Problems With Infusion Pumps and Extended-Release Opioids Topped Medical Safety Concerns Last Year: ISMP Report

Extended-release opioids and infusion pumps topped the list of persistent medication safety threats over last year, according to new warnings issued by medical safety experts.

The Institute for Safe Medication Practices (ISMP) released a report this week that highlights the 10 most persistent medication errors and hazards in 2020, which the group indicates can be avoided or minimized with changes by healthcare providers.

The list includes a range of problems plaguing medication distribution, with two of the top categories closely linked to the on-going COVID-19 pandemic, including vaccine administration errors and problems positioning infusion pumps outside of COVID-19 patients’ rooms. In addition, the group indicates that inappropriate prescribing, dispensing and administering of extended-release opioids during the coronavirus pandemic continues to pose a risk for isolated patients.

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Although substantial efforts have been made in recent years to address the opioid abuse epidemic in the United States, ISMP indicates that it continues to receive reports of inappropriate prescriptions, including fentanyl patches and other opioids that caused serious harm or death.

Research has found that opioid problems account for about 70% of drug overdose deaths in the United States, and often the medications are prescribed at higher doses that have been shown to not help decrease patient pain.

ISMP indicates that a 2020 survey of best practices associated with reducing the risk of opioid overdose problems still showed low compliance by healthcare providers.

Another risk highlighted in the report is the common practice of positioning hospital infusion pumps outside of COVID-19 patient rooms. Hospitals are placing infusion pumps in the hallways to conserve personal protective equipment for staff, but extension tubing can impact the volume of fluid needed for priming, flow rates and the time it takes the medications to reach the patient.

Other medication and medical device safety threats highlighted in the report include:

  • Not using smart infusion pumps with dose error-reduction systems in preoperative settings.
  • Medication loss in the tubing when administering small-volume infusions.
  • Errors administering oxytocin during delivery, leading to hyper stimulation of the uterus which can result in fetal distress, uterine rupture or emergency C-section births.
  • Errors involving COVID-19 vaccines, including refrigeration/freezer errors, mixing errors and other storage or administration errors.
  • Sterile compounding pharmacy errors.
  • Combining or manipulating commercially available sterile products outside the pharmacy.
  • Intraspinal injection errors with tranexamic acid, instead of anesthetic for epidurals.
  • Use of error prone abbreviations, symbols or dose designations when administering medications.

“We know that the pandemic has created an incredibly challenging year for healthcare providers,” said ISMP President Michael Cohen. “Obviously, organizations have to prioritize dealing with COVID-19 surges and care, but we hope that they can keep these important medication safety problems on their radar and address them once they are not fully consumed by the pandemic.”


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