Survey Shows Room for Improvement with Three New Best Practices for Hospitals

In our February 10, 2022 newsletter, we invited hospitals to participate in a short survey to establish a baseline of implementation for the three new Best Practices released in the 2022-2023 ISMP Targeted Medication Safety Best Practices for Hospitals. The three new Best Practices are associated with safeguarding against errors with oxytocin use (#17), expanding the use of barcode verification beyond inpatient care areas (#18), and improving safety with high-alert medications (#19). We want to sincerely thank the hospitals that participated in our survey and shared their valuable lessons learned regarding the barriers and enablers to implementation of the new Best Practices. An overview of the survey findings is presented in Table 1 and detailed below.

Respondent Profile

One hundred eighty-eight (N = 188) hospitals participated in our Best Practices survey. Nearly one-third (30%) of the hospitals were large with 500 beds or more; 21% had 300-499 beds; 27% had 100-299 beds; 16% had 26-99 beds; and 6% had 25 beds or less. Overall, more than two-thirds of responding hospitals reported employing one or more part- or full-time medication safety officer(s) (MSO). The percentage of hospitals with an MSO was higher in large hospitals with 500 beds or more (98%) when compared to hospitals with 499 beds or less (63%). With few exceptions, large hospitals with more than 500 beds, especially those with an MSO, reported higher levels of implementation for expanding the use of barcode technology (#18) and layering strategies to improve the safety of high-alert medications (#19). However, small hospitals with less than 100 beds and mid-sized hospitals with 100-499 beds reported higher levels of implementation for safeguarding against errors with oxytocin use (#17).

New Best Practice 17: Safe Oxytocin Use

New Best Practice #17 consists of five interventions designed to improve the safe use of oxytocin. The first intervention recommends the use of standard order sets for prescribing oxytocin antepartum and/or postpartum that reflect a standardized approach to labor induction or augmentation and the control of postpartum bleeding. Eighty-three percent of hospitals reported full implementation. All small hospitals with less than 100 beds reported full implementation. Anesthesia staff resistance to using a standard order set was the most frequently cited barrier to implementation, as were allowing prescribers to bypass the order set and accepting free-text orders. The most frequent enablers were the implementation of a systemwide standard order set and leadership requiring its use.

The second intervention recommends standardizing to a single concentration and bag size for both antepartum and postpartum oxytocin infusions. Overall, 84% of hospitals reported full implementation, with most respondents using a standard concentration of 30 units of oxytocin per 500 mL of lactated ringer’s or 0.9% sodium chloride for both antepartum and postpartum infusions. Anesthesia staff resistance to using a single concentration for both purposes was the most frequently cited barrier to implementation. A few respondents also reported “supply issues” as a barrier, although 2020 was the last time oxytocin vials were reported to be in short supply. The most frequent enabler was to offer a single concentration in the electronic prescribing system and infusion pump drug library.

The third intervention recommends standardizing how oxytocin doses, concentrations, and rates are expressed; and communicating orders in terms of the dose rate, aligning this with the smart pump dose error-reduction system (DERS). For standardizing the expression of oxytocin doses, concentrations, and rates, 80% of hospitals reported full implementation. Small hospitals with less than 100 beds (92%) reported full implementation more often than hospitals with 100 beds or more (76%). The primary barrier to implementation was allowing different dosing based on the drug’s indication (e.g., milliunits/minute for labor induction; units/hour for labor augmentation; mL/hour for postpartum bleeding). The most frequent enabler was to standardize the dosing units and concentration in order sets and the smart pump drug library. For communicating orders in terms of the dose rate and aligning this with smart infusion pump DERS, 82% of hospitals reported full implementation. The most frequently cited barrier was excluding oxytocin from infusion pump interoperability due to workflow challenges. Several respondents reported that reviewing oxytocin dose rate data during monthly meetings enabled them to address orders that were not communicated as a dose rate.

The fourth intervention recommends providing oxytocin in a ready-to-use form, as well as boldly labeling both sides of the infusion bag to differentiate oxytocin bags from plain hydrating solutions and magnesium infusions. Eighty-six percent of hospitals reported full implementation for providing oxytocin in a ready-to-use form (premixed by pharmacy or an outsourcer). Full implementation was greatest in small hospitals with less than 100 beds (92%), large hospitals with more than 500 beds (95%), and hospitals with an MSO (91%). Only 75% of hospitals without an MSO reported full implementation. Unavailability of a commercially available manufacturer premixed infusion and “supply issues” were cited as barriers to implementation. Enablers were requiring the pharmacy to prepare all infusions or purchasing premixed infusions from a compounding company. However, purchasing infusions from a compounding company was frequently listed as a barrier to labeling both sides of the infusion bag since compounders only label one side. Only 36% of hospitals reported full implementation of labeling both sides of the infusion bag.

The fifth intervention recommends not bringing an oxytocin infusion bag to the patient’s bedside until it is prescribed and needed. Fifty-seven percent of hospitals reported full implementation, while another 36% reported partial implementation. Full implementation was greatest in hospitals with an MSO (59%) when compared to hospitals without an MSO (45%). Frequently cited barriers to implementation included nurse staffing shortages; nursing preference to have emergency medications in the patient’s room; and the inability to leave the patient to retrieve an oxytocin infusion. No enablers were reported.

New Best Practice 18: Expand Barcode Scanning Technology

New Best Practice #18 consists of two interventions to expand the use of barcode verification prior to medication and vaccine administration beyond inpatient care areas. The first intervention recommends targeting clinical areas with a short or limited patient stay. Overall, approximately two-thirds to three-quarters of hospitals reported full implementation of barcode technology in infusion clinics (76%), post-anesthesia care units (73%), labor and delivery (72%), dialysis centers (67%), emergency departments (65%), and perioperative holding areas (63%). Lower levels of full implementation were reported in radiology (31%), cardiac catheterization labs (23%), procedure rooms (16%), and operating rooms (7%).

Only barriers to this intervention were reported, most frequently related to resource constraints, such as: lack of scanners or lack of space; information technology issues; insufficient staffing, particularly pharmacists; or workflow issues such as one-step prescribing and administration and lack of electronic order entry. Some of the barriers were related to specific outpatient locations, such as concerns about sterility and inaccessible patients’ identification bands in the operating room, and concerns about metal objects and the absence of barcodes on radiopharmaceuticals in radiology. Because no enablers for expanding barcode technology in limited-stay locations were provided by survey respondents, ISMP is collaborating with a health system to describe how they achieved full implementation of this technology in their operating and procedure rooms. Look for this article to appear in this newsletter within the next few months.

The second intervention with Best Practice #18 recommends regularly reviewing barcode scanning compliance rates and other metrics (e.g., bypassed or acknowledged alerts) to assess the utilization and effectiveness of this safety technology. For hospitals that had partially or fully implemented barcode technology in various limited-stay locations, 69% reported full implementation and 31% reported partial implementation for reviewing compliance and alert data. However, a few respondents said they were unable to tell whether compliance data reflected scanning before or after drug administration.

New Best Practice 19: Safe Use of High-Alert Medications

New Best Practice #19 consists of six interventions to improve the safe use of high-alert medications by layering strategies throughout the medication-use process. Very few hospitals reported no implementation of these interventions. Additionally, some respondents noted that the California (CA) Medication Error Reduction Plan (MERP) mandates some of the specific interventions associated with Best Practice #19.

The first intervention recommends creating a robust set of processes for managing risk for each medication on the facility’s high-alert medication list, impacting as many steps of the medication-use process as feasible. Sixty-four percent of hospitals reported full implementation and 35% reported partial implementation. Full implementation was greatest in large hospitals with 500 beds or more (77%) and lowest in mid-sized hospitals with 100 to 499 beds (57%). Numerous respondents noted that this was a time-consuming process, making it difficult to assess each drug on their high-alert medication list. Others reported that they had completed the task by prioritizing their list and addressing the highest priority drugs first. Several respondents said it was helpful to post guidance on managing the risks of high-alert medications in an accessible electronic format.

The second intervention recommends addressing system vulnerabilities at each stage of the medication-use process and ensuring that the strategies apply to prescribers, pharmacists, nurses, and other practitioners involved in the medication-use process. Sixty-three percent of hospitals reported full implementation and 36% reported partial implementation. Survey respondents reported that some phases of the medication-use process were easy to overlook if internal errors had not occurred in these phases.

The third intervention recommends the avoidance of relying only on low-leverage risk-reduction strategies (e.g., providing education) to prevent errors, and instead, bundling these with mid- and high-leverage strategies. Hospitals were split between full (51%) and partial (49%) implementation. Full implementation was greatest in large hospitals with 500 beds or more (76%) and in hospitals with an MSO (60%). Only 27% of hospitals without an MSO reported full implementation. Respondents only reported barriers to implementation, including medication technology costs and limitations, and lack of leadership support. A few respondents also noted their overreliance on high-alert medication labels, a low-leverage strategy.

The fourth intervention recommends limiting the use of independent double checks to select high-alert medications with the greatest risk for error within the organization. Sixty-six percent of hospitals reported full implementation and 31% reported partial implementation. Full implementation was greatest in mid-sized hospitals (76%). Only 47% of large hospitals with 500 beds or more reported full implementation. Respondents reported several barriers to limiting the use of independent double checks, including pediatric medication safety requirements and the need to standardize practices within a health system. Several respondents thought that electronically controlling the completion and documentation of independent double checks best enabled them to limit their use.

The fifth intervention recommends regularly assessing for risk by using information from internal and external sources. More than two-thirds (69%) of hospitals reported full implementation, and the remaining hospitals (31%) reported partial implementation. Full implementation was greatest for large hospitals with 500 beds or more (81%) and in hospitals with an MSO (74%). Only 56% of small hospitals with fewer than 100 beds and 59% of hospitals without an MSO reported full implementation. Only enablers to implementation were provided by respondents, including scheduling the review of both internal and external information at medication safety meetings, making the review a standing agenda item, and listing various reputable sources of external information, including the ISMP quarterly Action Agenda and National Alert Network (NAN) alerts.    

The sixth intervention recommends establishing outcome and process measures to monitor medication safety and routinely collecting data to determine the effectiveness of risk-reduction strategies. This intervention had the lowest rate of implementation for Best Practice #19, with only 41% reporting full implementation, 53% reporting partial implementation, and 6% reporting no implementation. Full implementation was greatest in hospitals with an MSO (45%) when compared to hospitals without an MSO (27%). The most frequent barrier to full implementation was an overreliance on internal voluntary reporting systems to assess and monitor medication safety.

Conclusion

These survey results suggest there is room for improvement with the three new Best Practices. We hope that hospitals use the survey results to prompt interdisciplinary discussions and take note of the barriers and enablers to implementation of these Best Practices. An Implementation Worksheet for all of the Best Practices is available and might be helpful to document your assessment of implementation status, actions required, and assignments.