Every year, the health system pharmacy director and I would sit down and review the latest Institute for Safe Medication Practices (ISMP) list of best practices. These are practices based on reports of medication errors from hospitals across the country. When the ISMP identifies a trend, it seeks the root causes. It then compiles preventive strategies and publishes them as ISMP Best Practices for Hospitals.

medication safety pills

I found these best practices to be a good source of goals for the pharmacy director. If there was a recommendation that we had not implemented, the director and I would add it to his goals for the upcoming year. The CMO should be a strong advocate for medication safety.

2016 – 2017 Medication Safety Best Practices

In the most recent list of best practices, there were updates to two of the first six practices (from the 2014 – 2015 list), and five new recommendations. Here is a summary of all 11 best practices.

The Original 6 Best Practices

  1. Dispense vinCRIStine (and other vinca alkaloids) in a minibag of a compatible solution and
    not in a syringe. This one is unchanged. The purpose for this practice is to prevent intrathecal infusion of these medications, which can lead to disability and death.
  2. Implement practices to prevent the administration of daily methotrexate dosing when the amounts are meant to be given weekly. The revision allowed for a manual process when an EMR was unable to provide a hard stop to avoid a mistake.
  3. Measure and record patient weights with each encounter, rather than using reported weights. And report all weights in metric units. The revision involved using the actual weight rather than a reported weight.
  4. All oral liquids, if not available in single dose packaging, should be administered in an oral syringe only. This helps to prevent administering oral liquids intravenously because an oral syringe cannot be attached to parenteral tubing.
  5. Purchase and use oral dosing devices labeled in metric units only (to avoid confusion with ounces or teaspoon labels).
  6. Eliminate glacial acetic acid from the hospital. This is to avoid accidental use of this caustic chemical, when vinegar or 0.25% acetic acid is called for.

5 New ISMP Best Practices

  1.  Segregate, sequester, and differentiate all neuromuscular blocking agents from other medications, wherever they are stored. This best practice was implemented to avoid accidental administration of an NMB when ventilatory assistance is not readily available.
  2. Administer high-alert intravenous medication infusions via a programmable infusion pump utilizing dose error-reduction software. This allows hospital-wide dosing limits to be followed. These smart pumps have been available for ten years. But some hospitals still have not deployed them.
  3. Ensure all appropriate antidotes, reversal agents, and rescue agents are readily available, with clear instructions for administration. This addresses the issue of delays in administration of antidotes and reversal agents that can lead to injury and death.
  4. Eliminate all 1,000 mL bags of sterile water (labeled for “injection,” “irrigation,” or “inhalation”) from all areas outside of the pharmacy. This practice was adopted in order to eliminate high volume IV infusions of sterile water, which can cause hemolysis and death.
  5. When compounding sterile preparations, perform an independent verification to ensure that the proper ingredients (medications and diluents) are added, including confirmation of the proper amount of each ingredient prior to its addition to the final container. This best practice was added because of continued reports of compounding errors associated with patient deaths.

These 11 best practices, along with much more detailed implementation advice, can be found in the recent ISMP Best Practices for Hospitals.


Many of these practices may already be in place at your facilities. If not, then bring the list of best practices to your Pharmacy and Therapeutics Committee (or equivalent) and follow this process:

  1. The pharmacy director or clinical pharmacist should provide a summary of the practices not yet in place.
  2. Select the most important best practice and set a timeline for implementation.
  3. Identify who needs to be involved in implementation. In addition to the pharmacy staff, you may need to obtain input from the medical staff, nursing staff, other ancillary personnel, the purchasing department, operating room staff, and others.
  4. For any best practice that requires a major capital investment (such as the smart pumps), be sure to add it to the budget process, if it's not possible to proceed as a non-budgeted item.
  5. Develop check lists to support implementation and reports to monitor progress.
  6. Report on the implementation progress at each subsequent meeting, with one member serving as the lead on the project.
  7. Educate and communicate with anyone that will be affected by the changes – use newsletters, meetings and emails to get the word out.
  8. Then go live with your new best practices!


Next Steps

Check out the ISMP report and discuss it at your next Pharmacy and Therapeutics meeting. Then take your plans for implementing any new best practices to your CEO, CFO and Senior Executive meetings. For major projects, such as purchase of smart infusion pumps for an entire hospital, integrate the process into your capital budget process. Consider adding these goals to your pharmacy director's annual list of management goals.

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