Description of Event or Problem · 1
JUST WANTED TO SHARE A STORY CONCERNING THE REMOVAL OF MEDICATIONS FROM FORMULARY CAN CAUSE DOWN STREAM PROBLEMS. THE MANUFACTURERS THAT MAKE NORMAL SALINE 150 ML BAGS DISCONTINUED THE PRODUCT. IN OUR CPOE ORDER SYSTEM WE HAD ACYCLOVIR PRE-PROGRAMMED WITH AN IV SET OF THE DRUG IN 150 ML BAGS. WHEN THESE BAGS WERE DISCONTINUED THE SYSTEM WAS UPDATED WITH ACYCLOVIR TO BE MIXED IN 100 ML BAGS. THE PROBLEM WAS WE HAD BUILT AN ALERT IN OUR SMART PUMPS IF THE CONCENTRATION EXCEEDED 7 MG/ML (INCREASED RISK OF PHLEBITIS). SINCE THE DOSING OF ACYCLOVIR IS BASED ON IBW WE WOULD NEVER EXCEED THIS CONCENTRATION WHEN IT WAS BUILT WITH THE 150 ML BAG. HOWEVER, WE HAD ALERTS FIRE NOW THAT THE BAG IS BUILT WITH THE 100 ML TOTAL VOLUME. A NURSE OVERRODE THE ALERT (SOFT ALERT). NO HARM WAS DONE HOWEVER, THIS GOES TO SHOW YOU MUST DO AN EVALUATION OF YOUR SYSTEM WHENEVER SOMETHING IS REMOVED FROM YOUR FORMULARY AS WELL BECAUSE IT CAN HAVE DOWN STREAM EFFECTS. (B)(6).