ISMP launches safety campaign for hospitals

December 17, 2013

The Institute for Safe Medication Practices (ISMP) has launched a national medication safety initiative and an accompanying guide.

The Institute for Safe Medication Practices (ISMP) has launched a national medication safety initiative, the “2014-2015 Targeted Medication Safety Best Practices for Hospitals,” and an accompanying guide.

“This initiative is intended to mobilize widespread adoption of consensus-based best practices on safety issues that continue to cause harmful errors despite prior ISMP warnings,” according to a statement in ISMP’s MedicationSafetyAlert newsletter.

ISMP published a Best Practices For Hospitals guide that details plans and goals for the national program. ISMP’s Targeted Best Practices include:

·       Using a weekly dosage regimen default for oral methotrexate. If it is overridden to daily, a hard stop verification of an appropriate oncologic indication should be required. In addition, hospitals should provide patient education by pharmacists for all weekly oral methotrexate discharge orders. “Ensure that written drug information leaflets are given to patients that contain clear instructions about the weekly dosing schedule,” ISMP wrote in the Best Practices guide.

· Dispensing vinCRIStine (and other vinca alkaloids) in a minibag of a compatible solution and not in syringes. “Vinca alkaloids…can cause fatal neurological effects if given via the intrathecal route instead of intravenously,” the guide stated.

· Measuring and expressing patient weights in metric units only. Ensure that scales used for weighing patients are set and measure only in metric units. “The goal of this best practice is to standardize the measurement and communication of patient weight using only metric units of measure. Significant medication errors have occurred when the patients’ weight is documented in non-metric units of measure (e.g., pounds), and it has been confused with kilograms (or grams),” the ISMP guide stated.

· Ensuring that all oral liquids that are not commercially available as unit dose products are dispensed by the pharmacy in oral syringes. “Use only oral syringes marked ‘Oral Use Only.’ Ensured that oral syringes used do not connect to any type of parenteral tubing used in the hospital,” the guide stated.

· Purchasing oral liquid dosing devices that only display the metric scale.

· Eliminating glacial acetic acid from all areas of the hospital, including the pharmacy, and replace it with vinegar (5% solution) or commercially available diluted acetic acid. “The use of hazardous chemicals in pharmacy compounding or for special therapeutic procedures and diagnostics is common in many hospitals. Patient harm has occurred when toxic chemicals have been misidentified as oral products, or when a very concentrated form of a chemical has been erroneously used in treating patients,” the guide stated.