Targeted medication safety best practices for community pharmacy

Medication Safety

Institute for Safe Medication Practices, Horsham, PA

In 2023, ISMP launched the first iteration of the ISMP Targeted Medication Safety Best Practices. The purpose of the best practices is to identify, inspire, and mobilize widespread, national adoption of consensus-based best practices to address recurring problems that continue to cause fatal and harmful errors despite repeated warnings in ISMP publications. The best practices are reviewed by an external expert advisory panel, and represent high-leverage error-reduction strategies, many of which have already been successfully adopted.

While the best practices might be challenging for some organizations to achieve, all are are practical and realistic, and their value in reducing medication errors is grounded in scientific research and/or expert analysis of medication errors and their causes. Implementation of the best practices can vastly improve medication safety and reduce the risk of significant patient harm. While these best practices were created for community pharmacy, some may be applicable to other health care settings such as medical offices and clinics. ISMP also offers best practices for hospitals.

Original best practices

The first five best practices published included the following:

1. Use a standard protocol to verify a patient’s identity, utilizing at least two patient identifiers, when receiving a prescription to be filled, responding to patient-specific questions, providing filled prescriptions to patients at the point-of-sale, delivering prescriptions to the patient’s home, and prior to administering vaccines or other treatments.
2. Install and use barcode verification during production (i.e., the prescription filling process) to scan each drug or vaccine package or container (e.g., bottle, carton) used to fill a prescription, including manufacturer cartons or bottles that may be dispensed to a patient.
3. Use a weekly dosage regimen default for oral methotrexate in electronic systems when medication orders are entered. Require verification and entry of an appropriate oncologic indication in order entry systems for daily orders. Create a forcing function (e.g., electronic stop in the sales register that requires intervention and acknowledgment by a pharmacist) to ensure that every oral methotrexate prescription is reviewed with the patient or a family member when a prescription is presented or refills are processed. Provide specific patient and/or family education for all oral methotrexate prescriptions.
4. Standardize to the use of the milliliter unit of measure when prescribing, dispensing, and measuring oral liquid medications.
5. Seek out and use information about medication safety risks and errors that have occurred in organizations outside of your pharmacy, including other affiliated pharmacies, and take action to prevent similar errors.

New best practices for 2025–2026

The Targeted Medication Safety Best Practices for Community Pharmacy are updated every 2 years. The list now comprises eight best practices, the five original best practices, and three new additions.

6. Obtain and use a patient’s weight to verify dosing of weight-based medications. In addition to obtaining and documenting the patient’s weight in metric units (i.e., kilograms or grams) when dispensing weight-based drugs, this best practices calls on pharmacies to work with software vendors and/or information technology staff to provide a discrete field within the pharmacy computer system to record the patient’s weight in metric units; configure the pharmacy computer system to capture patient weight data when included in an electronic prescription; build clinical decision support for weight-based dose checking; enable a mechanism to support staff to identify patient weights that require updating prior to dispensing weight-based medications; and provide a notification when a weight entry changes significantly from the previous entry.
7. Maximize the use of technology to prevent errors during the return-to-stock (RTS) process. Do not return medications from filled prescriptions into manufacturer stock bottles that have been opened or cells within automated dispensing technology. Create functionality within the pharmacy computer system to generate specific labels to apply to prescription bottles that require RTS. RTS labels should include the drug name, dosage strength, expiration date, description (e.g., tablet shape, color, imprint code), and a barcode that can be used when filling a subsequent prescription. Develop functionality to automate and guide the use of available RTS medications to fill prescriptions before reverting to sending prescriptions to an automated dispensing system for filling. Utilize barcode verification throughout the RTS process to ensure the correct RTS label is placed on the correct RTS prescription and during subsequent prescription fills.
8. Establish standard processes to prevent errors during vaccine preparation and administration. This best practice contains a number of specific recommendations. For example, ISMP encourages pharmacies to schedule dedicated resources and times for vaccinations. Also, as many error reports submitted to the ISMP Vaccine Errors Reporting Program indicated the errors were discovered when documenting the vaccination in the patient’s vaccine registry, ISMP recommends pharmacies verify a patient’s immunization status prior to administering vaccines by reviewing the patient’s history in the vaccine registry and the patient’s pharmacy record as available.

To minimize vaccine mix-ups when selecting a vaccine from the refrigerator or freezer, store vaccines separately based on the type and formulation (e.g., pediatric and adult formulations of the same vaccine). Also, store two-component vaccines together if storage requirements do not differ.

ISMP also recommends the use of prefilled syringes when available. If not available, prepare each vaccine dose immediately prior to administration and label with the vaccine name, dose, and—if appropriate—the indicated age range. Use barcode scanning technology to verify the correct vaccine(s), dose(s), and diluent(s) are selected and are being administered to the correct patient.

To minimize distractions at the point of administration, provide a separate area or room for vaccine administration, away from interruptions. If multiple patients (e.g., in the same family) are being vaccinated at the same time, bring one patient into the vaccination area at a time; or at a minimum, bring only one patient’s vaccines into the vaccination area at a time.

Engage the patient. Verify the patient’s identity using at least two unique identifiers (e.g., full name, date of birth, address). Use open-ended questions to ask the patient or caregiver what vaccine they are expecting to receive and verify that this information matches the vaccine in hand to be administered.

Community pharmacies should focus their medication safety efforts over the next 2 years on these best practices. Additional recommendations and the rationale for the best practices can be found in the full document. An Implementation Worksheet is also available to help community pharmacies identify gaps in the implementation of these best practices and develop an action plan to address vulnerabilities. ■