Medication Safety
Loren Bonner
From using a patient’s weight to verify dosing of weight-based medications to relying on technology to prevent errors during the return-to-stock process, ISMP identified several key areas where greater action is needed from pharmacy teams in its most recent set of targeted medication safety best practices.
ISMP’s 2025–2026 targeted medication safety best practices for community pharmacy, released in March 2025, provides practical recommendations to help prevent persistent medication safety issues in the community pharmacy as well as the ambulatory pharmacy setting.
“We identify specific medication safety issues that continue to cause fatal and harmful errors in patients, despite repeated warnings in ISMP publications,” said Michael Gaunt, PharmD, senior manager of Error Reporting Programs at ISMP.
ISMP launched its Targeted Medication Safety Best Practices for Hospitals in 2014. As with the acute care version—Targeted Medication Safety Best Practices for Hospitals—the community pharmacy Best Practices are updated as needed every 2 years.
In constantly receiving and reviewing error reports, Gaunt said they are continually identifying new topics worthy of being elevated to a “best practice.”
The new practices added to the 2025–2026 Best Practices address how to:
- Obtain and use a patient’s weight to verify dosing of weight-based medications.
- Maximize the use of technology to prevent errors during the return-to-stock process.
- Establish standard processes to prevent errors during vaccine preparation and administration.
- Additional best practices featured in the 2025–2026 guidelines that were retained from previous years include:
- Preventing wrong patient errors when filling prescriptions, responding to questions, and administering vaccines.
- Expanding and maximizing the use of barcode scanning during medication and vaccine dispensing and administration.
- Avoiding errors involving inadvertent daily dosing of methotrexate for noncancer indications.
- Standardizing the use of metric (mL) units of measure when prescribing, dispensing, and measuring oral liquid medications.
- Using information about medication safety risks and errors that have occurred in other organizations to take preventative action.
Implementation
“The best practices represent realistic and practical strategies, many of which have been implemented in other organizations,” said Gaunt.
He noted that pharmacies can discuss these practices in their safety meetings and incorporate them into their medication safety plans.
“While some recommendations in the different best practices will require investment in technology improvements that may require a longer timeline of implementation, other recommendations may be implemented more quickly,” said Gaunt. “The key is for pharmacies to assess their current implementation status and plan how they will implement the various parts of the best practices now and over time.”
He said some pharmacies already have technology in place to accomplish many of these issues. However, for other pharmacies, they will need to strategically plan and work with vendors or their internal IT resources to make that leap.
For instance, many—but not all—electronic prescriptions are being transmitted to pharmacies with patient weights.
“Pharmacies can be working with their internal IT support or external vendors as well as their pharmacy staff to begin to take advantage of the provided information to establish standard work and processes to verify weight-based doses and enable more robust electronic dose-range checking,” said Gaunt.
ISMP provides a tool to help community pharmacies analyze their current status, available at apha.us/ISMPWorksheet.
For each of the best practices, the worksheet allows pharmacies to document their implementation status and detail their plan for full implementation.
Engaging staff and patients
Gaunt noted that pharmacies need to engage staff and maintain ongoing communication around these best practices and other medication safety efforts.
“And again, engage patients and caregivers as well. We all too often miss out on this opportunity. Communicate to patients and caregivers that safety is a priority. Ask for their participation in ensuring what they are receiving is correct and preventing medication errors,” said Gaunt. ■