ISMP Names Top Medication Safety Issues of 2017

Given the crucial role that pharmacists play in promoting and ensuring medication safety, it is important to that they remain educated on common medication errors and ways to prevent them, according to the Institute for Safe Medication Practices (ISMP).

During a session at the American Society of Health System Pharmacists Midyear Clinical Meeting and Exhibition, Christina Michalek, PharmD, of the ISMP presented the organizations’ annual review of the year’s biggest medication safety issues.

From January 2017 to September 2017, the drug classes most often involved medication errors events included:

• Narcotics/Opioids (10%)
• Antimicrobial agents (10%)
• Antihypertensive agents (6%)
• Antithrombotic agents (6%)
• Anticonvulsant agents (4%)
• Insulin and antidiabetic agents (4%)
• Central nervous system stimulants (4%)

Of these, narcotics/opioids, antithrombotic agents, and insulin and antidiabetic agents are listed as “high alert” drugs by the ISMP, indicating that they are associated with a high risk of harm when used in error.

Focusing on errors involving opioids, Dr. Michalek highlighted improper dosing, failure to assess patient comorbidities, poor understanding of equi-analgesic potency, confusing drug names, and inadequate patient monitoring as common issues that lead to mistakes among this drug class. Additionally, she provided the following strategies for minimizing opioid-related medication errors:

• Conducting a patient assessment for all new long-acting opioid orders
• Questioning or clarifying all long-acting opioid orders in opioid-intolerant patients or for acute pain
• Implementing a restriction policy for long-acting opioids
• Setting up computer alerts
• Limiting types and strengths available in automated dispensing cabinets (ADCs)
• Utilizing barcode checks when filling ADCs
• Using tall man lettering
• Differentiating high potency and long-acting opioids
• Enhancing practitioner and patient education

As a best practice, naloxone should be made available at all patient care locations at which narcotics are stored.

Dr. Michalek also discussed the ISMP’s 2017 insulin guidelines, which recommend that providers inform patients of the type and dose of insulin they are about to receive, and that patients discharged on insulin are assessed on their understanding of their self-management.

Finally, Dr. Michalek recommended that providers use the ISMP’s medication safety self-assessment to review their compliance with best practices related to high alert medications.

Reference

Michalek C. ISMP’s Top Medication Safety Issues for 2017. Presented at: American Society of Health System Pharmacists Midyear Clinical Meeting and Exhibition. December 6, 2017. Orlando, Florida.