Best Practices for Addressing Common Medication Safety Errors

The Institute for Safe Medication Practices (ISMP) released its “2020-2021 Targeted Medication Safety Best Practices for Hospitals,” a resource that can be adopted to address errors that impact patient safety. ISMP says that, despite prior warnings, the list reflects recurrent mistakes that are causing patient harm.

Hospitals and healthcare organizations are advised to prioritize timely implementation of the following best practices:

  • Prevent inadvertent administration by the intrathecal route by dispensing vinCRIStine and other vinca alkaloids in a minibag of a compatible solution, not in a syringe.
  • Avoid accidental daily dosing of oral methotrexate by
    • using a weekly dosage regimen default in electronic systems when medication orders are entered,
    • requiring a hard stop verification of an appropriate oncologic indication for all daily oral methotrexate orders and
    • providing specific patient and/or family education for all oral methotrexate discharge orders.
  • Prevent missing or inaccurate patient weights and mix-ups between metric and non-metric units by
    • weighing each patient as soon as possible on admission and during each appropriate outpatient or emergency department encounter and
    • measuring and documenting patient weights in metric units.
  • Avoid unintended intravenous administration of oral medications by ensuring that all oral liquid medications that are not commercially available in unit dose packaging are dispensed by the pharmacy in an oral or enteral syringe.
  • Avoid mix-ups between milliliters and non-metric units when measuring oral liquid medications by purchasing oral liquid dosing devices that only display the metric scale.
  • Prevent inadvertent administration of neuromuscular blocking agents to patients by segregating and differentiating all neuromuscular blocking agents from other medications.
  • Prevent errors when administering intravenous medication infusions by
    • administering medication infusions via a programmable infusion pump utilizing dose error-reduction systems,
    • monitoring compliance with the use of smart pump dose error-reduction systems and
    • using a smart pump that allows programming a bolus or loading dose and continuous infusion rate with separate limits for each.
  • Avoid delay in administration or improper use of antidotes, reversal agents and rescue agents by ensuring all appropriate antidotes, reversal agents and rescue agents are readily available, having standardized protocols and/or coupled order sets in place that permit emergency administration.
  • Avoid accidental administration of an intravenous infusion of sterile water by eliminating all 1,000 mL bags of sterile water from all areas outside of the pharmacy.
  • Prevent errors during sterile compounding of medications by performing an independent verification to ensure that the proper ingredients and amounts are added.
  • Prevent inappropriate use of extended-release and long-acting opioids and fentanyl patches by eliminating the prescribing of patches for opioid-naive patients and/or patients with acute pain.
  • Prevent serious tissue injuries and amputations from injectable promethazine use by eliminating injectable promethazine from the formulary.
  • Use information about medication safety risks and errors that have occurred in other organizations and take action to prevent similar errors.
  • Avoid removal of medications from automated dispensing cabinets (ADC) using the “override” feature by
    • limiting the variety of medications that can be removed from an ADC,
    • requiring an order prior to removing any medication and
    • monitoring ADC overrides to verify appropriateness, transcription of orders and documentation of administration.

Click here to access the complete edition of the report.

In addition, MLMIC offers a number of resources that can help policyholders implement effective risk management strategies for the concerns identified by ISMP:

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