ISMP Medication Safety Best Practices for Hospitals

Posted on January 17, 2022

The Institute for Safe Medication Practices (ISMP) released its 2020–2021 Targeted Medication Safety Best Practices for Hospitals in late February of 2020. These best practices focus on trying to solve specific medication issues that can cause harmful errors for patients.

Since 2014, ISMP has been issuing Targeted Medication Safety Best Practices to help hospitals and pharmacies focus on and improve their medication safety efforts. The consensus-based recommendations are based on error reports from the ISMP National Medication Errors Reporting Program (ISMP MERP).

Using the best practices can help hospitals and other healthcare settings set realistic goals and reduce medication safety hazards, leading to better outcomes for patients. These best practices are intended to be attainable for hospitals and health systems and have already been successfully adopted by numerous organizations.

The 2020-2021 best practices feature two new items specifically focused on the override feature of automated dispensing cabinets and opioid prescriptions, as well as revisions to five other best practices.

2020-2021 Best Practices

You can find the full ISMP 2020-2021 Targeted Medication Safety Best Practices for Hospitals document here. This contains the recommended best practices, the reasoning and significance behind each recommendation, as well as related references and source material.

We will cover a summary of the best practices below:

Best Practice 1

Recommendation: Dispense vinCRIStine and other vinca alkaloids in a minibag of a compatible solution and not in a syringe.

This recommendation is to ensure that vinca alkaloids are only administered by the intravenous route. If given via the intrathecal route, vinca alkaloids have been shown to cause fatal neurological effects.

Best Practice 2

Recommendation A: Use a weekly dosage regimen default for oral methotrexate in electronic systems when medication orders are entered.

Recommendation B: Require a hard stop verification of an appropriate oncologic indication for all daily oral methotrexate orders

Recommendation C: Provide specific patient and/or family education for all oral methotrexate discharge orders

This recommendation is intended to prevent inadvertent daily dosing oral methotrexate both in the inpatient setting and after discharge. Since early 1996, harmful and fatal errors have been reported to ISMP involving the accidental daily dosing of oral methotrexate that was intended for weekly administration due to prescribing and dispensing errors.

Best Practice 3

Recommendation A: Weigh each patient as soon as possible on admission and during each appropriate* outpatient or emergency department encounter. Avoid the use of a stated, estimated, or historical weight.

Recommendation B: Measure and document patient weights in metric units only.

Because many medication doses are based on patient weight, this recommendation is intended to prevent under- and overdosing patients based on inaccurate stated, estimated, or historical weight. Using metric units helps to standardize measurement and communication of patient weight since the official product labeling for medications provides weight-based dosing using only metric units.

Best Practice 4 (Revised 2020-2021)

Recommendation: Ensure that all oral liquid medications that are not commercially available in unit dose packaging are dispensed by the pharmacy in an oral syringe or an enteral syringe that meets the International Organization for Standardization (ISO) 80369 standard, such as ENFit.

The goal of this recommendation is to prevent the unintended administration of oral medications via the intravenous route. Historically, ISMP has received reports that patients have accidentally been given oral liquid medication intravenously. This often occurs because an oral liquid was prepared extemporaneously or dispensed in a parenteral syringe that connects to vascular access lines.

Best Practice 5 (Revised 2020-2021)

Recommendation: Purchase oral liquid dosing devices (oral syringes/cups/droppers) that only display the metric scale.

Since 2000, ISMP has received more than 50 reports of mixups between milliliters (mL) and household measures such as drops and teaspoonfuls, some leading to injuries requiring hospitalization. This recommendation seeks to prevent these types of errors. By using liquid medication dosing devices (specifically oral syringes, cups, and droppers) that only display volume using the metric scale, there is less risk of dosage mix-ups between non-metric measurements.

Best Practice 6 (Archived in 2020-2021)

Recommendation: Eliminate glacial acetic acid from all areas of the hospital.

Reason for archiving: This recommendation was archived because hospitals have shown progress in removing or replacing glacial acetic acid with vinegar or commercially available diluted acetic acid to prevent accidental use.

While still important as a Best Practice, compliance with recommendations for an archived Best Practice signal that focus can be directed toward new and other existing Best Practices with lower adoption rates.

Best Practice 7

Recommendation: Segregate, sequester, and differentiate all neuromuscular blocking agents (NMBs) from other medications, wherever they are stored in the organization.

This recommendation is meant to prevent errors related to accidental administration of NMBs to patients. Because the respiratory muscles are paralyzed by these NMBs, errors in the compounding, dispensing, and administration of these medications have resulted in death or serious, permanent injury.

Best Practice 8 (Revised 2020-2021)

Recommendation A: Administer medication infusions via a programmable infusion pump utilizing dose error-reduction systems.

Recommendation B: Maintain a 95% or greater compliance rate for the use of dose error-reduction systems.

Recommendation C: Monitor compliance with use of smart pump dose error-reduction systems on a monthly basis.

Recommendation D: If your organization allows for the administration of an IV bolus or a loading dose from a continuous medication infusion, use a smart pump that allows programming of the bolus (or loading dose) and continuous infusion rate with separate limits for each.

The goal of this recommendation is to ensure the use of dose error-reduction technology to prevent infusion-related medication errors. Infusion-related medication errors expose patients to a higher risk of harm.

Programmable infusion pumps with dose error-reduction systems help to avert these potentially harmful errors by saving “rules” (hospital-defined dosing limits and other clinical advisories) entered into the drug library. These "rules" are then applied during pump programming to warn clinicians about potentially unsafe drug therapy.

Implementing bi-directional interoperability connecting the smart infusion pump and the electronic health record will further reduce the risk of programming errors and allow for more accurate documentation of infusing medications.

Best Practice 9

Recommendation: Ensure all appropriate antidotes, reversal agents, and rescue agents are readily available. Have standardized protocols and/or coupled order sets in place that permit the emergency administration of all appropriate antidotes, reversal agents, and rescue agents used in the facility. Have directions for use/administration readily available in all clinical areas where the antidotes, reversal agents, and rescue agents are used.

Some medications have a high potential to cause an adverse reaction if an overdose of the medication is administered, but some may also cause an adverse reaction even when the appropriate dose is administered. The goal of this recommendation is to ensure that if this happens, an antidote, reversal agent or rescue agent is readily available and can be administered without delay.

Best Practice 10

Recommendation: Eliminate all 1,000 mL bags of sterile water (labeled for “injection,” “irrigation,” or “inhalation”) from all areas outside of the pharmacy.

This recommendation is intended to prevent the accidental administration of an intravenous (IV) infusion of sterile water to a patient. Administering large quantities of hypotonic sterile water IV has resulted in patient harm, including death, from hemolysis.

Best Practice 11 (Revised 2020-2021)

Recommendation: When compounding sterile preparations, perform an independent verification to ensure that the proper ingredients (medications and diluents) are added, including confirmation of the proper amount (volume) of each ingredient prior to its addition to the final container.

ISMP has reported multiple serious compounding errors that caused patient harm or death mostly due to preparation of the wrong concentration/strength or using the wrong product or diluent. The goal of this recommendation is to prevent medication errors during sterile compounding of drugs that are not detected with proxy checks, such as the “syringe pull-back method” or other retrospective verification processes.

Best Practice 12 (Incorporated into NEW Best Practice 15)

Recommendation: Eliminate the prescribing of fentaNYL patches for opioid-naïve patients and/or patients with acute pain.

Best Practice 13

Recommendation: Eliminate injectable promethazine from the formulary.

Inadvertent arterial injection or IV extravasation of injectable promethazine can create a risk for serious tissue injuries and amputations. This recommendation is intended to eliminate that risk.

In 2009, ISMP recommended removal of injectable promethazine from an organization’s formulary, if possible, and use of safer alternatives such as 5-HT3 antagonists (e.g., ondansetron). At the time, these alternatives were significantly higher in cost. Now, these alternative injectable antiemetics have become available as generic products and are significantly less costly. Because of this, injectable promethazine has been used less frequently and the recommendation can be made to remove it from all formularies.

Best Practice 14

Recommendation: Seek out and use information about medication safety risks and errors that have occurred in other organizations outside of your facility and take action to prevent similar errors.

This recommendation is based on the fact that experience has shown that a medication error reported in one organization is also likely to occur in another. One of the most important ways to prevent medication errors is to learn from errors that have occurred in other organizations and to use that information to identify potential risk points or practices within your organization to prevent similar errors.

Best Practice 15 (NEW in 2020-2021)

Recommendation: Verify and document a patient’s opioid status (naïve versus tolerant* ) and type of pain (acute versus chronic) before prescribing and dispensing extended-release and long-acting opioids.

FentaNYL patches were the highest-ranking drug involved in serious adverse drug events (ADEs) reported to the US Food and Drug Administration (FDA) from 2008 through 2010. This recommendation is intended to support the appropriate prescribing of extended-release and long-acting opioid medications and prevent death and serious patient harm from inappropriate use of these medications. This recommendation also seeks to prevent the inappropriate use of fentaNYL patches to treat acute pain in patients who are opioid-naïve.

Best Practice 16 (NEW in 2020-2021)

Recommendation A: Limit the variety of medications that can be removed from an automated dispensing cabinet (ADC) using the override function.

Recommendation B: Require a medication order (e.g., electronic, written, telephone, verbal) prior to removing any medication from an ADC, including those removed using the override function.

Recommendation C: Monitor ADC overrides to verify appropriateness, transcription of orders, and documentation of administration.

Recommendation D: Periodically review for appropriateness the list of medications available using the override function.

Medications can be removed from automated dispensing cabinets with ease upon override. Practitioners often view the override process as a routine, rather than a risky step, and fail to recognize that the use of the feature should be justifiable based on the situation. Overriding and obtaining medication without cause and proper documentation can lead to harmful errors.

The goal of this recommendation is to minimize these risks and allow for proper review and documentation of medication dispensing.

Implementing These Best Practices

Staying up to date on medication recommendations and regulations is important for compliance, but also for ensuring the best possible outcomes for patients. Implementing these ISMP 2020–2021 Targeted Medication Safety Best Practices for hospitals can vastly improve medication safety and reduce the risk of significant patient harm. For hospitals and health systems, this means putting a plan of action in place to implement and maintain these recommendations.

For some organizations, this can be overwhelming. Keep in mind that some areas can be outsourced to help alleviate stress and costs — like unit-dose packaging with Safecor Health. Partnering with an FDA-regulated, cGMP compliant unit-dose packager can help reduce workloads and facilitate a faster path to compliance.

We’re here to help. Contact us to learn how Safecor Health can help you ensure patient safety.