Three New Best Practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals

ISMP has released its 2022-2023 Targeted Medication Safety Best Practices for Hospitals. The purpose of these Best Practices is to identify, inspire, and mobilize widespread, national adoption of consensus-based Best Practices in hospitals to address recurring problems that continue to cause fatal and harmful errors, despite repeated warnings in ISMP publications. The Best Practices, which are reviewed by an external expert advisory panel and approved by the ISMP Board of Directors, represent high-leverage error-reduction strategies, many of which have already been successfully adopted by hospitals. While the Best Practices might be challenging for some organizations to achieve, they are all practical and realistic, and their value in reducing medication errors is grounded in scientific research and/or expert analysis of medication errors and their causes. Their implementation can vastly improve medication safety and reduce the risk of significant patient harm. Keep in mind, while these Best Practices were created for hospitals, they are often applicable to other healthcare settings.

Three New Best Practices for 2022-2023

Initially introduced in 2014 with six Best Practices, the Targeted Medication Safety Best Practices for Hospitals are updated every 2 years. The 2022-2023 list now comprises 19 Best Practices, including the three new Best Practices described below.

New Best Practice 17: Safeguard against errors with oxytocin use.

1. Require the use of standard order sets for prescribing oxytocin antepartum and/or postpartum that reflect a standardized clinical approach to labor induction/augmentation and control of postpartum bleeding.

2. Standardize to a single concentration/bag size for both antepartum and postpartum oxytocin infusions (e.g., 30 units in 500 mL Lactated Ringers).

3. Standardize how oxytocin doses, concentration, and rates are expressed. Communicate orders for oxytocin infusions in terms of the dose rate (e.g., milliunits/minute) and align with the smart infusion pump dose error-reduction system (DERS).

4. Provide oxytocin in a ready-to-use form. Boldly label both sides of the infusion bag to differentiate oxytocin bags from plain hydrating solutions and magnesium infusions.

5. Avoid bringing oxytocin infusion bags to the patient’s bedside until it is prescribed and needed.

New Best Practice 18: Maximize the use of barcode verification prior to medication and vaccine administration by expanding use beyond inpatient care areas.

1. Specifically target clinical areas with an increased likelihood of a short or limited patient stay (e.g., emergency department, perioperative areas, infusion clinics, dialysis centers, radiology, labor and delivery areas, catheterization laboratory, outpatient areas).

2. Regularly review compliance and other metric data to assess utilization and effectiveness of this safety technology (e.g., scanning compliance rates; bypassed or acknowledged alerts).

New Best Practice 19: Layer numerous strategies throughout the medication-use process to improve safety with high-alert medications.

1. For each medication on the facility’s high-alert medication list, outline a robust set of processes for managing risk, impacting as many steps of the medication-use process as feasible.

2. Ensure that the strategies address system vulnerabilities in each stage of the medication-use process (i.e., prescribing, dispensing, administering, and monitoring) and apply to prescribers, pharmacists, nurses, and other practitioners involved in the medication-use process.

3. Avoid reliance on low-leverage risk-reduction strategies (e.g., applying high-alert medication labels on pharmacy storage bins, providing education) to prevent errors, and instead bundle these with mid- and high-leverage strategies.

4. Limit the use of independent double checks to select high-alert medications with the greatest risk for error within the organization (e.g., chemotherapy, opioid infusions, intravenous [IV] insulin, heparin infusions).

5. Regularly assess for risk in the systems and practices used to support the safe use of medications by using information from internal and external sources (e.g., The Joint Commission, ISMP).

6. Establish outcome and process measures to monitor safety and routinely collect data to determine the effectiveness of risk-reduction strategies.

Survey to Measure Baseline Implementation of New Best Practices

ISMP is conducting a short survey to obtain a baseline measurement of the current level of implementation of these three new Best Practices. We would sincerely appreciate your participation in this survey, regardless of whether you have implemented the Best Practices. Please complete the online survey by April 1, 2022. The survey questions are provided on pages 5 and 6 of the PDF version for your review prior to taking the online survey.

Additional Changes for 2022-2023

In addition to updating the references to newer ISMP Medication Safety Alert! newsletter publications where more information can be found for each Best Practice, the following supplemental information was included in the Rationale section of Best Practice 1: Dispense vinCRIStine and other vinca alkaloids in a minibag of a compatible solution and not in a syringe (additional information italicized below):

In 2020, the US Food and Drug Administration (FDA) changed the prescribing information (package insert) to call for dilution in a minibag only. The labeling for vinCRIStine now states: To reduce the potential for fatal medication errors due to incorrect route of administration, vinCRIStine sulfate injection should be diluted in a flexible plastic container and prominently labeled as indicated “FOR INTRAVENOUS USE ONLY—FATAL IF GIVEN BY OTHER ROUTES.” Preparation and administration of the drug in a syringe has been removed from the package insert.

Three Best Practices have been archived with the 2022-2023 update, joining another previously archived Best Practice (#6, Eliminate glacial acetic acid from all areas of the hospital):

Archived Best Practice 4: Ensure that all oral liquid medications that are not commercially available in unit dose packaging are dispensed by the pharmacy in an oral syringe or an enteral syringe that meets the International Organization for Standardization (ISO) 80369 standard, such as ENFit.

Archived Best Practice 5: Purchase oral liquid dosing devices (oral syringes/cups/droppers) that only display the metric scale.

Archived Best Practice 10: Eliminate all 1,000 mL bags of sterile water (labeled for “injection,” “irrigation,” or “inhalation”) from all areas outside of the pharmacy.

ISMP created a Best Practice “archive” designation in 2020. While archived Best Practices are still important and may not be fully implemented in all US hospitals, the “archive” designation signals that focus can be directed toward new and other existing Best Practices that have lower adoption rates. Archived Best Practices maintain their original Best Practice numbers.

Prior Survey Results

Prior to releasing the 2022-2023 Targeted Medication Safety Best Practices for Hospitals, ISMP conducted a survey between May and June 2021 to measure the progress with implementing the existing 2020-2021 Best Practices. These results were presented at the American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting on December 8, 2021. In case you missed that presentation, we have provided an overview of the survey findings in Table 1.

Most of the respondents who participated in the 2021 survey were from large US hospitals with more than 100 beds (82%), and nearly two-thirds (61%) had employed one or more full- or part-time medication safety officer(s) (MSO[s]). Comparing the 2021 survey findings to previous survey findings in 2019 (for Best Practices 1 through 14) and 2020 (for Best Practices 15 and 16), the percentage of respondents reporting full compliance with the Best Practices increased, stayed the same, or only went down a few percentage points. However, there was one exception. Between 2019 and 2021, full compliance with Best Practice 8 (Administer medication infusions via a programmable infusion pump with a DERS) decreased from 85% (2019) to 72% (2021). The decrease in full compliance might be due to the fact that, in 2020, this Best Practice was expanded to include all medication infusions, while in 2019, the Best Practice was limited to high-alert medication infusions.  

Conclusion

Hospitals and health systems should focus their medication safety efforts over the next 2 years on these 2022-2023 Best Practices. The rationale for recommending the Best Practices, along with related ISMP publications and guidelines for additional information, can be found in the full document. Related documents that might be helpful to hospitals include Frequently Asked Questions (FAQs) and an Implementation Worksheet that can help hospitals identify gaps in implementation of these Best Practices and develop an action plan to address vulnerabilities. Also, please do not forget to complete our short survey on the three new Best Practices for 2022-2023.

_{Table 1. Implementation of the 2020-2021 Targeted Medication Safety Best Practices for Hospitals*}

^{*Results from three surveys: N=156 (2021), N=164 (2020), N=206 (2019)}

^{†Best Practice archived in 2022}

^{‡Best Practice archived in 2020}