ISMP Releases List Of Medication Safety Best Practices

A group of medication safety experts have released a list of recommended best practices hospitals can use to avoid common medication errors that pose serious risks for patients.

The Institute for Safe Medication Practices (ISMP) issued its list of 2020-2021 Consensus Based Medication Safety Best Practices for Hospitals on February 24.

In many cases, doctors and healthcare staff select the wrong medication after only entering the first few letters of the drug name, inadvertently prescribe daily instead of weekly doses of medications, give incorrect products with look-a-like labels, provide incorrect medications after miscommunication errors, conduct unsafe overrides on automated dispensing cabinets, give medications via the wrong administration route, or give too much of a medication. The ISMP best practices list seeks to help healthcare professionals avoid these mistakes.

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The ISMP updates the list when new common errors emerge either due to new technology or new types of drugs. This year, the group includes new recommendations on handling opioid prescribing as well as the override feature on automated dispensing cabinets (ADCs).

The list’s new opioid best practices call for verification and documentation of a patient’s opioid status and type of pain before prescribing and dispensing the powerful painkillers. It also calls for order entry systems to default to the lowest initial starting dose and frequency for extended-release and long-acting opioid formulas.

In addition, the ISMP also recommends alerting practitioners when adjustments to opioids are needed due to age, kidney or liver problems, and eliminating the prescribing of fentanyl patches for new opioid patients or patients with acute pain, and removing them from ADCs where acute pain is primarily treated, such as in an emergency room.

The best practices for ADCs includes limiting the variety of medications which can be removed using the override function, requiring a medication order before any medication can be removed from the ADC, monitoring the use of the cabinets’ override function, as well as reviewing the appropriateness of the list of drugs that can be removed with the override function and restricting the override to drugs needed in emergencies.

The new best practices also revised six best practices and incorporated those into other items. For example, it eliminated glacial acetic acid, because hospitals have shown progress in removing or replacing it with vinegar or commercially available diluted acetic acid 0.25% to prevent accidental administration.

The ISMP first began issuing medication safety best practices in 2014. The recommendations are based on error reports received through the ISMP National Medication Errors Reporting Program and are reviewed by an external expert advisory panel and approved by the ISMP board of trustees.

The best practices are focused on the hospital setting but can be used in other clinical areas of healthcare as well.

Every year nearly 9,000 people in the U.S. die from medication errors. Most errors occur when healthcare staff are ordering the medications or during the prescribing stage. Errors often lead to patients receiving the wrong medication or receiving a medication at the wrong dose or wrong frequency.

The ISMP is a nonprofit organization focusing on preventing medication errors and other safety issues surrounding medication dispensing.


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