Hello All,

Do any of you have any form of REMS policy in place to track the drugs, REMS requirements and provider compliance? If so, would you be willing to share?
For the drugs that require provider registration, how do you confirm this when you get a prescription? Does your system allow for such documentation or is it documented on the hardcopy?

Are there specific indicators: eg. level of harm to patient, drug class involved in event, technologies in use, etc. that your organization or practice utilizes to drive cause analysis like ACA? I am looking to put some framework around the kind of events we should sometimes/always consider for deeper analysis. TIA!

Greetings,
Would anyone be willing to share how their organization currently handles levonorgestrel IUDs in regards to it's hazardous drug status? Do you require full PPE for administration?

Lexicomp states: Hazardous agent (NIOSH 2016 [group 2]).
Use appropriate precautions for receiving, handling, administration, and disposal. Gloves (single) should be worn during receiving, unpacking, and placing in storage. Double gloving and a protective gown are recommended for administration (NIOSH 2016). Assess risk to determine appropriate containment strategy (USP-NF 2017).

We are working to improve safety surrounding anticoagulation prescribing by including a required indication field when inpatient orders are placed. This additional information will help the pharmacist to ensure correct dosing, especially for DOACs.

Trying to gauge if any other institutions have an indication field for documentation when anticoagulants are ordered and if so, if it is required.

Many thanks in advance!

Hi all. I am an ambulatory med safety officer. I am trying to incorporate GEMBA walks into all of our serious safety event reviews. How do other teams approach GEMBA concerns in a totally remote team? Do you look at staffing levels and patient load as well? Any additional items to look at for GEMBA?

Carrie Steiner, Ambulatory Pharmacist Swedish Medical Group, WA

We are in the process of implementing electronic prescribing of chemotherapy orders in our adult inpatient unit. Do the providers or the pharmacists at your institution enter the chemotherapy plans into the EHR? If the pharmacist enters the orders does a second pharmacist double check?
In our pediatric department the providers enter the orders and there is a double check by a second provider prior to going to pharmacy for a double verification. We would like to mimic that workflow in the adult setting but are meeting some resistance.

Hello,

Does anyone have limits set to the amount of potassium allowed per container (potassium in any salt form) or know of any safe practice recommendations that address this?

Thank you,
Mara Miller, PharmD BCPS
Medication Safety Coordinator
Kaweah Health Medical Center Pharmacy
400 W Mineral King
Visalia, CA 93291
T: (559) 624-5652

Hello from Fulton County, Ohio.

We had a recent near miss/good catch reported by a nurse who obtained a medication from an open matrix drawer in our Omnicell. When attempting to administer using barcoded medication administration, she realized it was the wrong medication, sucralfate instead of isosorbide mononitrate. Upon further investigation, there was more of the wrong medication in the wrong pocket- the 2 medications were stored directly adjacent to one another in the Omnicell open matrix drawer.

Does any site consent patients for medications derived from blood products (e.g., IVIG, Kcentra) to cover for the risk that the med may carry a risk of transmitting infectious agents, e.g., viruses. There is also the possibility that unknown infectious agents may be present in such products.

Appreciate your feedback.

Renu Bajwa, PharmD

At my hospital, currently enteral nutrition (tube feeding and supplements like Juven, Beneprotein, etc.) are not on the MAR and not BCMA'ed by nursing on administration. We are starting to explore with nursing and dietary how to start doing this.

Just curious how many others are doing this, and from a technical standpoint, how you have these orders built in your EHR? (We are on Epic). Do you have them built as ERX/medication records (to auto-verify) but so that they do appear on the MAR with due times, and require BCMA scan?