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Still Outside the Bull’s Eye: 2014-2015 Targeted Medication Safety Best Practices (Baseline Survey Results)

In the January 16, 2014, newsletter issue, we introduced the 2014-2015 Targeted Medication Safety Best Practices for Hospitals. The purpose of the Targeted Medication Safety Best Practices is to identify, inspire, and mobilize national adoption of consensus-based best practices related to medication safety issues that continue to cause harmful and fatal errors, despite repeated warnings from ISMP and others. To monitor the effectiveness of this effort over the next 2 years, we conducted a short survey of US hospitals during the first quarter of 2014 to get a sense of the current level of implementation of these best practices as a baseline measure. Table 1 summarizes the survey findings from 483 respondents. Additional details are provided below.

TMSBP implementation

Respondent profile. About half (52%) of all respondents work in non-academic, non-government, non-profit hospitals. Nine percent work in for-profit hospitals, 9% work in government-owned hospitals, 20% work in academic hospitals, and 10% work in critical access hospitals. About two-thirds (69%) of the respondents were pharmacists, and about a quarter (28%) were nurses. The remaining respondents (3%) were physicians or hospital administrators. Survey responses from respondents who did not know the level of implementation of the best practice, or thought a best practice was not applicable, were not included in the analysis. 

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

About half (53%) of participating respondents reported full implementation of this best practice. Those who reported partial implementation (10%, calculated by combining responses D and E in Table 1) noted more frequent adoption of the practice with vinCRIStine than other vinca alkaloids, with more adult patients than pediatric patients, and with more inpatients than outpatients. Most respondents who were actively planning implementation (7%) anticipated completion within the next few months. 

Respondents from hospitals where a decision was made to NOT implement the best practice (8%) cited a variety of reasons, most frequently believing that other safeguards in place were sufficient, including a time out process prior to administration of intrathecal medications, dispensing vinca alkaloids in a large syringe, or taking other steps to differentiate the appearance of intrathecal medications. Difficulty gaining physician and nurse support for the practice was also noted, particularly for pediatric patients in regards to the risk of extravasation. One hospital noted that vesicant drug policies stipulated administration through a central line, and prescribers were hesitant to place a central line in all patients receiving vinCRIStine. Multiple respondents reported that the practice would NOT be implemented in their hospitals because it was inconvenient or unnecessary given the absence of any events at their facility.

ISMP comments. Evidence of misadministration of IV vinCRIStine by the intrathecal route has happened despite all other safeguards except administration in a minibag. See our September 5, 2013, newsletter article, Death and neurological devastation from intrathecal vinca alkaloids: Prepared in syringes = 120; Prepared in minibags = 0. If you experience difficulty in gaining support for implementing this practice with pediatric patients, view our Frequently Asked Questions (link at end of article) that provide evidence of the practice’s safety in regards to extravasation. Information is also available regarding safety via peripheral administration.   

2a. Use a weekly dosage regimen default for oral methotrexate. If overridden to daily, require a hard stop verification of an appropriate oncologic indication. 

About a quarter (28%) of respondents reported full implementation of this best practice. Most respondents who reported partial implementation (19%) indicated that order entry systems defaulted to a weekly dosage regimen but did not require a hard stop if the regimen was changed to a daily schedule. For hospitals in the planning stages (13%), many respondents anticipated implementation in March 2014. A few respondents reported that implementation would be delayed because their hospitals were involved in large-scale technology upgrades that needed to be implemented first.

The primary reasons cited by respondents in the few hospitals (2%) deciding NOT to implement the practice included the inability to set up a hard stop in current order entry systems or a belief that the best practice is not practical or necessary if treating mostly cancer patients.

ISMP comments. Be persistent with vendors when requesting the ability to build a hard stop related to daily methotrexate dosing. Also, while the focus of this best practice is to reduce errors when methotrexate is prescribed for non-oncologic conditions, the same medication safety practices should apply to all patient care settings, including cancer centers. Even when used for oncologic purposes, methotrexate is sometimes prescribed as a weekly regimen, not daily.

2b. Provide patient education by a pharmacist for all weekly oral methotrexate discharge orders. Provide patients with a drug information leaflet that contains clear instructions about weekly dosing, such as the free ISMP consumer leaflet.

Only 11% of respondents reported full implementation of this best practice, and just 11% reported partial implementation. Respondents reporting partial implementation noted that education was provided to patients in some areas of the hospital where a clinical pharmacist was readily available. However, many respondents commented that written information was not provided to patients during the educational sessions, or that the information provided was not clearly defined or organized. A few respondents also reported that educational efforts were inconsistent in their hospitals. Those actively planning to implement the best practice (13%) mostly anticipated completion by the fall of 2014.

A decision to NOT implement this best practice was made by 3% of respondents who reported inadequate resources, particularly pharmacy staff. Several respondents mentioned that nurses educate patients prior to discharge, or that the patient population does not support the need for education by a pharmacist.

ISMP comments. In many hospitals, the frequency of patients discharged on weekly methotrexate should be manageable for typical pharmacy staffing to facilitate education by a pharmacist on this crucial topic. A free consumer leaflet to standardize and support the education can be found at the end of this article.

3. Measure and express patient weights in metric units only. Ensure that scales used for weighing patients are set and measure only in metric units (kg, g). If scales can measure in pounds and kilograms/grams (kg/g), modify the scale to lock out the ability to weigh in pounds. Document weights using metric designations only. Use measured weight, not stated, historical, or estimated weight.

One-third (33%) of survey participants reported full implementation of this best practice. Respondents who reported partial implementation (36%) most often cited these barriers: 1) the inability to completely lock out or eliminate the measurement and documentation of weights in pounds with scales that measure in both kg/g and pounds, or with electronic prompts that allow entry of either measure; and 2) over-reliance on stated, estimated, or historical weights. Several respondents also mentioned difficulties with specialty beds that only weigh in pounds. Hospitals currently planning to implement the strategy (6%) suggested a timeline consistent with the arrival of new scales or updated technology, particularly in the fourth quarter of 2014. Respondents who work in hospitals where a decision was made to NOT implement this best practice (7%) cited as reasons the inability to lock out weights measured or displayed in pounds on scales and computer systems, and a belief that patients and parents of pediatric patients want to know their (or their child’s) weight in pounds, not kg or g. Numerous others cited lack of support for the best practices from nurses as well as hospital leadership, who believe clinicians and patients still think in terms of pounds, not metric units. ISMP comments: Pound to kg/g conversion charts should be available for nurses and other healthcare personnel to use when discussing measured weights with the patient and family. Having patients ask for their weight in pounds should not be a barrier to collecting and documenting the information in metric units. More on this topic and suggestions for managing other barriers to the best practice can be found at: www.ismp.org/sc?id=317

4. Ensure that all oral liquids that are not commercially available as unit dose products are dispensed by the pharmacy in an oral syringe. Use of an auxiliary label, “For oral use only,” is preferred if it does not obstruct critical information. Ensure that oral syringes do not connect to parenteral tubing in the hospital.

About half (52%) of survey participants reported full implementation of this best practice. Respondents who reported partial implementation (34%) still dispense bulk bottles or dosing cups for medications such as antibiotics, antacids, and certain controlled substances (e.g., methadone). Some respondents reported the use of bulk bottles or dosing cups for some medications for adults, although all oral liquid medication doses for pediatric patients were dispensed in oral syringes. A few participants felt that the oral syringes were not clearly labeled to alert staff that the drug is “For oral use only.” Several respondents also reported a few exceptions to the best practice; for example, one hospital dispenses acetaminophen in its original bottle, which is sent home with the patient upon discharge. Another respondent reported keeping a few oral liquid medicines in their original packaging, as recommended by the manufacturer. Respondents actively planning implementation of the practice (4%) anticipated completion within 6 months. Respondents who reported their hospitals will NOT be implementing the best practices (3%) cited storage issues and potential waste of pharmacy batched prefilled syringes, infrequent use of oral liquid medications, and disruption in pharmacy workflow or staffing shortages associated with pharmacy preparation of the syringes. One respondent reported that dose cups are used for all liquid medications after at least one error in which nurses, who were not familiar with seeing or using oral syringes, mistakenly thought an oral syringe contained a parenteral product and transferred the drug to a parenteral syringe for administration. ISMP comments. Education regarding the purpose and use of oral syringes should be provided during orientation of all professional staff who administer medications. Dispensing patient-specific doses in a unit dose cup is an acceptable practice. However, the risk with this practice is that nurses may draw the oral solution into a parenteral syringe for administration, which could lead to inadvertent misadministration and patient harm. Thus, the best practice is to dispense patient-specific doses in an oral syringe. For more information on this topic, visit: www.ismp.org/sc?id=318.

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

Approximately 39% of survey participants reported full implementation of this best practice. Respondents reporting partial implementation (17%) of the best practice noted that hospitals are exhausting the current supply of dosing devices before distributing the new devices. Those actively planning implementation of the best practices (9%) cited a timeline that began as soon as dosing devices with only metric units were available and purchased. Respondents who reported their hospitals will NOT be implementing these best practices (4%) provided several reasons: the current purchasing vendor under contract has been unable to find dosing devices with only metric measurements, and staff believe it is important to teach parents to measure doses using an oral syringe with both metric and non-metric designations, stating that parents understand teaspoon and tablespoon measurements better than metric designations. ISMP comments. Please see our Frequently Asked Questions (www.ismp.org/sc?id=319) for examples of vendors with dosing cups and oral syringes that display metric units only.

6. Eliminate glacial acetic acid from all areas of the hospital (laboratory excluded if the glacial acetic acid is purchased directly from an external source). Replace glacial acetic acid with vinegar (5% solution) or commercially available acetic acid 0.25% (for irrigation) or 2% (for otic use).

Almost three-quarters (74%) of survey participants have fully implemented this best practice, and another 8% reported partial implementation. Respondents who reported partial implementation felt glacial acetic acid was needed in the pharmacy to compound certain products (e.g., 6% dermatological solution). For hospitals in the planning stages (5%), most respondents anticipated implementation by March 2014. Only 1 survey participant reported that his or her hospital will NOT be implementing this best practice.

ISMP comments. If glacial acetic acid must be used in the laboratory or for research in non-patient care areas, see our Frequently Asked Questions (www.ismp.org/sc?id=320) for recommendations to promote safety.

Conclusion. We truly appreciate everyone’s participation in this baseline survey. Overall, ISMP was pleased to learn that, for many, the Targeted Best Practices have been accomplished or are on their to-do list. However, it was disappointing to learn the extent to which other respondents had not at least partially implemented important practices recommended by ISMP and other safety organizations for years. We are also disappointed to see that some organizations do not intend to pursue the best practices, we presume largely because they fail to perceive the immense risk they are taking without implementing the strategies. The 2014-2015 Targeted Medication Safety Best Practices were selected by a well-informed, expert advisory group that, like ISMP, felt these practices were critical to patient safety, highly effective, and achievable without significant capital expenditures. We strongly encourage ALL US hospitals to adopt these practices.


If you have questions or want to share an implementation strategy, policy, or guideline that we can recommend to others, please contact ISMP at: [email protected].