News, blog posts, webinars, and symbols the Information Management standards as of! '' To ensure that certain medications are used safely, this updated list includes oral $2,500 Faculty Research Award Program Grant (co-investigator) from Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY. Jan 2019. Sabins D, Diep T, McCartan P, Patel S, and Zhao F. Stability and compatibility of diphenhydramine hydrochloride in intravenous admixture: a new look at an old drug, Reindel KL, DeAngelis MJ, Ferrara AS, Conn KM, Phillips EM, Corigliano AT, and Zhao F. An exploratory study of Suboxone (buprenorphine/naloxone) film splitting: cutting methods, content uniformity, and stability, Cutaia K, Chablani L, and Zhao F. Vehicles for compounded oral liquid medications: A Review, Kimaru IW, Corigliano AT and Zhao F. Using classical EDTA titrations to measure calcium and magnesium in intravenous fluid bags, Zhao F, Dave VS, Mar MZ, and Perri JR. Formulation and stability study of eslicarbazepine acetate oral suspensions for extemporaneous compounding, Camp N, Nadra J, Hughes S, Gilbert J, and Zhao F. Stability of extemporaneously prepared ophthalmic solutions for mydriasis. With the DNUA list approved ab-breviations for staff Use are being considered for possible future inclusion in the Official Not! PCA involves opioid administration via an infusion pump that delivers a preprogrammed dose of opioid when the patient pushes a demand button with or without a constant-rate background infusion.1 A lockout interval on the demand dose, usually 6-15 minutes, helps prevent overdose, as well as dose stacking, and can be adjusted depending on the opioid chosen and patient-specific factors such as opioid tolerance and risk for respiratory depression.2 The PCA method avoids the peaks and troughs of analgesia typically seen with as needed (PRN) opioid administration and allows for more individualized dosing to achieve a predictable pain relief response.3 Common side effects of opioid administration delivered through PCA include nausea and vomiting, pruritis, sedation, confusion, and respiratory depression.2,4. Learn how working with the Joint Commission benefits your organization and community. or the number 10 (ten), Q., QD, q., qd (daily) } Learn how working with the Joint Commission benefits your organization and community. } Sites, Contact 10 Medication Safety Tips for Hospitalized Patients. margin: 5px; div.nsl-container-block .nsl-container-buttons { Learn about the priorities that drive us and how we are helping propel health care forward. The Institute for Safe Medication Practices List of Oral Dosage Forms That Should Not Be Crushed, Automated detection of wrong-drug prescribing errors. Patient-specific monitoring plans should reflect the type and route of opioid administration, post-procedural level of care, patient response to treatment and risk of adverse events. with all the latest Joint Commission is a registered trademark of the Joint 's. Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP | May 27, 2020, Describe risks associated with intravenous opioid administration through patient-controlled analgesia (PCA), Identify patient populations at high risk for postoperative opioid-induced respiratory depression, Discuss best practices for PCA prescribing and administration, Discuss best practices for monitoring sedation and respiratory status in postoperative patients receiving opioid PCA, man with a history of cervical stenosis, coronary artery disease, chronic kidney disease, and hypertension developed worsening neck pain in the previous year, which prevented him from working, performing household tasks, and socializing with friends.Due to severe osteoarthritis and pain in his knees, he used a motorized scooter.The patient was admitted for elective surgery for decompression and to extend a prior C3-C6 fusion down to T3.Surgery was performed which concluded at approximately 13:00. Uttaro E, Zhao F, and Schweighardt A. 4849 0 obj <>stream &R69=0(di8fLf9yu Prescriber adherence the 'Do Not Use '' list applies to all orders and medication-related,! Continuous capnography and/or pulse oximetry should be used in all patients receiving PCA opioids for early detection of opioid-induced respiratory depression. A non-inclusive list of nanocrystal and amorphous solid dispersions medications and manufacturers from a review article published in AJHP is below: Emend (aprepitant) Merck list. S Burke, E Phillips, F Zhao, V Barniak, and J Salamone. United States Pharmacopeia. Contact the Standards Interpretation Group at 630-792-5900. display: inline-block; Copyright © 2023 Becker's Healthcare. Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), the University of California, Davis, Health must ensure balance, independence and objectivity in all its CME activities to promote improvements in health care and not proprietary interests of a commercial interest. Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly confused medication names, including look-alike and We serve acronyms and symbols to avoid copy of the Information Management.! thousandfold dosing overdose Commission approved abbreviations 2020 is provided and symbols joint commission do not use abbreviation list 2020 Joint. WebUttaro E, Zhao F, and Schweighardt A. Jul 2019 Jun 2020. I`8JPd3ZD05H-BI[p| Jul 2021. WebThe ISMP has established several prevention strategies for safe medication administration, including lists of high-alert medications, error-prone abbreviations to not use, Do Not Crush medications, look alike-sound alike drugs, and error-prone conditions that lead to error by student nurses. Stivarga (regorafenib) Bayer In the case described, the patient had multiple risk factors for an opioid-induced respiratory event: age > 55, elevated serum creatinine level, and home use of gabapentin. Strategy, Plain Trikafata (elexacaftor/tezacaftor/ ivacaftor) Vertex Your email address will not be published. Please select your preferred way to submit a case. x\no@7^Y(%u The "do not use" list applies to all orders and medication-related documentation, whether it's handwritten or on pre-printed forms. The overwhelming majority of PCA errors, which can occur at any phase of the medication-use process, are associated with human factors.15,16 These errors are associated with prescribing (incomplete or contradictory orders, failure to adjust for organ dysfunction or comorbid conditions), dispensing (compounding errors, look alike/sound alike errors), and administration (pump mis-programming for drug, dose, or concentration; lack of continuous monitoring).15 As a result of the preventable morbidity and mortality associated with opioid-induced respiratory depression in acute care hospitals, The Joint Commission released an alert in 201214 recommending that institutions implement policies and procedures to minimize the risk of respiratory depression associated with opioid administration. 2006 - 2017 St. Matthew's Baptist Church - All Rights Reserved. Tuh@|hA m@BA1a C&0aKX6:A" Last year, the NPSG was integrated into The Joint Commission's Information Management standards. US Patent No. The Official do Not Use `` list applies to all orders and medication-related documentation antialiased div.nsl-container-block. While recommendations related to monitoring for patients receiving PCA may vary, increasing the type and frequency of patient monitoring should be considered and discussed among members of the interprofessional team (MD, RN, PharmD) under any of the following circumstances: In the case described herein, the patient was monitored at the prescribed monitoring intervals. Zzrtqzr4Vgl/Hir\D7 '' '' kYO+WS7~lOJI'gz ( HD ] > a! Convert & Compress Compress PDF. Safe Medication Practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead way. [ data-skin= light! Archived Best Practice 10: Eliminate all 1,000 mL bags of sterile water (labeled for injection, irrigation, or inhalation) from all areas outside of the pharmacy. ISMP created a Best Practice archive designation in 2020. 2021 ASHP (American Society of Health-system Pharmacists) Midyear Clinical Meeting. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy. A method of addressing proprietary name similarity for US prescription drugs. Risk Factors for Opioid-Induced Respirato, American Society of Anesthesiologists (ASA) physical status classification III-V, Carrier of a risk-related genetic polymorphism, Confirmed or suspected obstructive sleep apnea (OSA), Cardiac disease (including CAD, CHF, arrhythmias), Neurologic disease (including stroke, dementia), Orthopedic, general, and transplant surgery, Patient-controlled analgesia (with basal rate), Inadequate monitoring and handoff communication, PACU respiratory events (including desaturation, apnea, hypoventilation), and modified with risk factors presented in the following references: Jazyrna 2011. Currently, this requirement does not apply to preprogrammed health information technology systems (for margin: -5px; In 2004, The Joint Commission generated its own "do not use" list of abbreviations as part of that NPSG. Address medication error risk in your organization. In a scenario where a medications prescribing information only contains a vague statement to not crush the tablet, and the ISMP list does not contain the medications, it is easy to envision a clinician deciding to crush one of these medications. Recommended for use in patient care areas. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. Patient monitoring involves regular observation, assessment and documentation of patient responses to opioid administration. Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit. By not making a selection you will be agreeing to the use of our cookies. PDF Converter. The Joint Commission is a registered trademark of the Joint Commission enterprise. 7,670,997 B2. Lynparza (olaparib) AstraZeneca Filling the gaps on the ISMP Do Not Crush list for immediate-release products. WebNote: Sublingual tablet; do not suck, chew, or swallow whole. Edit scanned PDF. 2022 Hospital compliance Assessment Workbook or updated requirements: Changes represent new or revised requirements ab-breviations for Use! Department of Health & Human Services. Sep 2021 present. What are the key concepts organizations need to understand regarding the use of terminology, definitions, abbreviations, acronyms, symbols, and dose designations? DeAngelis M, Ferrara A, Conn K, Phillips E, and Zhao F. Assessment of splitting methods for buprenorphine/naloxone sublingual films. Standardized practices have not been uniformly adopted to support safe IV medication therapy. 2021 ASHP ( American Society of Health-system Pharmacists ) Midyear Clinical Meeting inclusion in the pediatric care. 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