March 2023

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Medication Safety: ISMP Targeted Medication Safety Best Practices for

Hospitals (2022)
About the Guideline
• The Institute for Safe Medication Practices (ISMP) is a nonprofit organization solely dedicated to
the prevention of medical errors.
• The goal of this guideline is to make hospitals aware of medication errors that have caused harm
and even death and to promote the implementation of recommended medication safety best
practices to avoid such occurrences.
• Although the guideline's focus is hospital-based sites, these best practices can also be
implemented in other types of health care organizations.
• The ISMP encourages health care organizations nationally to review and implement these best
practices within a two-year timeline.
• These best practices are reviewed by an outside expert advisory panel and then accepted by the
ISMP board of trustees.

Key Clinical Considerations

Become familiar with the recommendations and best-practice statements provided in this guideline,
especially if you work in an acute care setting.

Best Practice 1
• VinCRIStine and other vinca alkaloids should not be supplied in a syringe; instead, use a minibag
diluted with a compatible solution.
o This practice helps ensure that the medication is delivered intravenously and not
intrathecally, due to the risk of neurological effects, which can be fatal.

Best Practice 2
• When electronic order entry for oral methotrexate is used, a default weekly dosing schedule
should occur automatically.
• All daily oral methotrexate orders should necessitate a “hard stop” for an applicable oncologic
diagnosis.
o In manual systems and those electronic systems that cannot offer a hard stop, all
daily methotrexate orders should require clarification if an oncologic indication is not
documented.
o Hospitals, software vendors, and information technology departments need to work
collaboratively to make hard stops an integral part of electronic order-entry systems.
• Upon discharge on oral methotrexate, detailed patient or family education should be provided.
o All printed oral methotrexate discharge orders should be double-checked before being
given to the patient or family.
o The oral methotrexate dosing schedule should be written clearly and reviewed verbally.
Emphasize that the medication should not be taken as needed, and educate the patient
or family about the risk of taking additional doses.
o Ask the patient or family to repeat back the methotrexate instructions given, to ensure
understanding.
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o Give a copy of the ISMP high-alert medication consumer pamphlet on

oral methotrexate to the patient or family.

Best Practice 3
• The patient's weight should be an actual, measured weight. Do not use a previously
documented, verbal, or estimated weight. At each encounter (for example, on admission, in the
emergency room, or at an outpatient visit, if not an emergency situation), the patient's weight
should be measured as soon as possible.
o Metric scales should be placed in all areas where patients are received, and the metric
weight should be documented in the medical record.
• Metric units should be the standard and only measurement system used to measure a patient's
weight:
o Disable the setting for weight in pounds so that it is unavailable on scales that give
readings in both kilograms and pounds.
o If the patient or family asks for the weight in pounds, have a conversion chart available
near the scale.
o Ensure that all devices (for example, infusion pumps and places for documentation, such
as medical records, order forms, and instructions) activate a prompt for weight in
kilograms only.

Best Practice 7
• Neuromuscular blocking agents (NMBs) should be isolated from all other medications in all
areas where they are stored.
o If NMBs are not used regularly in an area, they should not be available in that area.
o In areas where NMBs are used regularly, they should be stored in a sealed case, if
possible, in a rapid sequence intubation (RSI) box.
o In limited areas, such as critical care, labor and delivery, perioperative areas, and in the
emergency department, NMBs may be made available in automated dispensing cabinets
(ADCs), preferably in pockets or drawers within a locked ADC or RSI box.
o Labels should be added to NMB cases wherever they are available in the hospital. They
should note the following: “WARNING: Causes respiratory arrest—patient must be
ventilated” or “WARNING: Paralyzing agent—causes respiratory arrest” or “WARNING:
Causes respiratory paralysis—patient must be ventilated” to clearly convey that
respiratory arrest can occur and that, in cases of respiratory arrest, ventilator assistance
will be needed.

Best Practice 8
• Programmable infusion pumps with dose error-reduction systems should be used
for medication infusions.
o Maintain a 95% or greater compliance with their use.
o Determine the monthly compliance rate for use.
o When programming allows and a loading dose is a portion of the continuous infusion,
divided limits should be programmed separately for each dose.
o Maintenance, updating, and testing should be performed regularly, and resources
should be made available as required.
o Confirm compatibility between the smart pump drug library and the drug data and
nomenclature in the electronic medical record.
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o Plan to use bidirectional smart infusion pump that interfaces with the electronic medical
record (automatic programming and documentation).

Best Practice 9
• Ensure that antidotes, reversal agents, and rescue medications are immediately accessible.
These medications should be provided in standardized protocols or order sets. Instructions for
use should be made available in clinical areas that use high-risk medications.
o To prevent injury in an emergency setting, determine which antidotes, reversal agents,
and rescue medications can be given without delay.
o After determining the list of these antidotes, develop standardized protocols or order
sets for their appropriate use.

Best Practice 11
• When compounding a sterile preparation, independent verification should occur before adding
it to its final container.
o Do not use an indirect or retrospective method; that is, do not check the label and not
the individual elements being combined as preparation is taking place. (Note: Indirect
methods may be used in an emergency; otherwise, implement an independent
verification process in all patient care areas where sterile compound preparations are
done.)
o Enhance the manual process by using technology to assist with verification (for example,
using barcodes, IV workflow software, or robotics).

Best Practice 12 (Incorporated into New Best Practice 15)

• FentaNYL patches should not be ordered for patients with acute pain or for opioid-naive
patients.

Best Practice 13
• Injectable promethazine should be eliminated from the formulary.
o Eliminate injectable promethazine from within the organization, including the
pharmacy.
o All clinical personnel should be aware that promethazine is a nonstocked,
nonformulary medication.
o Medical staff should approve and create a policy for a different antiemetic as an
automatic therapeutic alternative to convert to when promethazine is ordered.
o Promethazine should not be available on ordering protocols, order sets,
or medication order screens.
• Because an intramuscular injection (IM) of promethazine can inadvertently go intra-arterial and
potentially cause tissue damage, this best practice also applies to IM injections.

Best Practice 14
• Develop a method of learning about medication risks and errors that have occurred outside of
your organization, and create practices in which you can identify vulnerability within your
organization. Then develop procedures that can prevent similar occurrences.
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Best Practice 15
• Prior to ordering and distributing extended-release and long-acting opioids, determine and
document the type of pain (acute versus chronic) and the patient's opioid status (naive versus
tolerant).
o When ordering extended-release and long-acting opioids, create a method in the order-
entry system to ensure it will default in the beginning to the lowest dose and frequency.
o Due to age, kidney and liver impairment, or other narcotics ordered, dose modification
may be needed for extended-release and long-acting opioids, and practitioners should
be alerted.
• FentaNYL patches should be used only in the management of pain in opioid-tolerant patients.
o Alternative treatment options should be inadequate, and the pain should be severe
enough to require daily, around-the-clock, long-term opioid treatment.
• Extended-release formulations should be used only to manage pain for which alternative
treatments are inadequate and that is severe enough to require daily, around-the-clock, long-
term opioid treatment.

Best Practice 16
• The override function on an ADC should be limited to a small number of medications.
• A medication order (either verbal, written, via phone, or electronic) should be required prior to
removing any medication, including via an override on an ADC.
• Override medications should be monitored to determine the appropriateness of the medication,
that the order exists, and that the medication was dispensed and documented correctly.
• Override medications should be assessed intermittently for appropriateness.
• Limit medications that can be obtained via override for emergencies (as defined by the
organization) such as antidotes, lifesaving medications, reversal agents, and comfort measures
(for intractable nausea and vomiting or acute pain).

New Best Practice 17

• Safety measures in the use of oxytocin should be in place to prevent errors.
o Provide a consistent method utilizing standard order sets for prescribing oxytocin
antepartum and/or postpartum to manage postpartum bleeding during labor
induction/augmentation.
o Oxytocin infusion bags should be available in one identical concentration for both
antepartum and postpartum (e.g., 30 units in 500 mL Lactated Ringers).
o Standardize the system of oxytocin delivery in terms of concentration, dose, and
infusion rate. The smart infusion pump dose error-reduction system should be
supported by the method in which the oxytocin dose rate is ordered (i.e.,
milliunits/minute).
o Ready-to-use oxytocin infusions should be available and marked boldly on both sides of
the bag so they cannot be mistaken for hydrating fluids or magnesium infusions.
o Before an oxytocin order is given or required, infusion bags should not be brought to the
bedside.

New Best Practice 18

• The use of barcode authentication for dispensing medications and vaccinations should be
increased beyond the inpatient arena.
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o Special consideration should be given to clinical areas in which limited patient stays
occur frequently, such as the emergency department, radiology, dialysis, cardiac
catheterization suites, labor and delivery, infusion centers, perioperative areas, and
outpatient areas.
o Quality assessment of the use and effectiveness of safety technology, such as scanning
consistency and alarm responsiveness vs. evading, should be reviewed regularly for
compliance.

New Best Practice 19

• High-alert medications should have a multiple-layer approach throughout its utilization process
to improve safety measures.
o The list of high-alert medications in an organization should have multiple actions along
the course of its medication use to decrease the risk of error.
o All clinical professionals, such as practitioners, nurses, and pharmacists, involved in
the medication administration practice should be affected by the strategies created at
the susceptible points of medication use (ordering, delivering, administering, and
observing).
o Prevent errors by developing combined mid- and high-level risk tactics along with low-
level risk-reduction approaches (i.e., providing education, high-alert labels on pharmacy
bins, etc.).
o High-alert medications that are at the highest risk for error should require independent
double-check systems, but these should be limited (i.e., intravenous insulin, heparin
infusions, chemotherapy, opioid infusions).
o Both internal and external resources should be used to assess procedures and risks in an
organization on a regular basis for safe medication use.
o Assess risk-reduction strategies by collecting outcome data to determine their safety
and effectiveness.

Archived Best Practices

“Archived” best practices remain important but allow for attention to be paid to new and other best
practices not readily implemented. All archived best practices will keep their original number and be
cataloged after the unarchived new best practices.

Best Practice 4 (Moved to Archived Status in 2022)

• Oral liquid medications need to be delivered in unit-dose packaging, whenever possible, or they
should be distributed in an oral or enteral syringe by a pharmacy that meets the International
Organization for Standardization (ISO) 80369 standard:
o Bulk oral liquid medications should not be available on patient care floors or
departments.
o Use only oral syringes labeled “Oral Use Only.”
o Even when using ISO 80369 syringes, always add a label or highlight that they are for
oral use only.
• Ensure that parenteral tubing is not compatible with oral or enteral syringes within the
organization. (Exception: Some pharmacies may only use oral liquid medications in unit-dose
cups and bottles. In these cases, patient care floors or departments should be supplied with ISO
80369 syringes for patients who are unable to swallow from a cup or bottle.)
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Best Practice 5 (Moved to Archived Status in 2022)

• The metric unit should be labeled on oral liquid-dosing devices (cups, bottles, syringes).
o Upon discharge, teach patients who use oral liquid-dosing devices to ensure that the
devices use measurements in milliliters (mL) only.

Best Practice 6 (Moved to Archived Status in 2020)

• Glacial acetic acid should not be available in any area of the hospital.
o Replace it with vinegar (5% solution) or commercially available, diluted acetic acid 0.25%
(for irrigation) or 2% (for ear use).

Best Practice 10 (Moved to Archived Status in 2020)

• Remove all 1,000 mL (1L) bags of sterile water from any area outside the pharmacy.
o Create a different process for making sterile water available in clinical areas that need it
for irrigation, inhalation, or injection, such as 2,000 mL (2 L) bags, or bottles or vials of
sterile water.
o Create a policy that states that only the pharmacy can order 1,000 mL (1 L) bags of
sterile water.
o Collaborative efforts need to occur between the pharmacy and appropriate clinical
areas or departments, such as respiratory therapy, to develop procedures for safe
patient care when large volumes of sterile water are required.

Reference
Institute for Safe Medication Practices. (2022). 2022—2023 ISMP targeted medication safety best practices for hospitals.
Retrieved December 2022 from https://www.ismp.org/guidelines/best-practices-hospitals