Medication Safety

Brittany Botescu, PharmD

Early this year, the Institute for Safe Medication Practices (ISMP) released its latest guidance featuring recommendations to ensure appropriate medication delivery and patient-specific therapy considerations. This annual document of best medication safety practices provides consensus-based guidance for medication safety in hospitals in order to prevent fatal and harmful errors to patients.

Rationale and methods behind recommendations

To develop this guidance document, ISMP recruited the expert review of an external advisory panel approved by the ISMP Board of Trustees. They conducted error reports received from their National Medication Errors Reporting Program (ISMP MERP) from both consumers and health care practitioners.

“Error and close call reporting is vital for pharmacists and other health care practitioners,” said Christina Michalek, BSc Pharm, RPh, FASHP, medication safety specialist and administrative coordinator for the Medication Safety Officers Society at ISMP. “Because reporting helps to identify vulnerabilities in our systems, finding the weak points—which may often be hidden until they contribute to an error—gives us the opportunity to implement more targeted error reduction system strategies to prevent future patient harm.”

Since its inception in 1975, the ISMP MERP has gathered thousands of voluntary reports annually to collect insight on everything from fatal errors to “near misses” via voluntary submission. The goal is to use today’s errors to identify lessons learned, advocacy priorities, and opportunities for both the improvement of policies and products. Submissions provided via mediums such as the ISMP MERP have historically been used to inspire numerous improvements in product design, creation of preventive policy and regulatory standards, and even early warning signs to the health care community of unforeseen issues.

ISMP collaborates with a variety of different partners, including FDA, ECRI and National Coordinating Council for Medication Error Reporting and Prevention, when collecting and enforcing recommendations for best practices.

Best practices have been identified… now what?

With the collection of patient and practitioner input from across the nation, every pharmacy practice site may come away with new perceptions and practices for safe strategic plans. It’s worth noting that these steps toward implementation can sometimes take time to formally review and execute. Nonetheless, it’s important that pharmacies do not lose focus or sight of the importance of quality assurance and improvement through error prevention. ■

Recommendations

• Best practices outlined in this latest guidance include
• Tall Man lettering for look-alike/sound-alike drugs
• Attention to correct dosing intervals (e.g., daily vs. weekly)
• Attention to correct medication routes (e.g., intravenous vs. oral)
• Distinction between weight-based and nonweight-based medication dosing
• Delays in medication administration
• Prevention of sterile compounding errors
• Serious injuries and amputations from injectable promethazine use
• Appropriate use of extended-release and long-acting opioids and fentanyl patches to treat acute pain and/or patients who are opioid-naive
• Inappropriate removal of medications from automated dispensing cabinets using “override” features
• Errors associated with the use of oxytocin
• Implementation of barcode verification technology to care units beyond inpatient care units