ISMP Releases Targeted Medication Safety Best Practices for Hospitals

ISMP reports errors involving drug names are a common medication mistake, which could be addressed by a greater reliance on barcodes.

Despite major advancements in medical technology and precautions, many patients across the U.S. continue to be seriously injured each year by medication mix-ups and errors, prompting a group of medication safety experts to release a series of targeted best practices for hospitals and care facilities to follow.

The Institute for Safe Medication Practices (ISMP) issued the Targeted Medication Safety Best Practices for Hospitals (TMSBP) last week, outlining recommendations for hospital-specific medication administration practices that serve to reduce and mitigate harmful medication errors.

Injuries caused by hospital and nursing home medication mistakes have increased substantially over the past decade, with recent research estimating as many as 400,000 drug-related injuries from medication mix-ups occur in hospitals annually.

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The ISMP hospital medication safety recommendations were developed by an external expert advisory panel, who reviewed medication error reports submitted through the ISMP National Medication Errors Reporting Program (ISMP MERP).

Among the top recommendations include the need for hospitals to adopt policies that protect patients from receiving the wrong medications due to similarities in name. The report specifically calls for hospitals to address medication mix-up risks involving OxyContin, which is an opioid, and Oxytocin, which is a hormone used to induce labor or strengthen contraction for pregnant women.

According to the release, the organization has reviewed reports in which patients intended to receive pain management therapy with OxyContin, but were accidentally administered Oxytocin, which is commonly sold under the brand names Pitocin and Pitressin.

The organization states the best practice to prevent medication mix-ups for patients is to leverage the use of barcode technology to confirm the correct medication is administered. Hospitals are being encouraged to expand the use of barcode verification to care areas beyond inpatient units, and for pharmacists or other medication safety specialists to routinely assess the effectiveness of the technology.

The release also addresses the need for hospitals to adopt new policies on administering five high-alert medications, which include insulin, hydromorphone, morphine, acetaminophen and methadone. It is recommended that hospitals adopt a layered approach for high-alert medications that includes fail-safes, workflow redundancies, increased warnings and alert as well as using more automation and technology.

Additional recommendations outlined in the release include the prevention of accidental daily dosing of oral methotrexate intended for weekly administration, mix-ups between milliliters and non-metric units when measuring oral liquid medications, inappropriate use of fentanyl patches to treat acute pain and others.

ISMP is a prominent nonprofit organization devoted entirely to preventing medication errors, launching its widely regarded “Best Practice” initiative in 2014, with the intent to advance patient safety worldwide, by empowering the healthcare community with recommendations based off of real-world incident reports that cause patients harm. Since the launch, the organization has released updates to its Best Practices recommendations every other year, as needed.

Medication Mix-Ups

The FDA reviews drug names before they are approved for public use. During the lengthy process the agency compares the drugs name to others on the market and those under FDA review to ensure drug confusion doesn’t occur.

When approving names the FDA creates a list of names that could be confused with the proposed drug. During the process the FDA reviews spelling, pronunciation in different accents and how the name will appear written by hand in different handwriting samples. More than 22 pages are written on guidelines for drug name approval. However, in 2019, ISMP published in its ISMP Medication Safety Alert! Acute Care newsletter which looked at medication errors that were most frequently reported, could cause serious harm to patients, and which could be avoided or minimized through attainable changes.

At the top of the list was drug name medication errors, due to healthcare workers accidentally selecting a drug with a similar name. The report indicated this occurred primarily when a health care professional entered the first few letters of the drug name and was unaware that the wrong drug came up.

“Entering just the first few letter characters of a drug name or combination of the first few letters and product strength can allow the presentation of similar-looking drug names on technology screes, leading to selection errors,” the press release states. “This is a problem that has increased in frequency with the upswing in technological use. In fact, wrong selection errors may now rival or exceed those made with handwritten orders.”

In addition, the list names errors caused by drug labels that look too similar, misheard drug orders during verbal or telephone communications, unsafe overrides while using automated dispensing cabinets, unsafe IV push medication practices,  errors with tranexamic acid, unsafe labeling of prefilled syringes by compound drug manufacturers, unsafe use of syringes for vinca alkaloids, and massive zinc overdoses.


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