Implement These 3 Targeted Best Practices

The Institute for Safe Medication Practices (ISMP) has released its 2022-2023 Targeted Medication Safety Best Practices for Hospital, with which it aims to address problems that continue to cause fatal and harmful errors despite repeated warnings in ISMP publications.¹

Although the best practices might be challenging for some organizations to achieve, they are all practical and realistic and their value in reducing medication errors is grounded in expert analysis and/or scientific research on medication errors and their causes. Their implementation can vastly improve medication safety and reduce the risk of significant patient harm.

Although created for hospitals, the best practices are often applicable to other health care settings.

3 New Best Practices for 2022-2023

First released in 2014, the list, which originally included 6 best practices, is updated every 2 years and now comprises 19 best practices, including 3 newly introduced:

Best practice 17: Safeguard against errors with oxytocin use.

1. Avoid bringing oxytocin infusion bags to the patient’s bedside until it is prescribed and needed.

2. Provide oxytocin in a ready-to-use form. Boldly label both sides of the infusion bag to differentiate oxytocin bags from plain hydrating solutions and magnesium infusions.

3. Require the use of standard order sets for prescribing oxytocin antepartum and/or postpartum that reflect a standardized clinical approach to labor augmentation or induction and control of postpartum bleeding.

4. Standardize how oxytocin concentration, doses, and rates are expressed. Communicate orders for oxytocin infusions in terms of the dose rate (eg, milliunits/minute) and align with the smart infusion pump dose error-reduction system.

5. Standardize to a single bag or concentration size for both antepartum and postpartum oxytocin infusions, such as 30 units in 500 mL lactated Ringer’s.

Best practice 18: Maximize the use of barcode verification prior to medication and vaccine administration by expanding the use beyond inpatient care areas.

1. Regularly review compliance and other metric data to assess effectiveness and use of this safety technology, such as acknowledged or bypassed alerts and scanning compliance rates.

2. Specifically target clinical areas with an increased likelihood of a limited or short patient stay, such as catheterization laboratories, dialysis centers, emergency departments, infusion clinics, and labor and delivery, outpatient, perioperative, and radiology areas.

Best practice 19: Layer numerous strategies throughout the medication-use process to improve safety with high-alert medications.

1. Avoid reliance on low-leverage risk-reduction strategies, such as applying high-alert medication labels on pharmacy storage bins and providing education, to prevent errors, and instead bundle these with high- and mid-leverage strategies.

2. Ensure that the strategies address system vulnerabilities in each stage of the medication-use process (ie, prescribing, dispensing, administering, and monitoring) and apply to nurses, pharmacists, prescribers, and other practitioners involved in the medication-use process.

3. Establish outcome and process measures to monitor safety and routinely collect data to determine the effectiveness of risk-reduction strategies.

4. For each medication on the facility’s high-alert medication list, outline a robust set of processes for managing risk, affecting as many steps of the medication-use process as feasible.

5. Limit the use of independent double-checks to select high-alert medications with the greatest risk for error within the organization, such as chemotherapy, heparin and opioid infusions, and intravenous insulin.

6. Regularly assess for practices used to support the safe use of medications and risk in the systems by using information from external and internal sources, such as The Joint Commission and the ISMP.

Change to Best Practice 1

The following supplemental information is included in the rationale section of Best Practice 1: Dispense vincristine and other vinca alkaloids in a minibag of a compatible solution and not in a syringe. This was added: “In 2020, the US Food and Drug Administration (FDA) changed the prescribing information (package insert) to call for dilution in a minibag only (www.ismp.org/ node/18548). The labeling for vincristine now states: To reduce the potential for fatal medication errors due to incorrect route of administration, vincristine sulfate injection should be diluted in a flexible plastic container and prominently labeled as indicated ‘For intravenous use only—fatal if given by other routes.’ Preparation and administration of the drug in a syringe has been removed from the package insert.”

Conclusion

Health systems and hospitals should focus their medication safety efforts over the next 2 years on these 2022-2023 best practices, and other health
care providers can learn from them. The rationale for recommending the best practices, along with related ISMP guidelines and publications for additional information, is found in the full best practices document.¹ Related documents that might be helpful to hospitals include frequently asked questions² and an implementation worksheet³ that can help these institutions identify gaps in implementation of these best practices and develop an action plan to address vulnerabilities.

Michael J. Gaunt, PharmD, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Newsletter at the Institute for Safe Medication Practices in Horsham, Pennsylvania.

References

1. Targeted medication safety best practices for hospitals. Institute for Safe Medication Practices. February 9, 2022. Accessed February 14, 2022. www.ismp.org/guidelines/best-practices-hospitals

2. Frequently asked questions - targeted medication safety best practices for hospitals. Institute for Safe Medication Practices. Accessed February 14, 2022. www.ismp.org/tmsbp/faq

3. Worksheet for the targeted medication safety best practices for hospitals. Institute for Safe Medication Practices. February 9, 2022. Accessed February 14, 2022. www.ismp.org/resources/worksheet- ismp-targeted-medication-safety-best-practices-hospitals