I am curious how other sites are interpreting this or have found other guidance. We use the Aerogen syringes for some of our continuous inhalation products and they currently are not manufactured as sterile and we have not identified a sterile, safe substitute.

1.1
Scope
1.1.1 CSPs affected:
• Aqueous preparations for pulmonary inhalation.

We are an Epic facility and we have had a couple close calls with incorrect medication dosing due to adjusted body weight not being calculated if the gender identity fields do not indicate male or female. If responses such as "chose not to disclose," "Unable to collect," or "other" are chosen in any of the gender identity fields then Epic logic can't complete calculations requiring a male or female designation. Wondering if other facilities have experienced this and what was done help close this gap? Thanks!

Hi,

We were recently asked by a provider to add magnesium 5g/10mL vials to our crash carts and Pyxis cabinets in OB areas for preeclampsia patients who do not have IV access. The dose for preeclampsia IM is 10 grams.

Historically we have stocked the smaller vials 1g/2mL which can be used for IM injection if needed. We are hesitant to stock the larger concentrated vials in a crash cart or Pyxis. Will you please let me know what you stock for preeclampsia and where you store this?

Thank you,

We have had a couple of recent near misses related to medications being discontinued from the home medication list by med rec technicians that should not have. Because we utilize CancelRx, the discontinuation of the medication triggered a message to the patient's pharmacy to cancel the prescription. Has anyone else experienced issues with this? Are there any workflow changes anyone has implemented to help prevent this from happening?

Hello,

How fast do you allow magnesium to run in your facility? We have some providers (e.g., emergency) who want to give 2-4 grams over 20 minutes specifically for a fib, but nursing is concerned and at times has refused to give. Obviously we give higher doses for preeclampsia. I have found a couple of references that show safety when exceeding the 150 mg/minute recommended max rate, but I am curious what other facilities allow.

Thank you!

Hello,

Wondering if other sites have a good process for this. For patients that come in on an IUD, how is this being managed from an order rec process? We have had issues where a provider unintentionally ordered a patient's IUD for continuation in-hospital from their home med list, leading to our pharmacy dispensing one but luckily was caught by another pharmacist.

Looking to see how everyone incorporates PGY-1 residents in the med safety process at your institution. Do you do it longitudinally? Do you allow them to help investigate error reports and if so, do you allow them full access or do you de-identify them to keep names of staff confidential? Would appreciate seeing any and all recommendations you may have around this. Thanks in advance!

Hello fellow Med Safety officers.

I am looking to see how other institutions manage duplicate pain medications ordered via different routes, but for the same pain scale to comply with JCAHO's "Med orders are clear & accurate" standard.

For example:
Post-op ortho orders:
Oxy IR 10mg po q4hrs prn severe (7-10) pain
Dilaudid 0.5mg IV q2hrs prn severe (7-10) pain

Hello colleagues,

For those who have nebulized tranexamic acid for hemoptysis, how do you dispense it? Repackage and dispense from pharmacy or allow respiratory therapist to remove a vial from an ADC based on a linked order?

Thank you kindly,
Megan Fragale, PharmD, MS< BCPS
Medication Safety Officer
Skagit Regional Health

Does anyone have any USP 800 practice exceptions surrounding the use of methotrexate in ectopic pregnancy that allows its use for this indication outside of a sterile compounding containment environment? e.g., assessment of risk (AoR) that delineates appropriate storage, handling, disposal that would allow the frontline nursing staff to draw up and administer these onetime intramuscular doses.

Thank you!