ISMP releases updated medication safety best practices for hospitals

Abstract

In late February, the Institute for Safe Medication Practices (ISMP) released its 2020–2021 consensus-based medication safety best practices for hospitals. The document focuses on specific medication issues that continue to cause fatal harmful errors in patients despite repeated warnings from ISMP publications. New this year are two best practices focused on opioid prescribing and the “override” feature of automated dispensing cabinets. “ISMP’s Targeted Medication Safety Best Practices for Hospitals can be used by pharmacy staff to detect medication safety hazards that have been identified repeatedly as a source of harmful errors in patients,” said Christina Michalek, BS, RPh, FASHP, medication safety specialist and administrative coordinator for the Medication Safety Officers Society at ISMP. “We hope that pharmacists will take the lead on identifying and analyzing current gaps in processes and use that information to develop an action plan for full implementation of each best practice component.” The new opioid best practice was added to ensure appropriate prescribing of opioids, especially extended-release and long-acting opioids. A key to this best practice is verifying and documenting a patient’s opioid status (i.e., naive vs. tolerant) and the type of pain (i.e., acute vs. chronic) they have before prescribing any extended-release or long-acting agents. Safety issues addressed in ISMP’s Targeted Medication Safety Best Practices for Hospitals▪Vincristine (and other vinca alkaloids) inadvertently administered by the intrathecal route▪Accidental daily dosing of oral methotrexate intended for weekly administration▪Missing or inaccurate patient weights, and mix-ups between metric and nonmetric units when measuring and documenting weight▪Unintended I.V. administration of oral medications▪Mix-ups between milliliters and nonmetric units when measuring oral liquid medications▪Inadvertent administration of neuromuscular blocking agents to patients, especially those not receiving proper ventilator assistance▪Errors when administering I.V. medication infusions▪Delay in administration or improper use of antidotes, reversal agents, and rescue agents▪Accidental administration of an I.V. infusion of sterile water▪Errors during sterile compounding of medications▪Inappropriate use of extended-release and long-acting opioids and fentanyl patches to treat acute pain and/or patients who are opioid naive▪Serious tissue injuries and amputations from injectable promethazine use▪Lack of learning from external medication safety risks anderrors▪Removal of medications from automated dispensing cabinets using the override feature ▪Vincristine (and other vinca alkaloids) inadvertently administered by the intrathecal route▪Accidental daily dosing of oral methotrexate intended for weekly administration▪Missing or inaccurate patient weights, and mix-ups between metric and nonmetric units when measuring and documenting weight▪Unintended I.V. administration of oral medications▪Mix-ups between milliliters and nonmetric units when measuring oral liquid medications▪Inadvertent administration of neuromuscular blocking agents to patients, especially those not receiving proper ventilator assistance▪Errors when administering I.V. medication infusions▪Delay in administration or improper use of antidotes, reversal agents, and rescue agents▪Accidental administration of an I.V. infusion of sterile water▪Errors during sterile compounding of medications▪Inappropriate use of extended-release and long-acting opioids and fentanyl patches to treat acute pain and/or patients who are opioid naive▪Serious tissue injuries and amputations from injectable promethazine use▪Lack of learning from external medication safety risks anderrors▪Removal of medications from automated dispensing cabinets using the override feature As part of the best practice, pharmacists should default order entry systems to the lowest initial starting dose and frequency when initiating orders for extended release and long-acting opioids. ISMP continues to recommend avoiding the use of fentanyl patches in patients who are opioid naive and in those with acute pain. The organization noted that it continues to receive reports, including deaths, from improper use of fentanyl patches in these patient populations. The other new best practice focuses on automated dispensing cabinets and was created to help minimize the risks associated with removal of medications from these devices using the override feature. ISMP noted that many clinicians view the override process as a routine function without seeing the risks involved. The best practice states that the variety of medications removed using the override feature should be limited, medication orders should be required prior to removing any medications from automated dispensing cabinets, and overrides should be monitored to assess their appropriateness. The rest of the best practices document focuses on a variety of safety issues (see sidebar). Clinicians should review the full document on ISMP’s website. Michalek noted that the consensus-based best practices can be included as part of an organization’s medication safety strategic plan. “Since it will likely take some time to implement the best practices, pharmacists can add each to their organization’s medication safety dashboard and measure implementation status, or ‘compliance,’ over time,” she said. Within ISMP’s document, best practice 14 summarizes steps organizations can take to seek information about medication safety risks and steps to prevent similar errors at their institutions. Suggestions include appointing a medication safety officer to oversee the entire activity for the hospital, establishing a formal process to routinely review medication risks and errors, and identifying appropriate actions to minimize these risks.