At the recently held MSOS Member Meeting during the ASHP Medication Safety Collaborative in Minneapolis on June 4, 2017, a member shared an occurrence that happened in their facility. The member believed that a defect in BD’s (Pyxis) MedStation ES software resulted in the misinterpretation of an order frequency intended to be every Monday, Wednesday and Friday as every day that was associated with a patient incident. David Swenson, Vice President, Clinical Strategy, Medical Affairs, Medication Management Systems at BD attended that meeting and publicly volunteered to investigate the report. David shared his investigation For the full message with an excerpt of his findings, please click on the title above.
For years, insulin has been shown to be associated with more medication error-related harm than any other drug. The new ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults are designed to help healthcare practitioners prevent errors and improve outcomes for patients with diabetes. The guidelines, based on a multidisciplinary consensus conference of experts, provide recommendations for avoiding at-risk behaviors involving subcutaneous insulin across the entire continuum of care, including prescribing, preparation and administration, monitoring, and patient education. The document also addresses evolving practices, devices, and technology that aim to enhance the safety of insulin use, such as with concentrated insulin and insulin pen devices. For a copy, visit: https://www.ismp.org/Tools/guidelines/default.asp
The ISMP Medication Safety Self Assessment® for Antithrombotic Therapy has been updated and now includes safety strategies for some of the newer oral anticoagulants. Healthcare organizations can use the assessment to evaluate their current systems related to the use of antithrombotic agents, proactively identify potential improvement areas, and track their efforts over time. To access the revised antithrombotic self assessment, go to: http://www.ismp.org/selfassessments/Antithrombotic/2017.
The Medication Safety Officers Society’s (MSOS) first quarterly MSOS Member Briefing is scheduled to be held on Thursday, March 16, 2017 from 1:00-2:00 pm EST. Participants will hear short medication safety-related presentations from invited speakers on different topics and MSOS members focusing on what they have done at their organization to address a specific medication safety issue. The topics for this first webinar are:
Error reduction strategies to prevent inadvertent IV administration of inhaled medications. Randi Trope, DO, MBA, FAAP, FCCP. Cohen Children's Medical Center, Northwell Health
Going Dilaudid-Free – Implications for patient safety. Bonnie Levin, PharmD, MBA, MedStar Health
Is there fat in that SALAD? Preventing errors with conventional and alternative lipid dosage forms. Julie L. Kindsfater, PharmD, BCPS, Aurora Health Care
ISMP update on safety issues. Michael R. Cohen, RPh, MS, ScD (hon,), DPS (hon.), FASHP, Institute for Safe Medication Practices.
Moderated by E. Robert Feroli, FASHP, this webinar will not include CE credit, but is specifically designed to share ideas and experiences to enhance the knowledge of MSOS members on a variety of current medication safety topics. Attendance is FREE and restricted to MSOS members, but still limited, so be sure to sign up early. For registration information, go to: https://attendee.gotowebinar.com/register/2671086858718548225
Are you a nurse, or know a nurse executive interested in medication safety? ISMP will be conducting a free breakfast symposium at the American Organization of Nurse Executives Annual Meeting (AONE 2017) entitled Changing the Safety Paradigm on IV Medication Use: Recognizing the Risk and Taking Action at the Baltimore Convention Center on Friday, March 31, 2017 from 7:00-8:00am. Continuing education credit will be provided. For more information and to register, see: www.proce.com/AONE17