Does your organization utilize atropine ophthalmic drops administered sublingually or hyoscyamine for excessive secretions? If using atropine, what measures have you taken to ensure correct route of administration?

Do others have issues with administration and documentation confusion of insulin regular infusions related to units/hr and units/kg/hr? If so, what are some strategies you've used to reduce the risk for error? Our protocol is initial weight-based dosing (units/kg/hr) with subsequent percentage titrations in units/hr. We use Epic and it allows RNs to document using either of these units. Our pump is in units/hr. We do not use EndoTool. Thanks!

When patients get admitted with a U-500 patient's own insulin pump that is due to be refilled, how are organizations safely handling pump refilling?

Hi Everyone,

Wrong-weight errors may lead to patient harm, yet they are potentially easy to make (e.g., conversion between lbs and kg or translocation of a number/decimal during transcription).

I am wondering who out there has implemented technology on their scales that transmits data directly to the EHR. Hypothetically, this seems as though it could greatly reduce risk of error.

Wins? Barriers/Issues?

Thank you in advance for sharing,
Zach

We are currently looking at our admission medication reconciliation process. Currently if a patient has previously been in our hospital the home medications from a previous admission will pull in for review and update. The usual process would be for the nurse to update the list and then the provider reconcile the home medications for admission.

We recently had our Joint Commission survey and one of the surveyors mentioned that she is seeing a move towards pharmacist driven heparin protocols. She stated that more than half of the hospitals she has visited have switched to this. Our current heparin protocol is nurse driven. How many people utilize a pharmacist driven heparin drip protocol and have you seen major improvements with that? Does anyone have some examples they can share? Thanks!

Hi all,

I've had several people reach out regarding the publications for our corrected heparin levels, so I figured I would just go ahead and share them here. Please feel free to reach out if you'd like more information - I can do my best to help or can connect you to our hematology pharmacist.

Thanks,
Kara
krp4h@uvahealth.org

Hello,

Would appreciate your feedback. Would like to know if your hospital uses Anti-Xa assay to monitor heparin vs. aPTT?

Good evening MSOS Team,

I have some questions (below) which I appreciate your advice regarding Medication Reconciliation Continuum for EPIC Institutions.

1) Prior to Admission, when do they stop looking at this (how far back from the admission date).
2) Admitting medication Reconciliation: Who is completing this or reviewing this?
3) What level of work or review occurs with transfer or change in level of care?
4) How are they integrating High Risk Med Reconciliation (Best possible med history).

Our health system currently has three standard insulin infusion concentrations: 1 unit/mL (adults), 0.5 unit/mL (peds), and 0.2 unit/mL (NICU). Our medication safety council has received a request to eliminate the use of the 0.5 unit/mL concentration for multiple reasons--reports of wrong concentration errors, decreasing compounding needs, facilities that we transfer pediatric patients to do not use 0.5 unit/mL so our pharmacists are manually manipulating orders resulting in potential errors, etc.