Approved Hospital Formulary
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Approved Hospital Formulary
11/13/17 DC -- TJC - take a look in your areas
From: David Collette
To: Pharmacists
Sent: Monday, November 13, 2017 10:46:57 AM
Subject: TJC - take a look in your areas
Kurt Patton (our TJC consultant who just happens to be a pharmacist) recently spent a few days on campus and reported the following finding in the MM chapter:
* ICU patient was on a sedation titration; the MD wrote for a RASS of 0-1, but the patient was consistently at RASS -4, even while the drip was being increased [please include this info during your next nursing staff meeting - all drips must match the parameters set forth in the order]
* Emergency med box was found at Parkway. The lock was broken and the level of contents did not match the drug list [first, if the unit has Pyxis, we should not need a drug box; if the unit is allowed to have one, it must be in their policy and it must meet guidelines with regards to content, expiration dating, and security]
* Standing orders being used that have not gone through P&T [if you know of any orders being used in your area(s) that have not been through P&T, please make sure that they are brought to the Committee...this is a violation for all professionals involved: physicians for using them, pharmacists for verifying them, and nurse for enacting them; they should also be reviewed annually by Clinical Content Committee]
* Med safety posters with 2016 dating [we may need to put an "UPDATED January 2018 sticker over each]
* Tablet splitter was dirty/contaminated with previous patient's med [please take a look at these (as well as mortar and pestles, spatulas, and pill rushers) when in the med room]
* IV bags pre-spiked in CVOR [pre-spiked IV bags are not allowed in any area of the hospital---it is very common for procedural areas to do this---IV bags should be spiked just prior to use; please include this in your next nursing staff meeting]
--
David R. Collette, Pharm.D., FASHP
Operations Manager, Professional Services Huntsville Hospital Department of Pharmacy
To: Pharmacists
Sent: Monday, November 13, 2017 10:46:57 AM
Subject: TJC - take a look in your areas
Kurt Patton (our TJC consultant who just happens to be a pharmacist) recently spent a few days on campus and reported the following finding in the MM chapter:
* ICU patient was on a sedation titration; the MD wrote for a RASS of 0-1, but the patient was consistently at RASS -4, even while the drip was being increased [please include this info during your next nursing staff meeting - all drips must match the parameters set forth in the order]
* Emergency med box was found at Parkway. The lock was broken and the level of contents did not match the drug list [first, if the unit has Pyxis, we should not need a drug box; if the unit is allowed to have one, it must be in their policy and it must meet guidelines with regards to content, expiration dating, and security]
* Standing orders being used that have not gone through P&T [if you know of any orders being used in your area(s) that have not been through P&T, please make sure that they are brought to the Committee...this is a violation for all professionals involved: physicians for using them, pharmacists for verifying them, and nurse for enacting them; they should also be reviewed annually by Clinical Content Committee]
* Med safety posters with 2016 dating [we may need to put an "UPDATED January 2018 sticker over each]
* Tablet splitter was dirty/contaminated with previous patient's med [please take a look at these (as well as mortar and pestles, spatulas, and pill rushers) when in the med room]
* IV bags pre-spiked in CVOR [pre-spiked IV bags are not allowed in any area of the hospital---it is very common for procedural areas to do this---IV bags should be spiked just prior to use; please include this in your next nursing staff meeting]
--
David R. Collette, Pharm.D., FASHP
Operations Manager, Professional Services Huntsville Hospital Department of Pharmacy