Does anyone have an ADR event reporting policy they would be willing to share?

Thanks,
Jaime

Looking to see how inpatient U500 is being handled in the recent years. A quick search of the forum showed that previously many sites were switching to the U100 option while others are dispensing individual doses in pharmacy-drawn syringes. Is anyone using the U500 prefilled pens? If so, where are they stored in the medical center (ADC vs. med carts) and how are they monitored (if any). Thanks!

Due to national backorder of Lorazepam 2mg/ml vials, we were considering drawing up Lorazepam injection into BD 1ml syringes for IV administration. Does anyone have any info on stability when transferred from Multidose 30ml vial into 1ml labeled syringes by Pharmacy in the isolators?

Our standard for KCl replacement via peripheral lines is to give 10 mEq/100 mL at a rate of 100 mL/hr x however many bags are needed. Our RNs have expressed concern that many of our patients can't tolerate this rate, resulting in issues with charting and accessing the meds in the ADC. This has caused workarounds, delays, and the full run of replacements not being completed.

A group of RNs has requested that we change the default rate to allow for longer infusion times.

Has anyone moved away from the Q1H KCl replacement timeline, or experienced anything similar?

Hello colleagues,

The simple question I have is: are you stocking epinephrine for anaphylaxis in code carts (in any form: amps/vials, pens, kits)?

Background: Med error with verbal order for epinephrine IV for anaphylaxis. We stock anaphylaxis kits in Pyxis, not in the code carts. Nurses think that if we had the kit in the code cart, the error may have been prevented (thinking the kit would have prompted the RN to question the route further).

Do you have your Pyxis/Omnicell/ADC set up to allow user-to-user transfer of controlled substances by anesthesia providers in the OR? E.g. CRNA John pulls fentanyl 100 mcg for an OR case, does not give any to the patient and then goes to lunch. He signs out the med to CRNA Sally in Pyxis.

Thanks,
Will Vincent
Boston Medical Center

Hi everyone - does anyone dilute IVP lorazepam prior to administration? There is a manufacturer recommendation to dilute prior to intravenous administration but I have not seen it done in clinical practice because the volumes are so low (0.5 mL to 1 mL).

Hello,

Does anyone have a hospital policy on multi-dose vials that they are willing to share?

Thank you,

Matthew Beaulac

Hello.

I am new to the med safety role & in need of some expert advice on a process that is new to our facility.

Our anesthesiologists assist with pain managment at our hospital and a new physician has a practice of having nurses dilute dilaudid 1mg in 10mL normal saline and infusing it over 15 minutes to avoid "patient conflation of opioid-induced euphoria vs. true analgesic benefit."

We are looking into using the ADD-vantage system. In watching the Pfizer video, it looks like the plug floats around in the bag after mixing and could potentially block the flow of the fluid during administration. Does anyone use these and have you ever found this to be a problem?

Thank you!