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Sample Pro-Change Worksheets

Examples of worksheets that are used to review patient safety topics and determine the need for change within an organization.

ISMP Issue
ISMP Concern
Current Status
Action Needed
4/3/2002 Vol 7, Issue 7
  Methotrexate/Fosamax q day versus q week dispensing The possibility for occurrence exists with handwritten orders./td      
6/26/2002 Vol. 7, Issue 13
Main focus of the issue was Pediatric Guidelines for Preventing Medication Errors

Bar Coding at the Bedside
Planning Stages - Implementation goal of February 2003
Robot Technology

Available but not all Pediatric doses dispensed via the robot
Labels need to be clear and easily readable New laser printer with clearer print to be installed by December 2002      
Discharged Medications - lack of education and over medication In the future our retail pharmacy will offer on-site medication counseling. Currently the pediatric nursing staff is utilizing the "Learn More About education sheets to provide education to patients and families
Double pharmacy checks before medication dispensing - Same pharmacist does not enter order and dispense medication
In place      
Weight and Age based dosing checks Our Pharmacy system does not allow for weight based dosing alerts. It contains max dosing alerts
7/10/2002 Vol. 6, Issue 14
  Illegibility of Physician Handwriting
CAPOE implementation will resolve this issue      
  Pharmacy Phone Interruptions
Frequent phone interruptions in the main pharmacy - Nursing units are not calling their unit based pharmacist
  Pharmacy Phone Interruptions
Most frequent phone interruptions in the pharmacy at LVH-M are requests for tube returns.
08/21/02 Vol. 7, Issue 17
  Zyvox 600mg bid taken as Zovirax 600mg bid      
9/4/2002 Vol. 7, Issue 18
  Humalog given for a night time dose instead of Lantus
Lantus sent with patient label on box - not on floor stock. Humalog is a floor stock item.      
07/10/02 Vol. 7, Issue 14 and 09/18/02 Issue 19
  Trazodone 50mg UD tab looks like Tramadol 50mg
Tramadol (Non Formulary) is stored away from Trazodone in the pharmacy.
10/3/02 Vol. 7, Issue 20
  Special Alert- Methotrexate Overdose
The pharmacy computer system alerts the pharmacists when they try to enter a Methotrexate order that is an overdose
  An order written or appearing on the label as @50/hr taken as 250ml/hr.
@ is not included on our pharmacy labels. This could occur with a handwritten order on non-capoe units.
10/16/02 Vol. 7, Issue 21
  Rheo order for Rheomacrodex taken as Reopro on a verbal order
Discussion revealed that we have a "repeat back" policy for verbal/telephone orders. Physicians need to be aware of this policy.
11/13/02 Vol. 7, Issue 23
  Verbal Order -" Increase Lasix to 40 an hour"
Order read back completely 40mg vs 40ml
  Intimidation by physicians to give unsafe doses
Documentation is required by the physician. A chain of command is in place
  Writing oral liquids using volume vs metric weight Would generate call from pharmacy to the ordering physician. Pharmacy would educate the physician as needed.
1/22/03 Vol. 8, Issue 2
  Free water ordered to be given IV - 550 ml given IV, patient experienced hemolytic reaction, renal failure and died
This could happen
  Varivax vs VZIG mix up in OB

Varivax is frozen, VZIG is refrigerated, neither is a floor stock item
  Atrovent/Combivent Inhalers (not solutions) used in the patients with peanut allergies
Not an issue to date but no safeguards are in place. Brian reported that the retail pharmacy placed a warning on the patient information sheet that they print.
  IV Meperidine given in arterial line
Arterial lines are clearly identifiable
2/6/03 Vol. 8, Issue 3
  Confusion between Zanaflex (tizanidine) and Gabitril (tiagbine)
Not and issue to date but the drugs are stored close to each other on the pharmacy shelf
  Synagis concentration after reconstitution

Not an issue to date and we don't use that size vial in the pharmacy
2/20/03 Vol. 8, Issue 4
  Confusion between Seroquel and Serzone
Not and issue to date and the drugs are not stored close to each other
4-17-03 Vol. 8, Issue 8
  Mix up with Epinephrine and Ephedrine in L & D
These drugs are separated In L & D since Epinephrine is a floor stock drug but Ephedrine is not. Look alike/Sound alike warning is written on the box by pharmacy.
  Two channel pump mix up - Aggrastat hung through channel programmed for heparin
Our practice would not put 2 titratable drugs together on the same pump.
  Metherfine and Brethine mix up -- products made by the same company and look very similar
Not sure if this drugs are even on the same unit      
5/1/2003 Vol. 8, Issue 9
  Td given for PPD due to similar packaging
Td is floor stocked in the ED only, PPD is drawn up by the pharmacy department
  Default route changes after FDB update (IM changes to Inj after update)
Pharmacy analyst runs a report after a FDB update to fix the changes that were made.
  Vincristine given intrathecally
Inpatient places a "Not for intrathecal use" on the syringe. MPA does not use the label but they do not administer intrathecals.
5-15-03 Vol. 8, Issue 10
  Max dose for digoxin in computer
A warning does appear on CAPOE, however, it is very small in the bottom left corner of the screen
  Administration of IV medications too quickly
Guidelines are on all Critical Care Infusion cards and the pharmacy website
  Chloral Hydrate written 500mg 30" before appointment taken as 30 cc.
No previous errors associated with the use of ". The usage of " for minutes is not seen on our physician orders
5-29-03 Vol. 8, Issue 11
  Zetia 10mg/Zebeta 10 mg mix up
If Zetia is on our formulary we will place a warning in the computer
  Solu-Medrol/Depo-Medrol mix ups. Depo Medrol was given by IV route.
DepoMedrol already defaults to IM in our computer system
6-12-03 Vol. 5, Issue 12
  Oral syringes used for topical preparations
We do not use oral syringes for topical use
  Medications with several prescribed routes, e.g. Lasix 100 mg IV or PO daily
Pharmacy enters the order by IV route with a note stating "notify pharmacy when tolerating PO route". At that time the route is changed. Pharmacy would not place both routes in the computer at the same time. With CAPOE the physician would get a warning label that a duplicate medication has been ordered
  BP Monitor tubing may connect to IV ports
Don't know if our connections would cross fit
  Vaccine abbreviation confusion
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