Crack Red Alert 3 V1.12

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In response to a recent patient safety alert issued by the US Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid Services (CMS), our research division at ISMP has created a new tool called “Ionix Med” that assists healthcare providers by providing an interface with Google Health to enable healthcare providers to examine near-real-time data from their electronic health records (EHRs). By utilizing the Google Cloud Platform, Ionix Med provides a customized dashboard that provides a convenient visual representation of the patients’ whole record (see Figure 1), thus providing physicians with a user-friendly means to access information on the patients’ medical history, laboratory values, referrals, allergies, medications, immunizations, immunosuppressant medications, risk factors, and other healthcare issues related to the patient. To create and implement Ionix Med, our team collaborated with the practice of the New England Medical Center of Tufts University Health Sciences Center in Boston, Massachusetts. The training and documentation can be found at http://cdn.ismp.org/shows/186/Software_for_Clinical_Applications_A_Short_Summary.pdf .

The healthcare industry is led by industry veterans, and this month we received an alert from the Center for Medicare and Medicaid Services (CMS) who sent us a letter indicating that they are concerned about reports that the Healthcare Innovation and Information Technology Advisory Committee (HII-TAC) is poised to conduct a draft report to recommend a temporary moratorium on the use of insulin pens. This report could be scheduled for release this summer, which is usually the peak season for admissions at most hospitals. We think that a temporary moratorium on the use of insulin pens may have an unintended and harmful effect on patient care. Considering that ISMP has presented several strategies aimed at making insulin pens safer, more reliable, and more useful for patient use at the local, state, and federal levels, hospitals have not expressed concern that they will be unable to meet patient demand for insulin pens at a future date.

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The image above is what the nurses saw when they entered the ward after scanning the patient and receiving a red alert. After leaving the ward, the second nurse reportedly saw the patient crying, and she called the nurses station requesting a copy of the eMAR or an explanation for the unexpected alert.
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in the second month of the study, an alert on a specimen tray was triggered for an unknown reason. the tray had been scanned with an insulin pen and had been added to the bottle for that pen. unknown to the nurses who administered the insulin doses, that insulin pen had been used to administer insulin to that patients medication bin, resulting in the pen being cleaned and reused.
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