Quality & Patient Safety

ISMP's targeted medication safety best practices for 2017

Patient Safety Monitor, March 8, 2017

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Editor’s note: The Institute for Safe Medication Practices (ISMP) released its 2016–2017 Targeted Medication Safety Best Practices for Hospitals guide in December 2015. The first edition of the best practices came out in December 2013 and addressed specific medication safety issues identified by ISMP as causing fatal and harmful errors. This year there were five new best practices and two revised out of 11 total. Each of the best practices have been reviewed by an external expert advisory panel and approved by the ISMP Board of Trustees. Darryl Rich, PharmD, MBA, FASHP, is an ISMP medication safety specialist who spoke with PSMJ about the best practices.

PSMJ: Is there a difference between “targeted medication safety” and “medication safety,” or are the two synonymous?
Rich: No, they are not. First of all, medication safety has a lot of issues and a lot of strategies that can be used to prevent errors. And these [issues that the best practices are designed to prevent] are ones that are specifically and continuously reported as harmful or fatal to patients over 10 years or more by ISMP. We wanted people to focus on these specific best practices as a priority, [along with] all the other things we recommend.

PSMJ: Do you get numbers on how many facilities use your guidelines?
Rich: We have no idea. We put them out there and distribute them, but we have no way of knowing how many hospitals are using them. Hopefully, a lot. 

PSMJ: Have incidents of medication errors increased, decreased, or remained level over the last five years or so? What factors do you think caused this?
Rich: For a lot of these—because we were looking specifically at harmful or fatal events—there weren’t big numbers to begin with. Originally, there may have been four or five deaths caused by incidents that the best practice should help prevent. But those are four or five deaths that could have been prevented.

Looking at actual numbers of medication errors that have been reported in the past few years, we’ve had no deaths reported for any of these issues for the targeted best practices since they were released. Some of them were released in December 2013 and the other group was released in December 2015.

We have seen some “near misses” that have occurred related to neuromuscular blockers, vincristine, and sterile compounding. These occurred in hospitals that did not implement the best practices. Of interest, we had four cases of errors reported related to oral methotrexate, but these occurred in retail pharmacies, not hospitals.

We routinely conduct surveys of how many [organizations] have implemented the best practices. For specific best practices, we’re seeing an implementation rate as low as 33% to a high of 96%.

Certainly ones that require a technology change such as a hard stop verification of daily doses of oral methotrexate in their computer system, using metric weights, or using automation for sterile compounding tend to have the lowest rates of compliance.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Patient Safety Monitor.

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