Pharmascript October 2016: Medication Safety Corner- ISMP Best Practices Update

Agnes Ann Feemster, PharmD, BCPS
Assistant Dean, Experiential Learning Program
University of Maryland School of Pharmacy
Medication Safety Officer for Oncology at the Johns Hopkins Hospital

The Institute for Safe Medication Practices (ISMP) recently released the “2016-2017 Targeted Medication Safety Best Practices for Hospitals.” This version includes revisions to two existing best practices and incorporates five more recommendations to reduce errors in hospitalized patients. ISMP encourages concentration on the first six recommendations before moving on to the new best practices. The first six best practices are consistent with the 2014-2015 best practices guidelines.

Important revisions of the 2014-2015 best practices were made to the two practices involving oral methotrexate (Best Practice 2) and patient weights (Best Practice 3). Previous guidelines required hard stop verification of an appropriate oncologic indication for all daily oral methotrexate orders. This recommendation is still in effect, but this year’s update to Best Practice 2 contains two clarifications. Because some electronic order entry systems currently do not allow hard stops, the revised description states that clinicians must clarify all daily orders for methotrexate for patients with no documented oncologic diagnosis and should work with the software vendor to implement this critical feature. Another revision to Best Practice 2 involves patient education. Given that education for patients discharged on oral methotrexate can be effectively provided by a nurse, pharmacist, or physician, the second best practice no longer limits this function to a pharmacist. This revised best practice also extends the need for education to all oral methotrexate discharge orders and is not limited to weekly orders. The third best practice states that patients should be weighed as soon as possible rather than using a stated, estimated, or historical weight. Use of the metric system to measure and document weight is a continued recommendation.

The following five additional best practices are suggested to promote patient safety in hospitals:

1. Segregate, sequester, and differentiate all neuromuscular blocking agents (NMBs) from other medications, wherever they are stored in the organization. NMBs should be secured in patient care areas and labeled with “Warning: Paralyzing Agent- Causes Respiratory Arrest.”

2. Administer high-alert intravenous (IV) medication infusions through a programmable infusion pump using dose error-reduction software. This practice applies to inpatient and outpatient hospital settings and in all situations in which high-alert medications are infused by the IV route, including anesthesia use and patient-controlled analgesia.

Additionally, health systems should:
- Ensure that dose error-reduction software is employed on all smart pumps.
- Verify that drug libraries are built and installed and ensure staff is using the error-reduction software.
- Require periodic maintenance, updating, and testing of the software.
- Evaluate alerts regularly.

3. Ensure all appropriate antidotes, reversal agents, and rescue agents are readily available. Furthermore, standardized protocols and directions for use and administration should be easily accessible in all clinical areas where these agents are used.

4. Eliminate 1000-mL bags of sterile water labeled for injection, irrigation, and inhalation from all areas outside of the pharmacy. Instead, health-system pharmacists should use alternatives in patient care areas, such as two liter bags or vials.

5. When compounding sterile preparations, perform an independent verification to ensure that the proper ingredients are added, including confirmation of the proper volume of each ingredient prior to its addition to the final container. Proxy methods (e.g., the “syringe pull back method”) of verification for compounded sterile medication preparations should be eliminated.

At a minimum, health-system pharmacists should ensure that ingredients are confirmed prior to addition to the final container for:
- All high-alert medications, such as chemotherapy and parenteral nutrition
- All pediatric and neonatal preparations
- Pharmacy-prepared source and bulk containers
- Drugs administered through high-risk routes of administration, including intrathecal, epidural, and intraocular.

For more information, please see the following link: http://www.ismp.org/tools/bestpractices/TMSBP-for-hospitals.pdf