Hospitalized patients with asthma or COPD typically receive respiratory medications via inhalers (pressurized metered dose inhalers, dry powder inhalers, or soft mist inhalers) or nebulizers. Because in-hospital use of inhalers may be complicated by required interchanges from nonformulary home inhalers to inpatient formulary inhalers, clinician or patient errors in administration, unclear dosage received, wasted drug, misplaced devices, and increased costs, switching from the use of inhalers to an all-nebulization strategy may streamline processes and improve outcomes. As respiratory therapists and hospital pharmacists, we have had experience with making this switch in different types and sizes of hospital systems. Despite the challenges we encountered, each of our approaches to implement an all-nebulization protocol was ultimately successful. In this article, we summarize our learnings during the operationalization of all-nebulization protocols, describe the benefits we observed post-implementation, and provide recommendations including detailed guidance for how to implement this type of switch successfully.

Patients with end stage renal disease undergoing haemodialysis commonly have multimorbidity, which in turn leads to polypharmacy. Additionally, end stage renal disease limits the choice and dosage of medicines. In Namibia, patients can access care at privately run dialysis centres. Patients seen at state-run health facilities in need of renal care from the dialysis centres, have their renal care costs covered by the Ministry of Health and Social Services. The main purpose of this study was to assess the appropriateness of medication therapy among patients with end stage renal disease who underwent haemodialysis at two dialysis centres in Windhoek. Further, the study also compared prescribing patterns between state-funded and privately funded haemodialysis patients. A retrospective, quantitative and analytic design involving the review of clinical records of patients attending haemodialysis at the two dialysis centres. The types of medicines prescribed were classified according to the Anatomical Therapeutic Chemical (ATC) classification. The Drug Prescribing in Renal Failure Handbook was used as a primary reference for assessing the appropriateness of renal dosage adjustment. The primary references used to check for the appropriateness of medication choice were the KDIGO Clinical Practice Guidelines. Other references were used as secondary sources. A total of 147 patients' clinical records were reviewed and included in this study. About one-third (33.3%) of patients had at least one or more inappropriately selected medicines. Most patients 82.0% (n = 121) had at least one or more inappropriately renally adjusted medicines. More privately funded patients were prescribed Vitamin D or its analogues (P < .001), phosphate binders (P < .001), antithrombotic agents (P < .001), lipid modifying agents (P < .001), and angiotensin receptor blockers (P < .001). As anticipated, patients on haemodialysis were being managed with a relatively large number of medicines. Renal dosage adjustment could be improved to ensure patient safety. The differences in the prescribing of vital medicines such as phosphate binders, between state funded versus privately funded patients warrants further investigation.

Burnout, recognized by the World Health Organization as a medical condition, has been linked to decreased productivity, disengagement, and hopelessness among employees. While burnout in frontline staff has received increasing attention, the unique challenges of leadership burnout remain underexplored and often underdiscussed. According to the Development Dimensions International's Global Leadership Forecast, nearly 60% of leaders reported feeling "used up" at the end of the workday. Yet, stigma and shame often prevent leaders from acknowledging burnout openly. Recent initiatives have provided resources to help leaders recognize and mitigate burnout within their teams; however, the literature addressing burnout among leaders themselves is scarce. Understanding the institutional impact of leadership burnout is critical for cultivating a sustainable culture of well-being. Simply put: leaders must be well in order to lead well. Leaders play a vital role in recognizing, measuring, and addressing burnout risk factors across their organizations. However, unaddressed burnout at the leadership level can amplify organizational dysfunction and jeopardize long-term success. By acknowledging these risks and prioritizing their own well-being-putting their oxygen mask on first-leaders can better navigate uncertainty, safeguard their teams, and strengthen the resilience of the healthcare workforce.

Tirzepatide, a dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 receptor agonist (GLP-1 RA), has demonstrated significant efficacy in weight reduction and glycemic control in patients with type 2 diabetes and obesity. However, concerns have emerged regarding its potential association with ophthalmic adverse events, particularly non-arteritic anterior ischemic optic neuropathy (NAION). This study aimed to investigate the possible link between tirzepatide and ischemic optic neuropathy (ION) through pharmacovigilance analysis of the FDA Adverse Event Reporting System (FAERS) and to complement these findings with an infodemiology assessment using Google Trends. FAERS reports from January 2022 to June 2025 were analyzed using OpenVigil 2.1 to identify cases of ION with tirzepatide as the primary suspect drug. Disproportionality analyses were performed using the Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), and Relative Reporting Ratio (RRR), and Evans criteria were applied for causality assessment. In parallel, global search interest in tirzepatide was evaluated using Google Trends data from 2020 to 2025 to explore public awareness and its potential impact on reporting patterns. A total of 28 ION cases were identified for tirzepatide. The event is rare but serious. Disproportionality analysis yielded significant signals (ROR: 2.599, 95% CI: 1.778; 3.799; PRR: 2.598 95% CI: 1.778; 3.797; RRR: 2.522, 95% CI: 1.726; 3.685; Chi-Squared: 24.692), with Evans criteria supporting a "probable" drug-event association. Google Trends demonstrated an exponential rise in global search interest for tirzepatide, particularly in Western countries with high prevalence of obesity and type 2 diabetes, reflecting increased accessibility and use. The pharmacovigilance analysis suggests a potential association between tirzepatide and ION, warranting cautious clinical consideration and further investigation. The event is rare but serious. Integrating pharmacovigilance data with digital epidemiology may enhance early signal detection and risk management for rare but clinically significant adverse events such as NAION.

Cefazolin is not typically considered to be an antibiotic that can increase the risk of bleeding. Yet, rare cases of cefazolin independently inducing a vitamin-K-responsive coagulopathy have been described. We report a patient with methicillin-susceptible Staphylococcus aureus (MSSA) endocarditis who developed an abrupt and significant international normalized ratio (INR) surge on cefazolin in the absence of exposure to vitamin K antagonists or azoles. Although the administration of a single dose of oral vitamin K rapidly corrected the INR elevation, the INR rebounded to supratherapeutic range later in the hospital course and ultimately required a daily low-dose vitamin K regimen to suppress the INR elevation. Upon readmission, the patient's INR remained normal while on the combination of cefazolin and vitamin K supplementation. This case underscores that cefazolin can precipitate a clinically meaningful, vitamin-K-responsive INR elevation-especially in patients with renal dysfunction and low vitamin K reserve-and that proactive monitoring and supplementation may be warranted. Prior reports and mechanistic data are reviewed.

A patient at our institution was admitted to Labor & Delivery at 41-weeks' gestation for augmentation of early labor for spontaneous rupture of membranes. The anesthesia team placed an epidural catheter and initiated an infusion of bupivacaine with fentanyl for pain management. During nursing shift change several hours later, staff found oxytocin connected to the patient's epidural catheter. A root cause analysis identified that a combination of human error, workflow inefficiencies, and technology challenges contributed to this error. Because the neuraxial and oxytocin infusion bags were the same size, the Department of Pharmacy recommended switching oxytocin infusion bags to a more distinct size. We summarize the literature on inadvertent neuraxial medication infusions, which can lead to devastating consequences. While this patient experienced no adverse effects, we present this case as a cautionary case study to highlight the need for system-level interventions to enhance patient safety.

Background: Accurate recording of Controlled Drug (CD) transactions is a key legislative and professional responsibility in Australian hospitals. Following the introduction of ENFit™ enteral systems, designed to reduce wrong-route medication administration errors, discrepancies in oral liquid CD balances continued to be reported. Residual liquid that remained in ENFit™ syringes and multi-dose bottles after the withdrawal process was suggested as a contributing factor. Objective: To estimate the amount of oral liquid loss associated with the use of ENFit™ enteral syringes and bottle adapters, and to explore potential implications for oral liquid CD documentation accuracy. Methods: A laboratory-based simulation study was conducted to model the use of ENFit™ enteral syringes (1, 2.5, 5, and 10 mL) and ENFit™ bottle adapters during repeated withdrawals from 100 mL sample bottles. Simple syrup B.P. was selected for its viscosity comparable to that of oral liquid medications. Syringes and bottles were weighed before and after each withdrawal using a calibrated scale, and the weight of residual liquid was converted to volume using the density of simple syrup (1.27 g/mL). The viscosity of the test liquid was measured and compared with that of two commonly used oral liquid CDs. Results: Across 184 withdrawals, the mean (SD) total volume loss per 100 mL sample was 5.17 mL (0.63), representing a 4.5% to 5.9% discrepancy. Both the number of withdrawals and the syringe size correlated with greater liquid loss. The 10 mL syringes produced the highest loss per withdrawal, while 5 mL syringes produced the largest total loss due to a greater number of withdrawals. Conclusions: This study demonstrated a consistent, measurable loss of oral liquid CD (approximately 5%) when using ENFit™ enteral syringes and adapters, even under controlled conditions and when correct withdrawal technique was used. These losses may contribute to minor but recurring CD discrepancies in clinical practice. Healthcare organizations should consider these findings when developing policies for oral liquid CD handling and balance reconciliation. Strategies like correct device fit, unit-dose packaging, and gravimetric verification may improve accuracy, reduce discrepancy investigations, and enhance CD recording compliance.

Purpose: This article uses the story of the Disney-Pixar merger as an analogy for how pharmacy leaders can strengthen teams across generations. It explores how two creative cultures found success through patience, respect, and shared purpose, offering a practical way to blend tradition and innovation within modern pharmacy teams. Summary: The pharmacy profession spans multiple generations. Knowledge of the generational experiences, strengths, and expectations allows leaders to cultivate a transcending shared goal. This article focuses on three themes from the merger: patience and respect, open feedback, and shared learning. The C.S. Mott Children’s and Von Voigtlander Women’s Hospitals at Michigan Medicine offer examples of how intergenerational mentoring, open listening, and acknowledgment of individual contributions can improve trust, communication, and creativity in complex care environments. Conclusion: The Disney-Pixar merger demonstrates that distinct cultures can coexist and thrive through shared vision and mutual respect. Bob Iger’s integration of Pixar’s innovation with Disney’s storytelling created sustainable creativity. Similarly, pharmacy teams that unite generational experience with fresh perspectives can transform differences into collaboration, advancing safe, compassionate, and innovative patient care. Article Summary: This article applies lessons from the Disney-Pixar merger to pharmacy leadership, offering strategies such as Braintrust-style feedback, reverse mentoring, and tailored recognition to transform generational differences into collaboration, foster inclusivity, and enhance psychological safety within multigenerational healthcare teams.

Characterize opioid prescribing patterns in the ICU and post-hospital discharge in invasively mechanically ventilated (IMV) opioid-naïve and opioid-exposed patients. Single-center, retrospective cohort study. Tertiary academic medical center. Patients requiring IMV admitted to the MICU. None. Difference in opioid prescriptions at discharge from the hospital and opioid use during IMV between groups. A total of 85 patients were included, 60 (70.6%) were opioid-naïve and 25 (29.4%) were opioid-exposed prior to admission. Five (8.3%) opioid-naïve and 16 (64.0%) opioid-exposed were prescribed opioids on discharge (P < 0.001). Median morphine milligram equivalents (MME) per day during IMV did not differ between groups. Although opioid discharge prescribing was relatively uncommon among medical ICU patients who were opioid-naïve prior to admission, areas to evaluate and optimize opioid prescribing during IMV and at discharge were identified.

Coumarin derivatives, including warfarin and acenocoumarol, are widely used oral anticoagulants that inhibit vitamin K-dependent coagulation factors. They are commonly prescribed for the prophylaxis of thromboembolic disorders. Although effective, these agents are associated with many adverse drug reactions, which include hemorrhagic complications, warfarin-induced skin necrosis, hypersensitivity reactions, and, rarely, leukocytoclastic vasculitis (LCV). LCV is an immune-mediated small-vessel vasculitis characterised by palpable purpura, often triggered by drugs, infections, or autoimmune conditions. Here, we present the case of a 53-year-old female with a history of rheumatic heart disease and mechanical mitral valve replacement who developed LCV after 5 years on acenocoumarol. The reaction persisted despite adjunct therapy and worsened upon switching to warfarin, suggesting possible cross-reactivity between these coumarin derivatives. Ultimately, transitioning to apixaban led to the complete resolution of symptoms. This case underscores the importance of early recognition of drug-induced vasculitis and highlights the need for individualised anticoagulation strategies in patients with hypersensitivity reactions.