Institute For Safe Medication Practices Research Articles

Analysis of an Academic Medical Center’s Corrective Action Plan in Response to Fatal Medication Error Using the Institute for Safe Medication Practices’ Hierarchy of Effectiveness

Neuromuscular blocking agents (NMBAs) are high-alert medications that require special handling, necessitating a robust process that prevents medication error, identifies near misses, and ultimately protects patients from harm. One patient at a large academic medical center (AMC) was given vecuronium, a neuromuscular blocking agent, instead of midazolam, and died as a result. Thus, AMC was tasked by the Centers for Medicare & Medicaid Services (CMS) to make a list of actions to prevent a subsequent incident. When assessing AMC’s corrective action plan in comparison to the Institute for Safe Medication Practices’ hierarchy of effectiveness of risk-reduction strategies, it was revealed that 76% of strategies were of low leverage, 16% were of medium leverage, and 8% were of high leverage. In this context, AMC’s corrective action plan should have integrated more system-based interventions, which include medium- or high-leverage strategies, rather than relying heavily on initiatives dependent on human action. Despite the lack of these systemic tools, CMS granted approval for the plan. Overlooking these systemic tools may amplify patient harm and negatively impact workforce satisfaction and efficiency. Moreover, the absence of a “just culture” also plays a role in patient harm. Therefore, recognizing that medication errors in healthcare are predominantly attributed to human error highlights the importance of fostering a just culture that advocates for system accountability to enhance patient safety.

Analyzing override patterns in profiled automated dispensing cabinets at a tertiary care hospital in Saudi Arabia

BackgroundInappropriate automated dispensing cabinet (ADC) overrides pose a significant risk to patient safety. Bypassing pharmacist review during these overrides removes a vital safety check, leaving nurses to review complex medication orders alone. This can lead to overlooking incorrect orders and significantly increasing the potential for medication errors. While Institute for Safe Medication Practices (ISMP) guidelines promote profiled ADCs and safe override practices, there is no national standard for acceptable override rates. ObjectivesAssessing the appropriateness of ADC overrides of profiled ADCs at a tertiary hospital in Saudi Arabia in accordance with ISMP guidelines (third core safety process). MethodsThis retrospective observational study reviewed all override transactions for 13 profiled ADCs over a 3-month period, from 1 October 2022 until 31 December 2022. The target override rate was set at no more than 5%. After applying exclusions, the relevant data fields were extracted from electronic records of 2 integrated systems: the Omnicell dashboard and the BESTCare hospital information system. The study assessed whether the override transactions complying with the standard elements required for appropriate ADC overrides in accordance with ISMP recommendations and hospital regulations. ResultsSix hundred sixty-four override transactions from profiled ADCs were reviewed and evaluated. Although the overall override limit for profiled ADCs was met (1.9%), multiple inappropriate override practices were revealed. These inappropriate practices are missing physician orders (33.7%), undocumented verbal orders (31.5%), nonurgent physician orders (11%), missing (8.4%) or delayed (33.7%) administration records, and unrecognized override errors (5.3%). Only 3 (0.5%) met all the standard elements required for ADC overrides. ConclusionThe target override threshold of 5% is inadequate to demonstrate sufficient adherence to the standard elements of appropriate overrides or effectively prevent medication errors. Consequently, a significantly lower target threshold override limit, well below 5%, should be considered, especially with 24-hour pharmacy services and fully integrated computerized physician order entry with ADC system. A multidisciplinary override surveillance team is considered essential.

Implementation of a Heparin Infusion Calculator in the Electronic Health Record System as a Risk-Mitigation Strategy in a Community Teaching Hospital Emergency Department

IntroductionAccording to the Institute for Safe Medication Practices, unfractionated heparin is a high-risk medication due to the potential for medication errors and adverse events. Unfractionated heparin is often started in the emergency department for patients with acute coronary syndromes or coagulopathies. Risk-mitigation strategies should be implemented to ensure appropriate initiation and monitoring of this high-risk medication. In 2019, an unfractionated heparin calculator was built into the electronic health record at a community medical center. The purpose of this study was to evaluate the impact of the calculator as a risk-mitigation strategy. MethodsPatients ≥18 years old admitted between January 1, 2020, and December 31, 2020, were included if they were administered an unfractionated heparin infusion in the emergency department. Patient encounters were excluded if unfractionated heparin order was discontinued before administration. Patient encounters were classified into the unfractionated heparin calculator arm if the unfractionated heparin calculator was used to determine initial dosing, and the remaining patient encounters were classified into the unfractionated heparin no calculator arm. Unfractionated heparin orders were reviewed if a baseline activated partial thromboplastin time was collected and if the correct initial bolus dose and infusion rate were administered. The primary objective is to determine whether the use of unfractionated heparin initiation calculator reduced the rate of medication administration errors. Medication administration errors are defined as baseline activated partial thromboplastin time not collected or incorrectly collected or the administration of incorrect initial bolus dose and infusion rate. ResultsA total of 356 patient encounters with unfractionated heparin orders were included in the primary analysis. There were 13.9% errors (39 of 279) present when the calculator was used and 23.3% (18 of 77) when the calculator was not used (P = .046). There was 86% correct administration of heparin (240 of 279) when the calculator was used and 76% correct administrations (59 of 77) when the calculator was not used. DiscussionThe use of the unfractionated heparin infusion calculator in the emergency department led to decrease in medication administration errors. This is the first study to evaluate the integration of an unfractionated heparin calculator into the electronic health record.

Implementation Status and Challenges Associated With Implementation of the Targeted Medication Safety Best Practices in a Tertiary Hospital.

Background The Institute for Safe Medication Practices (ISMP) is a well-known non-profit organization dedicated to preventing medication errors. Every two years they publish best practices that can reduce the occurrence of medication errors. This study aims to evaluate the implementation status of these best practices and to understand barriers associated with non-implementation at a tertiary hospital in Saudi Arabia. Methodology This was a two-phase qualitative study. First, a survey consisting of the ISMP best practices was sent to employees (mainly heads of departments) to fill out the implementation rate for each best practice. Then an interview or a focus group was conducted to further validate their answers and understand why some best practices were not implemented. Results Our study found that the highest implemented best practices were having strategies to improve safety with high-alert medications (best practice #19, 85.7%), having antidotes and reversal agents readily available (best practice #9, 75%), independent verification of sterile preparation (best practice #11, 75%), and limiting the number of removable medications from the automated dispensing unit by override (best practice #16, 75%). The least implemented best practices were ensuring that oral liquid medications are dispensed in a syringe (best practice #4, 12.5%), maximizing use of barcode verification (best practice #18, 12.5%), purchasing oral liquid dosing devices that display metric scale (best practice #5, 25%), eliminating glacial acetic acid from all areas of the hospital (best practice #6, 28.6%), and eliminating all 1,000 mL of sterile water from all areas outside of the pharmacy (best practice #10, 28.6%). Challenges associated with implementation were related to knowledge, motivation, and opportunity in the environment, with the latter being the highest barrier associated with non-implementation. Conclusions Healthcare providers need to have knowledge about the best practices and the rationale behind them, the motivation to perform them, and the necessary resources to implement the best practices in their hospital.

Impact of 'Never Use' Abbreviations (Error-Prone Abbreviations-EPA's) List on the Incidence of EPAs in Inpatient Medical Prescriptions in Apex Tertiary Care Public Hospital in India.

The aim of the study was to assess the impact of never-use list and standardized abbreviations on error prone abbreviations. Abbreviations are commonly used in medical records to save time and space but use in prescriptions, which can lead to communication failures and preventable harm. Prescriptions need to be clear for correct interpretation. Hospitals should implement uniform use of approved abbreviations, such as an approved list or never-use list of abbreviations and symbols. In the hospital under study, there was no system of avoiding error prone abbreviations while prescribing any medication. Hence, an interventional study was performed to quantify and reduce the incidence of error prone abbreviations. The main objectives were to determine the incidence of error prone abbreviations, development and implementation of 'Never-use' list and standardized abbreviations and finally determine its effectiveness in reducing the error prone abbreviations in the prescriptions. The study design was pre-post interventional / quasi-experimental design. The settings were inpatient wards of broad specialties of a tertiary care hospital. 'Never-use' list and standardized abbreviations were developed by review of relevant literature, existing lists by Institute for Safe Medication Practices and Australian Commission on Safety and Quality in Health Care compared against findings of the pilot study of prescriptions for error prone abbreviations and experts' input. Poster copies of the lists were affixed in inpatient wards, doctors were educated, and poster pamphlets were distributed. Pre-intervention data was collected by a retrospective closed in-patient medical record review. Post-interventional incidence of error prone abbreviations was determined, and the effectiveness of the same was assessed by using statistical analysis. The incidence of error abbreviations in inpatient prescriptions was 47.5%, and the 'Never Use' list of abbreviations led to a statistically significant reduction of error prone abbreviations by 8.2% from 47.5% to 43.6% (P\0.006). 'Never Use' lists are effective in reducing the incidence of common error-prone abbreviations, and discipline-wise variation is observed.

Get Smart, Canada: Exploring Smart Pump Implementation, Management, and Compliance with Standards through a Nationwide Survey.

Smart pump technology is relatively new, and uncertainty exists regarding best practices for development and management of the drug libraries in these devices. In Canadian hospitals, IV smart pumps and their drug libraries are created and maintained according to recommendations from Accreditation Canada and guidelines from the US Institute for Safe Medication Practices (ISMP). Current compliance with these standards in Canada is unknown. However, neither organization provides specific operational steps detailing how to effectively create and manage a drug library, which leaves significant room for interpretation. Furthermore, the human resources dedicated to creation and management of these libraries in accordance with guidelines and standards are unknown. To describe current compliance with standards and guidelines for smart pump drug libraries; the processes used for drug library set-up, management, training, and support; and the resources currently used for these activities in Canadian hospitals. A 43-question online survey was made available in spring 2021 to multidisciplinary team members involved in implementation of IV smart pumps and/or management of drug libraries in Canadian hospitals. A total of 55 complete or partial responses were received. Most responses indicated that standards set by Accreditation Canada and ISMP were not being met, with only 30% (14/47) updating their libraries at least quarterly and 47% (20/43) performing quality reviews at least every 6 months. Although the majority of respondents reported regular monitoring of compliance, 30% (11/37) did not perform such monitoring. Results further indicated variation across Canadian hospitals in set-up, management, training, and support related to drug libraries, as well as variation in the human resources available for these activities. Canadian health authorities and organizations are not meeting current ISMP and Accreditation Canada standards for smart pumps. Variation exists in terms of strategies for creating and managing drug libraries, as well as in the training and resources needed to support these initiatives. Canadian health authorities and organizations should prioritize meeting these standards and should closely review the resources required to do so.

Medication Errors.

PRESIDENT EMERITUS OF THE INSTITUTE FOR SAFE MEDICATION PRACTICES (ISMP) The reports described in Medication Errors were received through the ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices (ISMP) at www.ismpl.org, 1-800 FAIL Safe, or [email protected]. Michael R. Cohen is a member of the Nursing 2022 editorial board.

Smart Use of Smart Infusion Pumps.

Smart infusion pumps have reduced but not eliminated medication errors. These errors are frequently related to misuse or underuse of the safety features of the pump.The Institute for Safe Medication Practices offers safety considerations for using smart pumps and suggestions for maintaining an institution's smart pump drug library.

Linguistic Analysis of Generic-Generic Drug Name Pairs Prone to Wrong-Drug Errors for which Tall-Man Lettering is Recommended

ObjectiveThe Institute for Safe Medication Practices (ISMP) and the United States Food and Drug Administration (FDA) disseminated widely used lists of drug name pairs involved in wrong-drug errors, for which they recommended tall-man lettering (TML). Linguistic similarity is believed responsible for confusion of these drugs. This study aims to quantify linguistic similarity and other linguistic properties of these generic-generic name pairs.MethodsThe FDA’s Phonetic and Orthographic Computer Analysis (POCA) software was used to generate numerical similarity scores for the generic-generic name pairs on these lists and to identify conflicts between these names and the names of other marketed products. Within each pair, differences in name length and the number of identical prefix (initial) letters and suffix (final) letters were determined.ResultsThe selected pairs shared a mean of 2.5 (± 1.8) identical prefix letters and 3.2 (± 2.9) identical suffix letters. The mean POCA score 69.5 (± 9.7), indicated moderate-to-high similarity. POCA scores for individual pairs ranged from 90 (most similar) to 46 (least similar). Individual names averaged 11.2 (± 9.1) high-similarity conflicts with names of other marketed drugs.ConclusionsPOCA analysis could be a valuable tool in determining whether linguistic similarity contributes to specific wrong-drug errors. The finding of 11.2 (± 9.1) high-similarity conflicts with names of other marketed drugs is more than for candidate names USAN accepts and suggests the names on the FDA and ISMP lists are linguistically problematic.

Look-alike Packaging.

Ann Shastay, MSN, RN, AOCN, is the Senior Manager, Publications, Institute for Safe Medication Practices, Plymouth Meeting, Pennsylvania. The author declares no conflicts of interest. Address for correspondence: Ann Shastay, MSN, RN, AOCN, Institute for Safe Medication Practices (ISMP), 5200 Butler Pike, Plymouth Meeting, PA 19462.

Safe Practices for Medication Administration via Enteral Tubes.

Medication errors are possible when drugs are given through enteral feeding tubes.The Institute for Safe Medication Practices has suggested strategies for reducing the common errors that can occur through use of this route of administration.

Operationalizing a Medication Safety Gap Assessment for a Large Health System.

Medication errors continue to be a leading cause of medical errors. In the United States alone, 7000 to 9000 people die annually due to a medication error, and many more are harmed. Since 2014, the Institute for Safe Medication Practices (ISMP) has advocated for several best practices in acute care facilities derived from reports of patient harm. The medication safety best practices chosen for this assessment were based on the 2020 ISMP Targeted Medication Safety Best Practices (TMSBP) and health system-identified opportunities. Each month, for 9 months, select best practices were covered with associated tools to assess the current state, document the gap, and close identified gaps. Overall, 121 acute care facilities participated in most safety best practice assessments. Of the best practices assessed, there were 8 practices that more than 20 hospitals documented as not implemented and 9 practices where more than 80 hospitals had fully implemented them. Full implementation of medication safety best practices is a resource-intensive process that requires strong change management leadership at a local level. As noted by the redundancy in published ISMP TMSBP, there is an opportunity to continue improving safety in acute care facilities across the United States.

Medication Errors.

PRESIDENT EMERITUS OF THE INSTITUTE FOR SAFE MEDICATION PRACTICES (ISMP) The reports described in Medication Errors were received through the ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices (ISMP) at www.ismp.org, 1-800-FAIL Safe, or [email protected]. Michael R. Cohen is a member of the Nursing2023 editorial board.

Medication Errors.

PRESIDENT EMERITUS OF THE INSTITUTE FOR SAFE MEDICATION PRACTICES (ISMP) The reports described in Medication Errors were received through the ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices (ISMP) at www.ismp.org, 1-800-FAIL Safe, or [email protected]. Michael R. Cohen is a member of the Nursing2023 editorial board.

Drug Formulations can Lead to Dosing Errors.

Ann Shastay, MSN, RN, AOCN, is Senior Manager, Publications, Institute for Safe Medication Practices, Horsham, Pennsylvania. The author declares no conflicts of interest. Address for correspondence: Ann Shastay, MSN, RN, AOCN Senior Manager, Publications Institute for Safe Medication Practices (ISMP) 5200 Butler Pike Plymouth Meeting, PA 19462 ([email protected]).

Medication Errors.

PRESIDENT EMERITUS OF THE INSTITUTE FOR SAFE MEDICATION PRACTICES (ISMP) The reports described in Medication Errors were received through the ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices (ISMP) at www.ismp.org, 1-800-FAIL Safe, or [email protected]. Michael R. Cohen is a member of the Nursing2022 editorial board.

1019: SURGICAL PHARMACISTS PERI-OP[EN] THE DOOR TO IMPROVED TRANSITIONS OF CARE

Introduction: Surgical patients pass through a myriad of transitions of care during their hospitalization. Often in elective procedures, patients will undergo surgery and immediate post-operative care prior to pharmacist profile review. Many patients, however, may be on high-risk medications per the Institute for Safe Medication Practices (ISMP) that need immediate attention in the perioperative setting. Additionally, intensive care units (ICU) are consistently at capacity, and therefore ways to decrease this burden should be optimized. Recognizing this, subspecialty surgical pharmacists began preoperatively reviewing patients. Methods: A pilot process of preemptive patient review of 412 elective surgical patients was established to assess home medications and pertinent past medical history. The goal was to prevent intra- and post-operative medication-related complications that may translate to poor surgical outcomes, admission to the ICU, or increased length of stay. The service line pharmacist would work with the perioperative pharmacist, surgeons, and anesthesiologists to optimize care, discuss potential barriers, and develop a plan. Results: 295 patients (71.6%) were identified to have 1 or more high-risk medications, with a range of 0-6 medications per patient, that required intervention or coordination of care. Some examples of interventions include: reducing missed doses of seizure mediations, identifying patients that may need intra-operative insulin drips to prevent DKA, identifying the need for stress dose steroids perioperatively to avoid shock, preventing post-operative atrial fibrillation by resuming home beta blockers, identifying intrathecal baclofen pumps, facilitating initiation of heart rate and blood pressure lowering medications in patients with strict hemodynamic goals, and coordinating with anesthesiologists and surgeons regarding intraoperative pain management for chronic pain patients. Conclusions: Preoperative review of elective surgical patients’ home medications and pertinent past medical history by a pharmacist can aid in improved transitions of care. Developing care plans and facilitating these transitions has the potential to decrease poor surgical outcomes, avoid unnecessary admission to the ICU, and decrease length of stay.

A failure in the medication delivery system-how disclosure and systems investigation improve patient safety.

A recent medication error at Vanderbilt University Medical Center contributed to the death of a patient. The ensuing criminal indictment of the administering nurse has shaken the medical community. This has led to clinical staff questioning whether they can disclose patient safety incidents without fear of criminal prosecution. However, because of the publicity of this case, hospitals can benefit from the lessons learned and mitigate the risk of this and similar events at their facilities. To uncover the most impactful and relevant safety recommendations, the Vanderbilt case is examined from a systems investigation perspective using the available public information gathered from media reports, the Tennessee Bureau of Investigation report, and Vanderbilt's corrective action plan submitted to CMS. We present an example of how hospitals can benefit from disclosure: Henry Ford Health used the Vanderbilt case study as part of its medication safety continuous improvement initiatives, which are underpinned by available medication safety recommendations from the Institute for Safe Medication Practices. Using this experience and the lessons learned from the Vanderbilt case, a proactive action plan is presented for hospitals nationwide to prevent the recurrence of this medication error. Without disclosure, these analyses and safety recommendations would not have been possible.

Characteristics of Lymphoma Patients Experiencing Unplanned Readmissions at a Large Academic Medical Center

Background: Patients with lymphoma frequently experience hospital readmissions. Yet, limited data exist describing hospital readmissions in the lymphoma population. In this study, we sought to identify additional patient-specific characteristics associated with unplanned readmissions in patients with lymphoma at our institution. Methods: We conducted a retrospective, single-center study of patients with lymphoma who were age >18 and discharged from medical oncology wards from January-December 2019 (index admission). We categorized patients as having high-risk medications per the Institute for Safe Medication Practices, potentially inappropriate medications (PIMs) for older patients (age 65+) per the American Geriatric Society Beers Criteria, and polypharmacy and major polypharmacy as 5 or more and 10 or more scheduled medications on the discharge medication list, respectively. We performed univariate logistic regression to assess the association of with having an unplanned readmission within 30 days of discharge from index admission. The following factors, selected for clinical relevance, were assessed: age; gender; race; marital status; Charlson comorbidity score; lymphoma diagnosis and related parameters (stage, LDH, prior treatment ECOG PS); index hospitalization reason, duration, discharge disposition and prior healthcare utilization; activities of daily living (ADL) status; Morse fall score; laboratory values at time of discharge; discharge medication list; 30-day readmission status and readmission reason if applicable. Results: We included 207 patients (mean age 63.9 years, 38.6% female, 83.1% white race, 56.8% partnered), 65 (31.4%) of whom experienced a 30-day unplanned readmission. Patients experiencing a 30-day unplanned readmission were more likely to have ECOG PS >2 (36.9% vs 14.2%, p<0.001), higher age-adjusted IPI score (score 0, 3.3% vs 7.8%; score 1, 23.3% vs 35.7%; score 2, 55.0% vs 47.8%; score > 3, 18.3% vs 8.7%; p=0.012), received CAR T-cell therapy (9.2% vs 2.1%, p=0.032), index length of stay >5 days (55.4% vs 33.1%, p=0.003), been discharged to a skilled nursing facility (12.3% vs 3.5%, p=0.023), albumin <3.5 g/dL (78.5% vs 52.1%, p<0.001), and sodium <135 mEq/L (18.5% vs 8.5%, p=0.041). Patients discharged home were less likely to have a 30-day unplanned readmission (56.9% vs 76.8%, p=0.004). Age, sex, marital status, Charlson comorbidity score, aggressive versus non-aggressive lymphoma diagnosis, prior lymphoma treatment, discharge home with services or to inpatient rehabilitation, Morse fall score, bowel and/or bladder continence, independence in feeding or bathing, neutropenia (ANC<1.5 k/mcL), and Hgb <10 g/dL were not significantly associated with increased likelihood for unplanned readmission. Among medication-related factors, we found that patients with major polypharmacy on the index admission discharge medication list had a higher likelihood for unplanned readmission (56.9% vs 37.3%, p=0.009). Patients with discharge medication lists with polypharmacy (90.8% vs 81.7%, 00, long-acting opiates (10.8% vs 4.2%, p=0.082), and/or anticoagulants (26.2% vs 15.5%, p=0.071) had a higher likelihood for unplanned readmissions, but these differences did not reach statistical significance. Presence of PIMs was not associated with readmission. Conclusions: In this relatively large cohort of patients with lymphoma, we identified several risk factors for unplanned hospital readmissions. We found associations among unplanned readmissions and impaired performance status, receipt of prior CAR T therapy, higher age-adjusted IPI score, discharge location (home, skilled nursing facility, etc), lower albumin and sodium levels, as well as major polypharmacy on the discharge medication list. Future directions include further efforts to identify lymphoma patients at high risk for hospital readmissions and developing readmission prevention strategies in those patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Medication Errors.

PRESIDENT EMERITUS OF THE INSTITUTE FOR SAFE MEDICATION PRACTICES (ISMP) The reports described in Medication Errors were received through the ISMP Medication Errors Reporting Program. Report errors, close calls, or hazardous conditions to the Institute for Safe Medication Practices (ISMP) at www.ismp.org, 1-800-FAIL Safe, or [email protected]. Michael R. Cohen is a member of the Nursing2022 editorial board.