Targeted Medication Safety Best Practices for Hospitals

The ISMP Targeted Medication Safety Best Practices for Hospitals were developed to identify, inspire, and mobilize widespread, national adoption of consensus-based Best Practices for specific medication safety issues that continue to cause fatal and harmful errors in patients, despite repeated warnings in ISMP publications.

The Best Practice recommendations presented in this guidance document are based on error reports received through the ISMP National Medication Errors Reporting Program (ISMP MERP) and have been reviewed by an external expert advisory panel and approved by the ISMP Board of Trustees. This initiative was first launched in 2014 and is updated with additional Best Practices, as needed, every two years.

While targeted for the hospital-based setting, some Best Practices are applicable to other healthcare settings. Facilities can focus their medication safety efforts on these Best Practices, which are realistic and have been successfully adopted by numerous organizations. The Best Practice recommendations contained within this document address the following safety issues:

• VinCRIStine (and other vinca alkaloids) inadvertently administered by the intrathecal route
• Accidental daily dosing of oral methotrexate intended for weekly administration
• Missing or inaccurate patient weights, and mix-ups between metric and non-metric units when measuring and documenting weight
• Unintended intravenous administration of oral medications
• Mix-ups between milliliters and non-metric units when measuring oral liquid medications
• Eliminating glacial acetic acid from all areas of the hospital
• Inadvertent administration of neuromuscular blocking agents to patients, especially those not receiving proper ventilator assistance
• Errors when administering intravenous medication infusions
• Delay in administration or improper use of antidotes, reversal agents, and rescue agents
• Accidental administration of an intravenous infusion of sterile water
• Errors during sterile compounding of medications
• Inappropriate use of extended-release and long-acting opioids and fentaNYL patches to treat acute pain and/or patients who are opioid-naïve
• Serious tissue injuries and amputations from injectable promethazine use
• Lack of learning from external medication safety risks and errors
• Verifying and documenting patient's opioid status
• Removal of medications from automated dispensing cabinets using the "override" feature
• Errors associated with oxytocin use
• Barcode verification to care areas beyond inpatient care units
• Enact error-prevention strategies and monitor outcomes to reduce the risk of harm with high-alert medications
• Prevent wrong-route errors with tranexamic acid
• Prevent medication errors during transitions of care
• Prevent errors with vaccines