New International Best Practices Guidelines Seek To Reduce Medication Errors

A group of international medication experts indicate that there are recommending three new “best practices” that could help prevent many serious injuries and deaths associated with medication errors if adopted worldwide.

The International Medication Safety Network (IMSN) published a list of Global Targeted Medication Safety Best Practices on May 30, which seek to prevent common medication errors that can have serious consequences. These are the first such best practices recommendations released by the group, which was founded in 2006.

The group looked at data on medication errors and found three common characteristics: first, they are likely to occur repeatedly if not addressed; second, they are easily identifiable and recognized and cannot be attributed to other causes’ and third, they are avoidable.

Preventing these deadly events is possible by the implementation of risk-reduction strategies that reduce or eliminate the possibility of errors, make errors visible, and minimize their consequences,” the IMSN stated in its announcement. “The primary goal is to redesign the medication management process to make it harder for errors to reach the patient.”

The three best practices are aimed at specific drugs and treatments which are commonly linked to adverse health events due to medication mistakes.

The first calls for the removal of all ampule and vials of potassium concentrate injections from inpatient drug storage on nursing units. This is because they have been linked to a number of adverse events where the vials have been accidentally used instead of sterile water or saline, resulting in deaths of children and adults. The solution, simply separating them from other drugs in the storage unit, would eliminate the problem, the IMSN determined.

The second best practice calls for preparing and dispensing vinca alkaloids, used in chemotherapy, only in minibags, and never in syringes. This is because the drugs are meant to be administered intravenously, and never by any other route. However, there have been cases where it was dispensed into spinal fluid and mistaken for other injection drugs, resulting in serious injuries or deaths. If they are not distributed in syringes, but instead in minibags which can only be used for intravenous delivery, the IMSN believes the medication errors would be far less likely.

The third global targeted medication safety best practice calls for better oversight of dosing of methotrexate for non-oncologic conditions in order to prevent daily dosing. Methotrexate is used to treat illnesses like psoriasis and rheumatoid arthritis. However, at higher doses it is associated with serious and sometimes fatal blood problems.

While it is usually prescribed once a week, it is sometimes prescribed daily for specific cancer patients. If non-cancer patients get the daily dose, however, it could lead to serious or fatal adverse events. This third safety best practice calls for the creation of a number of checks to ensure it is only prescribed weekly for non-oncologic patients, such as through the use of electronic records and specifying which day of the week the drug should be taken.

The group hopes to work with hospitals and international professional organizations, as well as drug regulators worldwide to implement the best practices on a global scale.