MSOS Discussion Board

IM/ subcutaneous doses from pharmacy and prevention of wrong route errors

Jennifer Bonvechio's picture

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Hello med safety friends,

My pharmacy currently dispenses subcutaneous doses plus overfill, along with the subcutaneous needle in the bag (not connected). Having the subcutaneous needle dispensed with the dose syringe was to help mitigate wrong route errors. Our pharmacy department would like to get away from dispensing needles altogether. What are your safeguards to mitigate wrong route errors with subcutaneous/ IM medications? We do indicate on label that 0.05 mL has been added.

NPSG AC Metrics on Peri-Op Anticoagulation

Manisa Tanprayoon's picture

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Hello Members,

Can you share the metrics you use at your institutions to meet NPSG AC requirements re: Use of approved protocols and evidence-based practice guidelines for perioperative management of all patients on oral anticoagulants?

We have approved guidelines available but not strictly asked the team to strictly follow since certain cases may required them to deviate from the guidelines.

Any info/insight is greatly appreciated!

Thank you,

Manisa

NICU 1ml enfit syringe

EunJi Ko's picture

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Hi,

We've been noticing whenever we make a NICU syringe (any med) using a 1 ml enfit syringe, a lot of times it leads to either a huge air bubble in the syringe or volume loss. It doesn't happen with the 3ml or 5ml syringe though. I was wondering if other institutions experience the same and if they use a different syringe or cap for a 1ml syringe?

Medication syringes look alike risk with sodium chloride flush - safety strategies?

Emily N Warner's picture

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Is anyone else practicing where atropine (NDC 64253-400-30) and/or calcium chloride 10% syringes (NDC 64253-900-30) are in the soft packaging and visually look like BD sodium chloride 0.9% flush syringes when face down? There was the recent ISMP MedAlert highlighting this concern as a safety brief (Volume 30 Issue 3 from Feb 13, 2025). We are switching our calcium chloride back to the box packaging to prevent medication mix up errors. If this is happening anywhere else, I'm curious if there are safety strategies being utilized that have been found to be effective. Thank you!

Medication syringes look alike risk with sodium chloride flush - safety strategies?

Emily N Warner's picture

Forums: 

Is anyone else practicing where atropine (NDC 64253-400-30) and/or calcium chloride 10% syringes (NDC 64253-900-30) are in the soft packaging and visually look like BD sodium chloride 0.9% flush syringes when face down? There was the recent ISMP MedAlert highlighting this concern as a safety brief (Volume 30 Issue 3 from Feb 13, 2025). We are switching our calcium chloride back to the box packaging to prevent medication mix up errors. If this is happening anywhere else, I'm curious if there are safety strategies being utilized that have been found to be effective. Thank you!

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