Sign up now for the next quarterly MSOS Member Briefings webinar scheduled to be held on Thursday, December 14, 2017 from 1:00-2:00pm EST. Short medication safety-related presentations for this webinar will include topics on the management of ketamine, elimination of double-checks for SQ insulin, changing systems based on error reports, and update from the FDA on drug shortages and an ISMP update. For more information, click on the header above. To register, go to: https://register.gotowebinar.com/register/5787674558169084418

MSOS is adding a “Quick Survey” feature to our website next month. Members will be asked one new question of interest each month on the MSOS website, that will offer 3 to 5 multiple choice options. Participants will receive instant feedback of the survey results. We are reaching out to MSOS members to ask for ideas/topics for the one question surveys that would be of interest to them. Please submit your ideas as a multiple choice question with answers to admin@medsafetyofficer.org. Members will receive an announcement with each new survey that is posted to the website.

Please note: If you add an attachment to any Forum post, it will not be viewable in the email that is sent to all members. The attachment is only viewable in the Forum section of the MSOS website (www.medsafetyoffice.org).This is due to the functionality of the software we utilize. Please take this into consideration when writing and viewing posts. Thanks. 

Med-ERRS, a subsidiary of ISMP, is looking for a few pharmacists who will be attending the ASHP Midyear Clinical Meeting in Orlando FL to participate in a half-day advisory board. The advisory board will be focused on compounding products in the pharmacy. Following the meeting, you may be asked at a later date to review the proceedings, which will be developed into a white paper. The advisory board meeting will take place on Sunday, December 3, 2017 from noon-4PM. There will be an honorarium for participation. If you are interested or have questions, please email Susan Proulx, PharmD at sproulx@med-errs.com, with your resume/CV attached. More details will be provided as we get closer to the meeting. Thanks!

ISMP has introduced a new tool to help hospitals, long-term care facilities, and certain outpatient facilities evaluate their best practices related to high-alert medications, identify opportunities for improvement, and track their experiences over time. The ISMP Medication Safety Self Assessment® for High-Alert Medications focuses on general high-alert medications and 11 specific medication categories--including opioids, insulin, neuromuscular blocking agents, chemotherapy, and moderate and minimal sedation. Participants who submit assessment findings to ISMP anonymously via a secure internet portal by December 15, 2017 will be able to obtain their weighted scores so they can compare themselves to demographically similar organizations. Participation also can help organizations meet requirements for managing high-alert medications from regulatory and accrediting agencies, such as the Centers for Medicare & Medicaid Services and The Joint Commission. To access the self assessment workbook, go to: http://www.ismp.org/selfassessments/SAHAM. 

Opioids are still among the most frequent high-alert medications to cause patient harm, and anesthesia providers are in a key position to support improved understanding of the risks associated with the use of opioids. An ISMP symposium on opioid safety is being held at the American Society of Anesthesiologists (ASA) meeting on October 22, 2017 in Boston, MA. Please encourage your anesthesiology department to attend--there will be discussion about current opioid medication safety challenges and the potential leadership role for anesthesiologists in error prevention. For more information or to register, go to: http://surveys.ismp.org/s3/freseniuskabi-ANES17

Sign up now for the next MSOS Member Briefings webinar scheduled on Wednesday, September 13, 2017 from 1:00-2:00 pm EST. Topics will include:

• improving compliance with smart pumps
• handling unmeasurable doses in the NICU
• convincing the C-suite that medication error rates cannot be compared between organizations
• update from ISMP

This free webinar has limited attendance and is restricted to MSOS members. For registration information, go to https://register.gotowebinar.com/register/7556140055314428162.  Click on the title above for more information. 

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.