Guidelines

Targeted Medication Safety Best Practices for Hospitals

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

The consensus 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 setting, some best practices may be 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
  • Accidental topical application of glacial acetic acid
  • Inadvertent administration of neuromuscular blocking agents to patients not receiving proper ventilator assistance
  • Infusion-related errors when administering high-alert intravenous medications
  • 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 drugs, especially high-alert medications
  • Inappropriate use of 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

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