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Robert Packer Hospital

                                                                                                   Clinical Quality Committee Meeting


                                                                                                   DATE:  Tuesday, December 11, 2018

                                                                                                                   TIME:  Noon
                                Present: Joseph Ronsivalle, DO (Chair), Douglas Trostle, MD, Willow Bronson-Golay, Kelly Coldiron, Barb Pennypacker, Jill Stenson, Nicole
                                Teeter, Vania Brown-Small, Barb Gordon, Michael Gum, Barbara Hayes, Renee Jankowski, Kim Joedicke, Andrew Klee, Deb Luchaco, Melissa,
                                Susan Sinay, Kim Worden, Sergio Zullich, Janet Cunningham, Kristen Nash, DO.

                              Meeting Started: 12:02 PM                                                                                                                                 Meeting Adjourned: 1:02 PM
                                           TOPIC                                                       DISCUSSION/CONCLUSION                                                             RECOMMENDATIONS/
                                                                                                                                                                                         ACTION/FOLLOW UP
                                                                                                                                                                                        /RESPONSIBLE PARTY

                                I.    Old Business                Minutes from December 11, 2018 were reviewed. Dr. Ronsivalle motioned to accept                                    Minutes Approved
                                                                  minutes as presented, seconded by Sergio Zullich and Janet Cunningham. There was no
                                                                  dissent.
                                II.  Pharmacy &                   Kim Joedicke provided report from Pharmacy and Therapeutics Committee.                                             Motion to approve formulary
                                Therapeutics – Copy of                •  Reported Adverse Drug Reactions (ADRs) and Medication Errors for October                                    changes and policy revisions
                                presentation attached to                   2018 included 31 ADRs with 2 determined to be preventable and 21 medication                               made by Dr. Ronsivalle,
                                official minutes                           errors.                                                                                                   seconded by Jill Stenson and
                                                                      •  Infusion Center formulary changes for approval:                                                             Dr. Trostle, there was no
                                                                                o  Add Infliximab-Abda (Renflexis) as second biosimilar to Remicade (first                           dissent. Motion carried.
                                                                                    biosimilar is Inflectra). Inflectra is the most cost effective and should be

                                                                                    first choice for NEW starts unless insurance dictates otherwise.
                                                                                o  Conversion of IVIG from Gammunex-C to Privigen. Privigen is currently
                                                                                    the most cost effective IVIG product. All new starts should use Privigen.
                                                                                    Current patients will transition to Privigen at the approval of their provider
                                                                                    with a new order. Potential annual cost savings of $130,000 systemwide.
                                                                      •  Policy changes for approval:
                                                                                o  Controlled Medications RPH-A-744-2202 revised, nursing will no longer
                                                                                    inventory controlled substances in Automated Dispensing Machines.
                                                                                o  Medication Storage and Security RPH-A-744-2200 revised to include
                                                                                    dispensing process for first doses on cartless units and the stocking
                                                                                    process for IV fluids by Supply and Distribution personnel.
                                                                                o  Medication Dispensing and Distribution RPH-A-744-4100 revised to
                                                                                    include bedside medication boxes as a medication storage location.
                                                                                o  Omnicell Anesthesia System RPH-A-744-2208 revised due to the
                                                                                    transition from Aesynt Anesthesia Carts to Omnicell Anesthesia Carts.
                                                                      •  P&T Committee to review Andexanet Alfa (Andexxa) which reverses bleeding
                                                                           related to the use of Rivaroxaban (Xarelto) and Apixaban (Eliquis) ONLY.


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