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List of medication safety best practices grows in most recent update

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Medication Safety

Olivia C. Welter, PharmD

The Institute for Safe Medicine Practices (ISMP) updates its Targeted Medication Safety Best Practices for Hospitals list biannually. The original 6 best practices were published in 2014, with each review resulting in added guidance. The 2022–2023 edition includes 3 new best practices—highlighted below—that focus on error prevention and improving safety.

Oxytocin use

The first of the new best practices is for safeguarding against errors with oxytocin use. Oxytocin is widely used for pregnant patients in labor, and errors in its administration could cause severe medical issues. A major focus of this best practice is on process standardization. Here is what ISMP recommends for improved safety when using oxytocin:

  • Standard oxytocin prescribing order sets for labor management and control of postpartum bleeding should be required, as it removes room for prescriber error when entering orders for the drug.
  • Oxytocin concentration and bag size should be standardized for patients needing infusions in both antepartum and postpartum situations.
  • Pharmacies should maintain stock of ready-to-use bags for oxytocin infusion in their inventory, labeling the bags boldly to differentiate them from regular hydrating infusions.
  • Oxytocin infusion orders should be communicated using dose rates which are compatible with the hospital's smart infusion pump dose error-reduction system.
  • Like with all medications, hospital staff should only bring oxytocin infusion bags to the patient's room or bedside when it has been prescribed and is actively needed.

When asked why ISMP decided to focus on oxytocin specifically in this best practice, Christina Michalek, RPh, FASHP, ISMP director of membership and patient safety organization, replied that “Organizations may have adopted some of the recommendations listed. However, we were seeing room for improvement. For example, some organizations adopted a standard infusion concentration, but there were some practitioners or care settings within the organization [in which cases] the standard was not used.”

Barcode verification

While barcoding is widely implemented in inpatient settings, other types of care areas may not be using it to its fullest potential. This added best practice encourages hospitals to incorporate barcoding to the maximum extent in areas where patient stays tend to be limited. ISMP made the following recommendations related to barcoding:

  • Hospitals should specifically target clinical areas, which hold patients for short periods when implementing barcoding more universally. Such areas include EDs, perioperative areas, infusion clinics, dialysis centers, radiology areas, labor and delivery areas, catheterization laboratories, and outpatient areas.
  • Reviewing compliance and other metrics, including number of bypassed or acknowledged alerts, is an additional strategy hospitals can adopt to ensure effectiveness of the safety technology.

“Although the safeguard is commonly used in inpatient care areas, adoption tends to lag in procedural settings and other areas, particularly where there is a short or limited patient encounter. Expanding barcode verification to these areas will help to prevent errors,” said Michalek.

Layered medication safety strategies

The third and final addition to the best practices list suggests strategies that hospitals can implement and layer to maximize safety with high-alert medications. Here are the recommendations set forth by ISMP for layered safety strategies:

  • Hospitals should outline individual procedures for managing risk of each medication on the hospital's high-alert list, being sure to confront vulnerabilities within systems at each stage of the medication use process.
  • Hospital staff should focus on mid- to high-leverage risk reduction strategies to prevent errors, avoiding low-leverage strategies, which are associated with higher error rates.
  • Care teams should limit use of independent double-checks when managing high-alert medications with a high risk for error, such as chemotherapy, opioid infusions, intravenous insulin, and heparin infusions.
  • Hospitals should regularly assess aspects of their risk management practices by using information from internal sources and should additionally consult external sources such as The Joint Commission, ISMP, and FDA.
  • Hospitals should have an ongoing commitment to maintaining risk mitigation by establishing measures that can be used for monitoring safety and collecting data to determine effectiveness of implemented strategies.

“Events continue to happen in hospitals with medications that are on the hospital's list of high-alert medications,” said Michalek. “Many organizations rely primarily on midrange error-reduction strategies, such as implementing a double-check, and fail to add robust strategies throughout the entire medication use process.”



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