251 Good Catches....and counting!

March 2024

• Catch: Incorrect dose of zidovudine was ordered for infant
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Incorrect frequency of aztreonam ordered
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: TPN orders on OMS and Epic do not match (x3)
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Tylenol 1 g IV ordered for a 40 kg patient
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Pharmacy technician received a call from nurse that they did not receive dose of Zosyn, pharmacist checked patient’s MAR and it had already been hung
  • Fix: Continue to utilize patient’s MAR to track medications
• Catch: Patient in GRACE program did not have opioid order set entered, just the regular set
  • Fix: Continue to clarify incorrect med orders upon order verification
  • Fix: Continue to perform profile reviews
• Catch: Exparel was ordered as a multi-use dose, order was seen by technician
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Incorrect dose of narcotic was drawn up and went through Doseedge, was caught by the pharmacist on the final check
  • Fix: Continue to verify syringes through Doseedge and at the final check
• Catch: Heparin ordered IV instead of SC
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch:  Inappropriate antibiotic coverage - Gentamicin ordered for pre-op instead of clindamycin
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Fluid for NICU ordered incorrectly
  • Fix: Continue to clarify incorrect med orders upon order verification
  • Fix: Continue to report/notify any changes with Epic
• Catch: TPN ordered with incorrect weight
  • Fix: Continue to clarify incorrect med orders upon order verification

Feb 2024

• Catch: Wrong dose of Wellbutrin home medication entered
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: Calcium gluconate with precipitate was caught by technician
  • Fix: Continue to inspect medications and double check with pharmacist if it looks unusual
• Catch: Cefotetan was already administered but another dose of cefotetan was ordered
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: Clarified that ASMTER is receiving appropriate notification of their patients with positive cultures
  
  • Fix: Continue to report/notify any changes with Epic
• Catch: Flagyl with a default dose of 600mg q4h on Epic, pharmacist changed to appropriate dose of 500mg q8h
  • Fix: Continue to report/notify any changes with Epic
• Catch: Patient with a positive culture in ASMT but was not being treated
  • Fix: Clinical pharmacists will continue to complete profile reviews for interventions.
• Catch: Fluid ordered for NICU entered on Epic did not match order on Pedinotes
  • o    Fix: Continue to clarify incorrect med orders upon order verification
• Catch: TPN ordered for NICU entered on Epic did not match order on Pedinotes
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Pharmacist received call from retail pharmacy on change in patient’s medication dose, but patient was already discharged and didn’t know about change. Patient was contacted.
  • Fix: Clinical pharmacists will continue to complete profile reviews for interventions.
• Catch: Incorrect dose of ampicillin was ordered.
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Beverage found in medication cabinet on nursing unit
  • Fix: Continue to inspect units
• Catch: ASMT ordered fluids for patient, pharmacist called and it’s not what they meant to order
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Labetalol was ordered and the wrong start time was entered
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Lorazepam entered but patient was already on Xanax
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch:  Phenergan IV was ordered but the incorrect formulation was ordered
  • Fix: Continue to clarify incorrect med orders upon order verification

Jan 2024  **ONE YEAR OF GOOD CATCHES**

•  Catch: Penicillin G 5 mil U IM entered for adult, MD actually wanted 2.4 mil IM once
  • Fix: Continue to clarify incorrect med orders upon order verification
•  Catch: Labetalol 400mg entered but MD forgot to discontinue labetalol 300mg  
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
•  Catch: 24 doses of ampicillin entered for baby instead of 2 doses
  • Fix: Continue to clarify incorrect med orders upon order verification
•  Catch: Protonix 80mg entered instead of 40mg
  • Fix: Continue to clarify incorrect med orders upon order verification
•  Catch: Pedi notes said antibiotics was discontinued but was still on MAR, pharmacist called and the med was discontinued 
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
•  Catch: Versed ordered for baby 1.5mg/kg instead of 0.25 mg/kg 
  • Fix: Continue to clarify incorrect med orders upon order verification
•  Catch: Gentamicin 5 mg/kg entered by MD instead of 4 mg/kg for baby
  • Fix: Continue to clarify incorrect med orders upon order verification
•  Catch: Poly vi sol ordered by MD instead of poly with iron 
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Wrong dose of Suboxone entered
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Hydrocortisone entered and dosed by BSA instead of mg/kg
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Height of 24 ft entered for patient, caught by pharmacy technician
• Catch: ART line was not entered on patients MAR
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: Clindamycin 300 q8h entered instead of 900 q8h
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Lorazepam was entered for patient but patient was already on alprazolam.
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: MD notes said patient was on ceftriaxone 2g IV q24h but on patient’s MAR it was cefazolin 2g IV q24h
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: Discharged script for ibuprofen when contraindicated (patient with renal dysfunction)
  • Fix: Continue to perform medication reconciliation for discharge teachings

208 Good Catches....and counting!

December 2023

• Catch: Hydromorphone IM ordered instead of IV
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Patient with elevated serum creatinine. Pharmacist called to adjust ampicillin/sulbactam dose and enoxaparin was switched to heparin.
  • Fix: Clinical pharmacist continue to perform profile reviews for all medications with renal dysfunction.
• Catch: Pharmacist entered 0.2 NS instead of ordered 0.45 NS
  • Fix: Continue to perform profile reviews
• Catch: Labetalol 100mg BID was discontinued and 400mg BID was entered. MD meant to enter labetalol 200mg BID
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Home medication metformin IR entered instead of XR
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: During a discharge teaching, prescription label directions provided the incorrect dose. Pharmacist called the retail pharmacy to get the label changed.
  • Fix: Continue to verify product and directions prior to patient discharge
• Catch: Order entered for Beyfortus 50mg instead of 100mg for infant weighing > 5kg
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Nystatin about to fall off MAR, but baby didn’t receive most of the doses due to being NPO.  Pharmacist clarified with MD – MD wanted baby on nystatin for a full 7 days, so time was extended
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: Tylenol dose entered was too high for neonate
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Incorrect gentamicin dose entered for neonate
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: An opened nicotine patch found in inventory
  • Fix: Check that medication is stored and disposed correctly
• Catch: Patient with renal dysfunction and outpatient renal consult has being discharge prescription for ibuprofen
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: Two different narcotics were found in the same pocket
  • Fix: Check medication is stored in correct bin/box when dispensing and storing medications
• Catch: Unsecure narcotic was left on top of the Pyxis machine
  • Fix: Check that medication is stored and disposed correctly
• Catch: Pyxis pull of nifedipine three times
• Catch: 900 expired sodium chloride vials stored in the pharmacy
  • Fix: Check expiration dates in inventory
• Catch: Nifedipine 60mg BID entered.  When pharmacist clarified the order, MD meant 60mg total daily dose (30mg BID)
  • Fix: Continue to clarify incorrect med orders upon order verification

November 2023

• Catch: Incorrect Tylenol dose put in for circumcision
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Incorrect dose of penicillin ordered
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Betamethasone 25mg x2 doses put in instead of 12.5 mg x2.
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Morphine IR tablets found in locker with morphine ER tablets
  • Fix: Check medication is stored in correct bin/box when dispensing and storing medications
• Catch: Epinephrine 1 mcg/kg/min entered instead of 0.1 mcg/kg/min.
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: MD entered lovenox treatment dose without discontinuing prophylaxis dose.
  • Fix: Continue to review active medication list upon order verification
• Catch: RN entered dermoplast on baby’s profile instead of mom’s.
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: RN entered levothyroxine to be given daily instead of MWF.
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: 2 syringes for 2 diff babies found in one bag when pharmacist checked
  • Fix: Continue to verify product prior to dispensing
• Catch: Found during profile reviews, baby given 21ml sodium bicarbonate
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: Wrong heparin dose was calculated and bag was hung.
  • Fix: Continue to implement first-pass
• Catch: Order entered for D10, heparin, and sodium chloride. Instead a starter TPN was entered (contains dextrose, trophamine, ca gluconate and heparin).
  • Fix: Continue to implement first-pass
• Catch: Enoxaparin 40mg dose already given and additional order for later that evening.
  • Fix: Continue to review active medication list upon order verification
• Catch: Omegaven ordered instead of smof lipids
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification.

October 30 – November 3

• Catch: Jessica M found incorrectly labeled syringes and caught error before dispensing
• Catch: Danny caught a bag that was half empty before it was dispensed. 
• Catch: Julie found a mix up between sulfaDIAzine 500 mg and sulfaSALAzine 500mg tablets. Please be careful when you are receiving or filling
• Catch: Danny notified leadership that the counts were off in OR.
• Catch: Normal saline put in for 20ml/hr instead of 20ml bolus
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification.
• Catch: Only one drug put in for anti-retroviral regimen, should have been 2
  • Fix: Clinical pharmacists will continue to complete profile reviews for interventions.
• Catch: Gentamicin IM ordered instead of IV
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification.
• Catch: Duplex cefepime found in 1g box
  • Fix: Check medication is stored in correct bin/box when dispensing and storing medications
•  

October 23 – 27

• Catch: Pharmacy technician found 2 Ancef in cabinet, checked to see if it was discontinued but nurse said patient is still on it, it just was not given
  • Fix: Continue to verify if patients are on medications before returning to pharmacy
• Catch: Prescriber ordered heparin at 1 unit/kg/day instead of 1 unit/ml
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification.
• Catch: Bactrim order put in for 6mg/kg instead of 6 ml/kg
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification.

October 16 – 20

• Catch: Discharge counseling for labetalol bid, patient had actually been receiving tid. Pharmacy student called to clarify and it was actually tid.
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: Clonidine 0.1 patch put in after 3 days of patient receiving it (supposed to be every 7 days)
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: Pharmacist caught Ancef put in for 2g q6h, instead of q8h
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification.
• Catch: Amphotericin B mg/kg dosing vs dose ordered was different (supposed to be 30mg/kg but dose written is for 40 mg/kg)
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification.

October 9 – 13

• Catch: Cytomel inputted instead of cytotec
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: MD notes stated patient completed steroid course but patient was still on steroid, course not yet completed
  • Fix: Clinical pharmacists will continue to complete profile reviews for interventions.
• Catch: 130 prenatal tabs entered instead of 1
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Home medication put in for Lexapro, pharmacist saw on notes that patient is actually on sertraline
  • Fix: Continue to perform profile reviews and medication reconciliation as needed

October 2 – 6

• Catch: Patient’s home medication being restarted with the strength lithium 90000mg
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: Medication entered in for every 3 days instead of every 3 hours
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Wrong dose of fluoxetine entered
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Lantus given even if blood glucose was <60
• Catch: Components of crash cart packs got switched and was verified
  • Implement double check verification procedures when verifying crash cart components
• Catch: Pharmacy technician noticed simethicone suspension appeared separated in syringe, turns out it was okay that it was separated after they researched it
  • Fix: Continue to inspect medications and double check with pharmacist if it looks unusual

Aug 28 – Sept 1

• Catch: Postop enoxaparin 40mg dose already given and additional order for later that evening.
  • Fix: Continue to review active medication list upon order verification
• Catch: ASMT patient transferred from previous facility. Previously received vancomycin from outside facility. Vancomycin ordered without knowledge of prior vancomycin dose.
  • Fix: Continue to review medications upon transfer.
• Catch: NP ordered hepatitis immune globulin for neonate instead of hepatitis vaccine.
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: Circ medication orders for baby girl
  • Continue to clarify incorrect med orders with prescriber upon order verification.
• Patrick found Intralipids next to the SMOFs bin in the IV room.  Please be aware that these are look-alikes stored in separate locations

Aug 21 – 25

• Catch: CPOE duplicate magnesium riders by two different prescribers
  • Fix: Continue to review medications on MAR upon order verification
• Catch: Two ParaGards charged due to Pyxis pull and pharmacy dispensing an additional Paragard. 
  • Fix: Do not dispense medication if available on the unit via Pyxis.
• Catch: CPOE duplicate potassium rider orders by different providers.
  • Fix: Continue to review active and discontinued medication list upon order verification
• Catch: Zidovudine automatic stop order of 4 weeks on MAR instead of prescribed 6 weeks.
  • Continue to consider stop dates when verifying medications.
• Catch: CPOE quetiapine wrong dose (incorrect 20mg vs. 100mg correct)
  • Continue to clarify incorrect med orders upon order verification

August 14 – 18

• Catch: Fiorcet is now a controlled substance! Nurses unaware green sheets were needed for fiorcet.
  • Fix: In lieu of the green sheet, notify Mark of patients on fioricet so it can be added to Pyxis.
• Catch: TPN electrolyte ordered for 2 mEq/day instead of 0.2 mEq/day
  • Fix: Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Neonate with low renal function. Medications renally adjusted antibiotics
  • Fix: Clinical pharmacists will continue to complete profile reviews for interventions.

August 7 – 11

• Catch: Pharmacy technician identified empty container with patient label
  • Fix: Continue to inspect medications before returning to stock.
• Catch: Infant on poly-vi-sol 0.5mL daily with pharmacy consult for poly-vi-sol teaching.
  • Fix: Clarify discharge poly-vi-sol 0.5mL doses. Poly-vi-sol discharge doses are generally 1mL.
• Catch: CPOE 20mEq Potassium 1 L bag. Physician wanted a potassium rider instead.
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification.
  • ASMTER management/prescribers have been notified of this CPOE error.
• Catch: Incorrect stop date for heparin fluids.
  • Fix: All fluids running through venous lines (PICC, UVC, Broviac) should have a 24 hour stop date. Fluid running through ART (arterial) lines have a 48 hour stop date.

August  1

• Andrea caught two different patient’s medication in the same chemo bag.  Good Catch on a High Alert Medication!
• Danny found a glitch in the black dot stickering workflow
• Deondra found an unsecured Dilaudid tablet on top of the pyxis on 2B
• Miss Jessica for finding two patient’s medication in the same bag in a unit’s cabinet

July 24 – 28

• Catch: Biofire +MRSE and patient not on correct antibiotics
  • Fix: Clinical pharmacists will continue to complete profile reviews for interventions.
• Catch: Spanish speaking patient with discharge prescriptions in English
  • Fix: Continue to customize patient education for Meds2Beds patients
• Catch: Incorrect patients / multiple patients associated with barcode scanning in OMS
  • Fix: Continue to use two patient identifiers to ensure correct patient
• Catch: Medications stored in wrong bin in the pharmacy
  • Fix: Check medication is stored in correct bin when dispensing and storing medications
• Catch: CPOE incorrect dose and frequency (midazolam PRN vs. midazolam continuous infusion)
  • Fix: Continue to clarify incorrect med orders upon order verification.

July 17 – 21

• Catch: Appropriately navigated rare medication request, KCentra
  • Appropriately notified pharmacy director, pharmacy operations, and clinical of consignment request – plans to add consignment meds to technology systems (Meditech, Smart Pumps).
  • Refer to Lippincott procedures “Blood and blood product transfusion” for administration information, including IV tubing and flushing procedures.
• Catch: CPOE omission of discontinuation of antibiotics. Orders for discontinuation was not entered appropriately in PediNotes
  • Fix: Clinical pharmacist to continue to perform profile reviews as needed
• Catch: Transcription error of gentamicin start time. Transcribed as “now” instead of 48h from last dose.
  • Fix: Verify medication start time when entering orders.
• Catch: CPOE duplicate labetalol when adjusting medication from daily to BID dosing
  • Fix: Continue to review active medication list when verifying orders
• Catch: Prevented expired piperacillin/tazobactam from being dispensed
  • Fix: Continue to check beyond use date prior to dispensing medication from pharmacy
• Catch: Wrong calcium solution on shelf (calcium carbonate packaged as calcium gluconate)
  • Fix: Implement double check verification procedures when preparing stock solution
• Miss Angie for finding 10 expired cases of Zosyn 3.375 by following correct procedures and rotating stock when receiving an order also finding identifying a Robinol mix up
• Lawanda for catching her own mistake, pointing it out to help others not make the same mistake, and immediately correcting it so it didn’t reach the patient.  Culture of Safety!
• Miss Julie for letting everyone know about the Exam room on 5B

July 10 – 14

• Catch: CPOE incorrect penicillin (PCN G procaine vs. PCN G potassium)
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: Wrong blue sheet with drug
  • Fix: Verify correct blue sheet when processing controlled substances
• Catch: Prepared incorrect amount of cysteine in neonatal TPN.
  • Fix: Double check cysteine amount when adjusting trophamine amounts.
• Catch: Prevented expired valganciclovir from being dispensed
  • Fix: Continue to check BUD’s of medications that bypasses DoseEdge
• Catch: PCN desensitization – wrong orderset used
  • Fix: Clarify patient history for all PCN desensitization protocols
• Catch: Lab error – Lab reported clindamycin sensitivity incorrectly
  • Fix: Clinical pharmacist to continue to perform profile reviews as needed
• Catch: CPOE incorrect dose. Error related to verbal order (phenobarbital vs. promethazine)
  • Fix: Continue to clarify incorrect med orders upon order verification

July 3 – 7

• Catch: Incorrect sodium chloride dose ordered (10X higher - incorrect 10mEq/kg vs. correct 1mEq/kg) in neonatal TPN
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Duplicate enoxaparin ordered
  • Fix: Continue to review active medication list upon order verification
• Catch: Expired medication stored in pharmacy
  • Fix: Prioritize “soon to expire” medications to prevent waste
• Catch: CPOE duplicate therapy (Amlodipine and Nifedipine)
  • Continue to perform profile reviews and medication reconciliation as needed

106 Good Catches....and counting!

Jun 26 – 30

• Catch: Incorrect dose of PCN G Benzathine (incorrect 1.2 million correct 2.4 million)
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Incorrect dose prepared through DoseEdge – did not have any medication in syringe
  • Fix: Continue to visual inspect final product if not clearly seen through DoseEdge
• Catch: Incorrect dosing frequency for Rocephin (incorrect q12h; correct q24h)
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Clarified orders for long-acting insulin (glargine) in patient at risk for hypoglycemia
  • Fix: Clinical pharmacists will continue to complete profile reviews for interventions.
• Catch: CPOE incorrect formulation (isosorbite mononitrate vs. isosorbide dinitrate)
  • Fix: Continue to clarify incorrect LASA medication orders upon order verification
• Catch: CPOE incorrect mesalamine formulation
  • Fix: Continue to clarify incorrect LASA medication orders upon order verification
• Catch: Incorrect hydrocortisone dose prepared using transfer mode through DoseEdge. (Order for 50mg, but used whole 100mg vial)
  • Fix: Look at the dose and verify that the whole vial matches the dose when using the Prep Mode: Transfer Needle

Jun 19 - 23

• Catch: Incorrect orders for fluids with Calcium and Phosphate
  • Fix: Continue to assess calcium-phosphate precipitation when verify orders.
• Catch: CPOE incorrect fentanyl dose when titrating down, requiring 1mL
  • Fix: Continue to clarify unusual required volumes when verifying orders or compounding
• Catch: CPOE incorrect gentamicin duration, ordered “once”
  • Fix: Clinical pharmacists will continue to review all kinetic consults.
• Catch: CPOE incorrect dose due to incorrect dosing units – calcium mEq vs. mg
  • Fix: Continue to clarify unusual required volumes when verifying orders or compounding
• Catch: Written order, incorrect dose for morphine 2 grams
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Order verification, incorrect dose when implementing therapeutic interchange
  • Fix: Clarify unusual doses or partial pills when processing medication orders / implementing therapeutic interchange
• Catch: CPOE Cephalexin incorrect dosing frequency for UTI (incorrect q12h; correct q6h)
  • Fix: Continue to clarify incorrect med orders upon order verification

Jun 5 – Jun 9

• Catch: Dispensed incorrect vaccine dispensed to unit (adult vs. infant)
  • Fix: Verify product prior to dispensing. Utilize BABY MEDS bag.  Use barcode scanning.
• Catch: CPOE frequency and instructions. Incorrect: Lidocaine 5% patch BID apply on incision.   
  • Correct: Lidocaine 5% patch daily.  Patch should be avoided on broken skin/incision.
• Catch: Transcription error of NICU order – furosemide entered without specifying # doses.
  • Fix: Continue to perform profile reviews of high-risk patients
• Catch: Expired medications in patient rooms bins in L&D’s Pyxis
  • Fix: Inventory “Room” on the Pyxis Tower Unit when checking for meds on the IV Status Round (8am).
• Catch: Upon profile review, identified patient with bacterial vaginosis, not being treated. 
  • Fix: Clinical pharmacists will continue to complete profile reviews for interventions.
• Catch: Inadvertent pharmacy order entry of “1mg”
  • Fix: Pay attention to of units when converting # of tablets to # mg

May 30 – Jun 2

• Catch: Prevented expired lorazepam from being dispensed
  • Fix: Continue to check beyond use date prior to dispensing medication from pharmacy
• Catch: Discharge Rx for Macrobid in a patient with bacteremia
  • Fix: Continue to assess antibiotic indications for Meds2Beds patients
• Catch: CPhT notified RPh of duplicate medication Ativan IV and PO
  • Fix: Continue to clarify medication dispensing requests
• Catch: MD ordered TPN with high osmolarity for peripheral line
  • Fix: Continue to verify osmolarity when upon TPN order verification
• Catch: CPOE duplicate dexamethasone tapering order
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification.
• Catch: Wrong timing/scheduling of promethazine and ondansetron
  • Fix: Alternate promethazine/ondansetron on hyperemesis orders upon order verification
• Catch: Immediately notify Kirk/Cortney of spills in laminar hood requiring deep clean that may impact sterile compounding
• Catch: CPOE incorrect dosage form of oxycodone (incorrect ER vs. correct IR)
  • Fix: Continue to clarify incorrect med orders upon order verification

May 22 – 26

• Catch: CPOE acetaminophen IV doses exceeded max 50 mg/kg/day
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: Incorrect dose adjustment of both dose and interval for hydrocortisone weaning in neonate
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: Ciprofloxacin for neonate – continue to notify clinical pharmacist of unusual orders to follow
• Catch: Incorrect antibiotic days of therapy prescriptions being filled
  • Fix: Continue to perform medication reconciliation for Meds2Beds patients
• Catch: CPOE duplicate therapy. Patient already on albuterol with new orders for levalbuterol.
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification.
• Catch: CPOE morphine allergy override in patient with severe allergy to morphine – “throat closing”
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification.
• Catch: Inaccurate weight gain documented in critical patient (incorrect: 15kg wt gain in 24h)
  • Fix: Clinical to continue to monitor patients on TPN, including fluids and daily weight

May 15 – 19

• Catch: CPOE wrong formulation / strength of vitamin D
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: Wrong height entered (incorrect: 8ft). Fix: Continue to perform profile reviews
• Catch: Retail did not fill Rx insulin b/c it was too soon for refill, but patient without supply at home.
  • Fix: Continue to perform medication reconciliation for Meds2Beds patients
• Catch: MD ordered TPN with high osmolarity for peripheral line
  • Fix: Continue to verify osmolarity when upon TPN order verification
• Catch: CPOE wrong nevirapine duration (incorrect x3 doses; supposed to be 6 weeks)
  • Fix: Verify duration upon order verification. Spedele contacted to check PediNotes setup.
• Catch: CPOE wrong nifedipine formulation (incorrect IR; supposed to be XR)
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification.

May 8 – 12

• Catch: Discontinued scheduled ibuprofen in patient with elevated SCr 5
  • Fix: Clinical pharmacists will continue to complete profile reviews for interventions.
• Catch: Tubing connected to wrong additive during compounder setup
  • Fix: Pharmacists will continue to verify compounder setup prior to compounding.
• Catch: CPOE incorrect Post-exposure Prophylaxis (incorrect: Isentress + Truvada + Tivicay vs. correct Truvada + Tivicay).
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: CPOE incorrect aspirin frequency.  (incorrect: q4hPRN vs. intended x1 dose)
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: CPOE metronidazole wrong frequency (intended x1 dose)
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification

May 1 – 5

• Catch: TPN compounder set up early
  • Fix: Verify A vs. B day before setting up compounder to ensure valve sets are used < 24h.
• Catch: Incorrect route.  Nurse requested sterile water in preparation for ceftriaxone IV administration (incorrect) instead of ordered lidocaine for IM administration (correct).
  • Fix: Continue to clarify diluents required for medication preparation for administration.
• Catch: Prevented severe allergic reaction in patient with uncoded allergies (labetalol)
  • Fix: Continue to review patient allergies upon order verification
• Catch: Duplicate PACU orderset entered
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: CPOE incorrect bupropion dose (3X lower; incorrect 50mg vs. 150mg)
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: CPOE wrong route of cefazolin administration (incorrect, unintended IM vs. correct IV)
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification

April 17 - 28

• Catch: CPOE incorrect liraglutide dose (10X higher; incorrect 18mg vs. 1.8 mg)
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: Preliminary cultures +Gram negative Rods, and patient on vancomycin monotherapy
  • Fix: Continue to use clinical surveillance tool for antimicrobial stewardship interventions
• Catch: CPOE incorrect patient. When pharmacy called unit to clarify an order, it was discovered that the medication was entered on the wrong patient.
• Catch: TPN rate exceeded hard limit of smart pump
  • Fix: Continue to notify clinical pharmacy staff of smart pump programming issues

April 10 – 14

• Catch: MD progress note antibiotic days of therapy inconsistent with MAR stop date
  • Fix: Continue work-up patients prior to interdisciplinary rounding
• Catch: CPOE wrong frequency (incorrect levofloxacin QID vs. correct levofloxacin daily)
  • Fix: Continue to clarify incorrect med orders upon order verification.
• Catch: CPOE wrong frequency – piperacillin/tazobactam ordered preop, and again 2 hours later
  • Fix: Continue to clarify incorrect med orders upon order verification.
• Catch: CPOE meropenem entered as “ONCE” in patient with positive blood cultures
  • Fix: Clinical pharmacist to continue to perform profile reviews
• Catch: Make sure to adjust start time of all scheduled analgesics to prevent duplicate NSAIDs and/or APAP due at the same time (e.g. ketorolac, ibuprofen, IV acetaminophen, oral acetaminophen)

Apr 3 – 6

• Catch: Bypass scanning - wrong dose to be pulled (incorrect fluoxetine 10mg vs. correct 20mg)
  • Fix: Scan all medications from Pharmogistics when pulling medications off shelf
• Catch: CPOE wrong drug – methotrexate
  • Fix: Continue to clarify incorrect med orders upon order verification. Considering patient was also receiving TXA, methergine would have make more sense.
• Catch: Omission of antibiotics due to automatic stop order
  • Fix: Continue to perform profile reviews and evaluate duration of therapy for antibiotics. Plans to evaluate and revise automatic stop order policy.

Mar 27 – 31

• Catch: CPOE omission of Truvada when ordering HIV Post-Exposure Prophylaxis
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: Wrong expiration date of refrigerated medication in Crash Cart
  • Fix: Set to earliest expiration date; not just the manufacturer’s expiration
• Catch: Wrong oral syringe adapter for NICU outpatient prescription, incompatible with oral syringe
  • Fix: Continue to demonstrate drawing up oral syringes as part of discharge teaching
• Catch: Educated prescriber that osmolarity info is available in PediNotes when prescribing TPN

Mar 20 – 24

• Catch: Pharmacist appropriately utilized double check process for chemotherapy dose
• Catch: CPOE gabapentin 1200mg PO TID in patient with renal dysfunction
  • Fix: Continue to renally dose medications upon order verification and/or profile review
• Catch: CPOE omission to discontinue ampicillin (inactive in PediNotes; active in Meditech)
  • Fix: Continue to perform profile reviews
• Catch: CPOE to continue a home medication that the patient is no longer taking
  • Fix: Continue to perform profile reviews and medication reconciliation as needed

Mar 13 – 17

• Catch: CPOE incorrect TPN template (incorrect < 0.5kg template when neonate gained weight)
  • Fix: Continue to verify TPN template with weight changes
• Catch: Recommended renal dosing in neonate with poor urine output
  • Clinical pharmacist to continue to perform profile reviews
• Catch: CPOE potassium chloride 50mEq PO order
  • Fix: Continue to recommend lab monitoring for doses exceeding KCl 40 mEq

Mar 6 – 10

• Catch: CPOE incorrect home quetiapine dose (8X higher; incorrect 800mg vs. correct 100mg)
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: CPOE incorrect rate for potassium chloride in NICU
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: CPOE incorrect topiramate dose (10X higher; incorrect 500mg vs. correct 50mg)
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: MD d/c’d med due to enoxaparin order and thrombocytopenia (MT alert)
  • Fix: Continue to communicate drug-lab interactions to prescribers

Feb 27 – Mar 3

• Catch: CPOE incorrect home medication regimen (Pregabalin)
  • Fix: Continue to perform profile reviews and medication reconciliation as needed
• Catch: MD d/c’d med due to interaction (tramadol + nortriptyline ¯ seizure threshold, MT alert).
  • Fix: Continue to communicate drug-drug interactions to prescribers
• Catch: CPOE incorrect methadone dose, significantly higher than previous dose.
  • Fix: Continue to clarify significant changes in methadone and/or morphine titration
• Catch: CPOE incorrect concentration of Kenalog. (incorrect 40mg/mL vs. correct 10mg/mL).
  • Fix: Triamcinolone 10mg/mL more likely. Clarify if concentration 40mg/mL is ordered.
• Catch: Upon profile review, identified patient +clue cells, not being treated. 
  • Fix: Clinical pharmacists will continue to complete profile reviews for interventions.

Feb 20 – 24

• Catch: CPOE duplicate therapy (Vortioxetine and Sertraline)
  • Continue to perform profile reviews and medication reconciliation as needed
• Catch: Incorrect medication placed in bag with different medication label prior to dispensing
  • Fix: Continue to verify product prior to dispensing
• Catch: CPOE nitrofurantoin for patient with renal dysfunction
  • Fix: Continue to assess renal function upon order verification

Feb 13 – 17

• Catch: Incorrect storage of fentanyl epidural bags stored with oxytocin bags
  • Fix: Check label when storing medications
• Catch: Prevented incorrect med in Pyxis fill (incorrect lactulose for lidocaine stock-out)
  • Fix: Continue to verify correct medication during Pyxis fill
• Catch: CPOE incorrect dosage form of oxycodone (incorrect ER vs. correct IR)
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: CPOE unusually high bosentan dose
  • Fix: Continue to clarify doses not supported by Neofax or Lexicomp
• Catch: Prevented incorrect med in Pyxis fill (HYDROcodone mixed in with oxycodone for cartfill)
  • Fix: For cartfill, separate different drugs and formulations in different bags
• Catch: CPOE incorrect dose of therapeutic enoxaparin (90 kg à orders for 100mg BID)
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: CPOE clonidine concentration 100 mcg/mL different than standard dilution of 10 mcg/mL
  • Fix: Continue to verify dose and concentration upon order verification

Feb 6 – 10

• Catch: Adult Boostrix (Tdap) vaccine incorrectly placed in BABY MEDS bag
  • Fix: Continue to verify product prior to dispensing
• Catch: CPOE incorrect frequency of Curosurf
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: CPOE incorrect dose of gentamicin for neonate
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: CPOE incorrect propanolol dose (8X higher; incorrect 10mg inj vs. correct 2mg inj)
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: CPOE incorrect drug/dose (nicardipine 10mg vs. nifedipine 10mg)
  • Fix: Continue to clarify incorrect med orders upon order verification
• Catch: CPOE incorrect quantity (mg vs. #of tablets)
  • Fix: Continue to clarify incorrect med orders upon order verification

Jan 30 – Feb 1, 2023

• Catch: Incorrect dose adjustment of both dose and interval for vancomycin
  • Fix: Sent out communication clarifying vancomycin adjustments are usually dose or interval
• Catch: Label comments with incorrect filter for TPN with lipids (1.2 micron filter required for lipids)
  • Fix: Continue to review label comments prior to dispensing
• Catch: CPOE incorrect penicillin (PCN G procaine vs. PCN G potassium)
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: During 2^nd check process, nurse appropriately clarified with pharmacy weight-based dosing
• Catch: Patient needed to pass flatus for discharge, but without bowel regimen on MAR
  • Fix: Recommended adding bowel regimen

Jan 23 – 27, 2023

• Catch: Incorrect formulation metoprolol succinate vs. tartrate prescription being filled
  • Continue to perform profile reviews and medication reconciliation as needed
• Catch: Nurse appropriately clarified BUD of Prostin prior to administration
  • Fix: Update pharmacy procedures of Prostin BUD of 24h
• Catch: Nurse appropriately returned unsecured medication to pharmacy
• Catch: Patient reports drug interaction with unique specialty home medication
  • Fix: Continue to screen drug interactions upon order verification
• Catch: CPOE route of “IM” but label comment specified “IV” for olanzapine
  • Fix: Added option in Meditech for IV olanzapine – restricted to psychiatry.

Jan 16 - 20, 2023

• Catch: CPOE incorrect dosage form (Metformin IR vs. Metformin XR)
  • Fix: Updated CPOE drug library with Metformin XR
• Catch: CPOE incorrect linezolid dose
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: CPOE incorrect potassium dose (10X higher) in TPN
  • Fix: Continue to clarify incorrect med orders with prescriber upon order verification
• Catch: Compound incorrect MVI amount in neonatal TPN
  • Fix: Continue to visually inspect TPN prior to dispensing as part of double-check process
• Catch: Incorrect discharged prescriptions being filled
  • Fix: Continue to perform medication reconciliation for Meds2Beds patients
• Catch: Patient unaware she was to discontinue taking Clonidine patch at discharge
  • Fix: Continue to educate patients on medication changes at discharge
• Catch: Patient receiving excessive fluids while on TPN
  • Fix: Clinical to continue to monitor patients on TPN, including fluids
• Catch: Piperacillin/tazobactam vial not compatible with patient’s LR maintenance fluid
  • Fix: Continue to assess for IV incompatibilities upon order verification