News Release

ISMP Issues New Guidelines for Safe Electronic Communication of Medication Information

Strategies Provided for Dealing with Potential Confusion

The Institute for Safe Medication Practices (ISMP) has released new Guidelines for Safe Electronic Communication of Medication Information to help healthcare practitioners navigate implementation of electronic health records, electronic prescribing, and other health information technology. The guidelines identify potential medication safety issues and provide recommendations for avoiding potential confusion that is unique to electronic communication in both inpatient and outpatient settings.

While health information technologies are now a mainstay in healthcare, they have had an impact on how medications are prescribed, dispensed, and administered.  If the conventions used to communicate medication information electronically are not carefully considered, these technologies may contribute to medication errors rather than mitigate risks. Examples of issues with electronic communication that have resulted in medication errors include: misinterpretation of symbols, dose designations, and abbreviations; unsafe defaults used to prepopulate fields with missing data (for example, default to number of teaspoons to administer rather than mL); and restricted character spaces or truncated listings that make it impossible to communicate the full name and dose of a medication.

ISMP’s new guidelines address safely communicating about medications when working with electronic formats including electronic health records (EHRs), pharmacy computer systems, e-prescribing systems, and other displays of electronic health information when using medication administration records, barcode scanning systems, smart infusion pumps, and automated dispensing cabinets (ADCs).

The guidelines provide specific recommendations for the safe presentation of electronic information in the following categories:

  • Drug names

  • Doses, dosing units, weights and measures, and directions

  • Product selection menus and search choices

  • Complete medication orders or prescriptions

  • Medication information

  • Patient information associated with medication safety

Clinicians and more than 50 healthcare organizations and groups, including federal and state government agencies, professional associations, electronic information vendors, standards-setting organizations, and international organizations commented on the draft guidelines.

Click here to download a copy of the ISMP Guidelines for Safe Electronic Communication of Medication Information.

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