this process can't be used and we are trying to figure out a way to improve the process.

We have need to send patient specific subcutaneous IV preparations to our floors.  The nurses are asking we send the preparations with a subcutaneous needle primed and attached so they do not lose any medication in the needle (these are small doses so 0.1mL lost to the needle could easily be 25% of the dose).  Has anyone done this successfully?  I am concerned that the needles could fall off during transport. I have asked the technicians to put these preparations into separate sealed bags when delivering.  I know there has to be a better way to do this.  Suggestions?

Phenytoin and fosphenytoin are now considered "hazardous" by NIOSH on their 2014 list... It is currently stocked in ADCs in our emergency room and critical care areas. Are people removing phenytoin/fosphenytoin from ADCs and mixing all doses in a chemo hood? Is anyone making an expection in their hazardous drug handling policy for STAT meds?

Good morning

We received a query that the sender and ISMP would appreciate your input. Does your hospital IT system have the ability to notify the nurse by a visual or audio cue which medications are in the time-critical period of giving to meet CMS guidelines for drug administration?

If you don't mind what system are you using? Thanks!

Ivy Andreica, BSN, PharmD

Dear colleagues,

If you have a few minutes, would you please tell us if you are having any trouble scanning Exparel? We are curious as someone reported to us that their system is not able to scan Exparel's barcode as it contains a large amount of characters. We contacted the company but thus far no feedback. We are doing data gathering all the same.

How do you enter meds intended for the fetus in utero?

Are they entered on the mother's chart, or is there a separate chart created specific for fetal med administration?

thanks

Susan

Does anyone have an algorithm for what medications are stored in pyxis as well as a process for frequent review of inventory that they are willing to share?

Sean O'Neill

Medication Safety Officer

The Children's of Philadelphia

Do you have standard heparin concentrations for IR thrombectomy procedures?

Our IR specialists would like to be able to infuse 300-500unit/hr, but our therapeutic heparin concentration of 100unit/mL yields only 3-5m/hr, so they run an extra NS at 30mL/hr through the side arm of the popliteal sheath.

Do you allow specific heparin concentrations for IR procedures?