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What’s New in the Patient Safety World

April 2020

More Gems from ISMP

 

ISMP has come out with its biweekly medication safety alerts and other valuable resources for many years. But 2 recent ISMP resources have been particularly valuable. ISMP’s Targeted Medication Safety Best Practices for Hospitals was published last month. Here are the best practices (the ISMP document has extensive details for each best practice):

 

BEST PRACTICE 1:

Dispense vinCRIStine and other vinca alkaloids in a minibag of a compatible solution and not in a syringe.

 

BEST PRACTICE 2:

a)     Use a weekly dosage regimen default for oral methotrexate in electronic systems when medication orders are entered.

b)     Require a hard stop verification of an appropriate oncologic indication for all daily oral methotrexate orders.

c)     Provide specific patient and/or family education for all oral methotrexate discharge orders.

 

BEST PRACTICE 3:

a)     Weigh each patient as soon as possible on admission and during each appropriate outpatient or emergency department encounter. Avoid the use of a stated, estimated, or historical weight.

b)     Measure and document patient weights in metric units only.

 

BEST PRACTICE 4:

Ensure that all oral liquid medications that are not commercially available in unit dose packaging are dispensed by the pharmacy in an oral syringe or an enteral syringe that meets the International Organization for Standardization (ISO) 80369 standard, such as ENFit.

 

BEST PRACTICE 5:

Purchase oral liquid dosing devices (oral syringes/cups/droppers) that only display the metric scale.

In addition, if patients are taking an oral liquid medication after discharge, educate patients to request appropriate oral dosing devices to measure oral liquid volumes in milliliters (mL) only.

 

BEST PRACTICE 6: (ARCHIVED)

Eliminate glacial acetic acid from all areas of the hospital.

While still important as a Best Practice, compliance with recommendations for an archived Best Practice signal that focus can be directed toward new and other existing Best Practices with lower adoption rates. Archived Best Practices maintain their original Best Practice number but will be listed after the unarchived Best Practices.

 

BEST PRACTICE 7:

Segregate, sequester, and differentiate all neuromuscular blocking agents (NMBs) from other medications, wherever they are stored in the organization.

 

BEST PRACTICE 8:

a)     Administer medication infusions via a programmable infusion pump utilizing dose error-reduction systems.

b)     Maintain a 95% or greater compliance rate for the use of dose error-reduction systems.

c)     Monitor compliance with use of smart pump dose error-reduction systems on a monthly basis.

d)     If your organization allows for the administration of an IV bolus or a loading dose from a continuous medication infusion, use a smart pump that allows programming of the bolus (or loading dose) and continuous infusion rate with separate limits for each.

 

BEST PRACTICE 9:

Ensure all appropriate antidotes, reversal agents, and rescue agents are readily available. Have standardized protocols and/or coupled order sets in place that permit the emergency administration of all appropriate antidotes, reversal agents, and rescue agents used in the facility. Have directions for use/administration readily available in all clinical areas where the antidotes, reversal agents, and rescue agents are used.

 

BEST PRACTICE 10:

Eliminate all 1,000 mL bags of sterile water (labeled for “injection,” “irrigation,” or “inhalation”) from all areas outside of the pharmacy.

 

BEST PRACTICE 11:

When compounding sterile preparations, perform an independent verification to ensure that the proper ingredients (medications and diluents) are added, including confirmation of the proper amount (volume) of each ingredient prior to its addition to the final container.

 

BEST PRACTICE 12: (INCORPORATED INTO NEW BEST PRACTICE 15)

Eliminate the prescribing of fentaNYL patches for opioid-naïve patients and/or patients with acute pain.

 

BEST PRACTICE 13:

Eliminate injectable promethazine from the formulary.

 

BEST PRACTICE 14:

Seek out and use information about medication safety risks and errors that have occurred in other organizations outside of your facility and take action to prevent similar errors.

 

NEW BEST PRACTICE 15:

Verify and document a patient’s opioid status (naïve versus tolerant) and type of pain (acute versus chronic) before prescribing and dispensing extended-release and long-acting opioids.

 

NEW BEST PRACTICE 16:

a)     Limit the variety of medications that can be removed from an automated dispensing cabinet (ADC) using the override function.

b)     Require a medication order (e.g., electronic, written, telephone, verbal) prior to removing any medication from an ADC, including those removed using the override function.

c)     Monitor ADC overrides to verify appropriateness, transcription of orders, and documentation of administration.

d)     Periodically review for appropriateness the list of medications available using the override function.

 

 

Earlier this year, ISMP released its Top 10 Medication Errors and Hazards (ISMP 2020). Here is the list:

  1. Selecting the wrong medication after entering the first few letters of the drug name
  2. Daily instead of weekly oral methotrexate for non-oncologic conditions
  3. Errors and hazards due to look-alike labeling of manufacturers’ products
  4. Misheard drug orders/recommendations during verbal/telephone communication
  5. Unsafe “overrides” with automated dispensing cabinets
  6. Unsafe practices associated with adult IV push medications
  7. Wrong route (intraspinal injection) errors with tranexamic acid
  8. Unsafe labeling of prefilled syringes and infusions by 503b compounders
  9. Unsafe use of syringes for vinca alkaloids
  10. 1,000-fold overdoses with zinc

 

We’re pleased that we have covered virtually all these topics over the years, but ISMP has done a superb job of putting this all together in a concise, informative format. Download the documents from the ISMP site and make sure your hospital or other healthcare facility is following these best practices.

 

 

References:

 

 

ISMP (Institute for Safe Medication Practices). Targeted Medication Safety Best Practices for Hospitals. ISMP 2020; February 21, 2020

https://www.ismp.org/guidelines/best-practices-hospitals

 

 

ISMP (Institute for Safe Medication Practices). Start the New Year Off Right by Preventing These Top 10 Medication Errors and Hazards. ISMP 2020; January 16, 2020

https://www.ismp.org/resources/start-new-year-right-preventing-these-top-10-medication-errors-and-hazards

 

 

 

 

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