ISMP Releases Top 10 Medication Errors and Hazards for 2020

The Institute for Safe Medication Practices (ISMP) released the “Top 10 Medication Errors and Hazards” which should be addressed when developing a 2020 medication safety improvement plan.

An article issued by the organization reviews the following hazards and recommended solutions for each threat.  ISMP notes that this list does not reflect “the most frequently reported problems or those that have caused the most serious consequences to patients, although these factors were considered, but rather errors and hazards that have been persistent and can be avoided or minimized with system and practice changes.”

 1. Selecting the wrong medication after entering the first few letters of the drug name. Often, only the “first few letter characters of a drug name, or a combination of the first few letters and product strength, potentially allows the presentation of similar looking drug names on technology screens” which “increases the risk of selection errors or population of a field with an unintended drug.” ISMP Guidelines for Safe Electronic Communication of Medication Information recommend “a minimum of the first 5 letters of a drug name during product searches to limit similar names from appearing together on the same screen.”

2. Daily instead of weekly oral methotrexate for non-oncologic conditions. According to the US Food and Drug Administration (FDA), “up to 4 per 1,000 patients may mistakenly take the drug daily instead of weekly.”

3. Errors and hazards due to look-alike labeling of manufacturers’ products. Healthcare facilities are urged to establish “a process to ensure that all new products are evaluated by practitioners who may use them, looking at the actual packages in their work environment, before drugs are added to inventory.”

4. Misheard drug orders/recommendations during verbal/telephone communication. When conditions require verbal or telephone orders, such as emergency or sterile procedures, “the receiver should READ BACK (or repeat back during sterile procedures) the drug therapy (drug, dose, route, frequency), SPELLING the drug name, and stating the dose in single digits (e.g., one-five for 15).”

5. Unsafe “overrides” with automated dispensing cabinets (ADC). ISMP says the following three unsafe conditions all involve the removal of a medication from an ADC without a pharmacist’s review of the order: overuse of overrides, removal of a drug from an ADC without an order and removal of an ordered drug from a non-profiled ADC.

See ISMP’s Guidelines for the Safe Use of Automated Dispensing Cabinets

6. Unsafe practices associated with adult IV push medications. ISMP encourages hospitals to use its Safe Practice Guidelines for Adult IV Push Medications

7. Wrong route (intraspinal injection) errors with tranexamic acid. ISMP reports that cases often involve “mix-ups between tranexamic acid and bupivacaine or ropivacaine” and that “all three products are available in vials with blue caps.”

8. Unsafe labeling of prefilled syringes and infusions by 503b compounders. ISMP says this is due, in part, to “the lack of standardized, FDA-reviewed labeling of prefilled syringes and premixed IV infusions prepared by compounding pharmacies.”

9. Unsafe use of syringes for vinca alkaloids. ISMP is asking that FDA remove administration of vinca alkaloids by a syringe from the prescribing information. In the interim, hospitals are encouraged “to make it a rule to always dilute vinca alkaloids in a minibag prior to administration, even for pediatric patients.”

10. 1,000-fold overdoses with zinc. ISMP advises “all healthcare providers to build, test, and heed maximum dose warnings in parenteral nutrition (PN) order entry systems, with a hard stop for critical zinc overdoses (e.g., above 250 mcg/kg for pediatric PN). Pediatric PN templates should default to mcg dosing units for zinc, which should also correspond to the way orders are entered in automated compounders.

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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