2022-2023 TMSBP final Medication management.pdf

www.ismp.org
ISMP Targeted Medication
Safety Best Practices
for Hospitals
2022-2023

2 2022-2023 ISMP Targeted Medication Safety Best Practices for Hospitals
T
he purpose of the ISMP Targeted Medication Safety Best Practices
for Hospitals is to identify, inspire, and mobilize widespread,
adoption of consensus-based Best Practices for specific
medication safety issues that continue to cause fatal and harmful errors
in patients despite repeated warnings in ISMP publications. Hospitals
and health systems can focus their medication safety efforts over the
next 2 years on these Best Practices, which are realistic and have been
successfully adopted by numerous organizations. While targeted for
the hospital-based setting, some Best Practices are applicable to other
healthcare settings. The ISMP Targeted Medication Safety Best Practices
for Hospitals have been reviewed by an external Expert Advisory Panel
and approved by the ISMP Board of Directors. Related issues of the ISMP
Medication Safety Alert!®
are referenced after each Best Practice (bolded
dates indicate those that are key articles).
ISMP encourages hospitals that have not implemented the ISMP Targeted
Medication Safety Best Practices for Hospitals to do so as a priority, while
implementing the new Best Practices for 2022-2023. Related documents
include ISMP Targeted Medication Safety Best Practices for Hospitals
Frequently Asked Questions (FAQs) and an ISMP Targeted Medication
Safety Best Practices for Hospitals implementation worksheet.

2022-2023 ISMP Targeted Medication Safety Best Practices for Hospitals 3
BEST PRACTICE 1:
Dispense vinCRIStine and other vinca alkaloids in a minibag of a compatible solution and not in a syringe.
Rationale:
The goal of this Best Practice is to ensure that vinca alkaloids are only administered by
the intravenous route. Vinca alkaloids (vinBLAStine, vinorelbine, vinCRIStine, vinCRIStine
liposomal, etc.) can cause fatal neurological effects if given via the intrathecal route
instead of intravenously. VinCRIStine is particularly problematic and the most frequently
reported vinca alkaloid associated with inadvertent intrathecal administration. Deaths
have been reported throughout the world when the drug was dispensed in a syringe and
given into spinal fluid instead of intravenously. For example, more than 130 cases have
been reported worldwide with vinCRIStine given to leukemic patients. This often happens
when a syringe of vinCRIStine is mistakenly used instead of a syringe of cytarabine,
hydrocortisone, or methotrexate, which are supposed to be given into spinal fluid to the
same leukemic patient. When vinca alkaloids are injected intrathecally, destruction of the
central nervous system occurs, radiating out from the injection site. The few survivors
of this medication error have experienced devastating neurological damage. Despite
repeated warnings by various national and international safety agencies, deaths from this
type of error still occur. The product labeling of all currently marketed vinca alkaloids also
carry a special warning (“For Intravenous Use Only—Fatal If Given by Other Routes”).
An effective prevention strategy that reduces the risk of inadvertently administering
vinca alkaloids via the intrathecal route is to dilute the drug in a minibag that contains a
volume that is too large for intrathecal administration (e.g., 25 mL for pediatric patients
and 50 mL for adult patients). Many organizations have successfully switched to preparing
vinca alkaloids in minibags, including pediatric hospitals and health systems, overcoming
concerns of extravasation and other complications. There have been no reported cases
of accidental administration of a vinca alkaloid by the intrathecal route when dispensed
in a minibag. This Best Practice is supported by The Joint Commission (TJC),1
the American
Society of Clinical Oncology (ASCO),2
the Oncology Nursing Society (ONS),2,3
the National
Comprehensive Cancer Network (NCCN), and the World Health Organization.4
In 2019, the International Medication Safety Network (IMSN) introduced new Global
Targeted Medication Safety Best Practice 2 - Prepare and dispense vinca alkaloids in a minibag,
never in a syringe aimed at preventing fatalities due to medication errors with inadvertent
intraspinal injection of vinCRIStine.
In 2020, the US Food and Drug Administration (FDA) also changed the prescribing
information (package insert) to call for dilution in a minibag only (www.ismp.org/
node/18548). 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.
References:
1. The Joint Commission. Eliminating vincristine administration events. Quick Safety. 2017;37:1-3. (www.ismp.org/ext/348)
2. Neuss MN, Gilmore TR, Belderson KM, et al. 2016 Updated American Society of Clinical Oncology/Oncology Nursing
Society Chemotherapy Administration Safety Standards, including Standards for Pediatric Oncology. J Oncol Pract.
2016;12(12):1262-71.
3. Schulmeister L. Preventing vincristine administration errors: does evidence support minibag infusions? Clin J Oncol
Nurs. 2006;10(2):271-3.
4. World Health Organization. Vincristine (and other vinca alkaloids) should only be given intravenously via a minibag.
Information Exchange System, Alert No. 115, July 18, 2007. (www.ismp.org/ext/232)
Best Practice 1
First Introduced:
2014-2015
Related ISMP
Medication
Safety Alerts!:
December 17,
2020; July 2,
2020; April 11,
2019; March 14,
2019; September
5, 2013; May 20,
2010; August 14,
2008; July 26, 2007;
May 18, 2006;
February 23,
2006; December 1,
2005; May 1, 2003;
February 6, 2003;
April 5, 2000;
November 4, 1998;
September 23,
1998; June 18, 1997.

2022-2023 ISMP Targeted Medication Safety Best Practices for Hospitals
4
BEST PRACTICE 2:
a) Use a weekly dosage regimen default for oral methotrexate in electronic systems when medication orders
are entered.
b) Require a hard stop verification of an appropriate oncologic indication for all daily oral methotrexate orders.
• For manual systems and electronic order entry systems that cannot provide a hard stop, clarify all daily
orders for methotrexate if the patient does not have a documented appropriate oncologic diagnosis.
• Hospitals need to work with their software vendors and information technology departments to ensure that
this hard stop is available. Software vendors need to ensure that their order entry systems are capable of
this hard stop as an important patient safety component of their systems.
c) Provide specific patient and/or family education for all oral methotrexate discharge orders.
• Double-check all printed medication lists and discharge instructions to ensure that they indicate the correct
dosage regimen for oral methotrexate prior to providing them to the patient.
• Ensure that the process for providing discharge instructions for oral methotrexate includes clear written
instructions AND clear verbal instructions that specifically review the dosing schedule, emphasize the danger
with taking extra doses, and specify that the medication should not be taken “as needed” for symptom control.
• Require the patient to repeat back the instructions to validate that the patient understands the dosing
schedule and toxicities of the medication if taken more frequently than prescribed.
• Provide all patients with a copy of the free ISMP high-alert medication consumer leaflet on oral methotrexate
(found at: www.ismp.org/ext/221).
Rationale:
The goal of this Best Practice is to prevent errors involving inadvertent daily dosing of
oral methotrexate both in the inpatient setting and after discharge. Since early 1996,
harmful and fatal errors have been reported to ISMP involving the accidental daily
dosing of oral methotrexate that was intended for weekly administration.
Methotrexate is a folate antimetabolite used to treat different types of cancers. Since
the drug’s introduction, its labeled indications have expanded to include non-oncologic
uses. It is now used to treat a variety of autoimmune diseases (e.g., psoriasis, severe
rheumatoid arthritis, lupus) and other disorders. When used for immunomodulation to
treat disorders such as rheumatoid arthritis, the drug is administered once a week.
Prescribing errors occur when physicians or other providers, who are familiar with
prescribing many medications for daily administration, erroneously prescribe this
medication daily instead of weekly. Dispensing errors occur in much the same way,
when pharmacy technicians and pharmacists inadvertently select/approve daily instead
of weekly administration during order entry or verification. Patient errors have occurred
when complex directions were misunderstood. While patient harm and fatalities have
occurred during hospitalization, many have occurred after discharge.
Ongoing errors with oral methotrexate for non-oncologic use suggest that more needs
to be done to reduce the risk of patient harm. It is important for hospitals not only to
ensure that the proper dosage regimen is administered during hospitalization, but
also to implement effective, proactive strategies so that the proper dosage regimen is
maintained after discharge. While all hospitals routinely provide discharge instructions
to patients and/or families about the patients’ medication use after discharge, extra
attention is important with oral methotrexate so that the patient and/or family
understands both the proper dosage regimen and potential toxicities when taking
more than prescribed.
Best Practice 2
First Introduced:
2014-2015
Related ISMP
Medication Safety
Alerts!:
August 9, 2018;
September 19, 2013;
March 26, 2009;
December 13, 2007;
November 4, 2004;
December 3, 2002;
April 3, 2002.
See also: ISMP
QuarterWatch®
December 4, 2019.
www.ismp.org/
node/13521
BEST PRACTICE 2 – continued on page 5

In 2019, the International Medication Safety Network (IMSN) introduced new Global
Targeted Medication Safety Best Practice 3 - Prevent inadvertent daily dosing of oral
methotrexate for non-oncologic conditions aimed at preventing accidental daily instead
of weekly dosing of methotrexate.
Rationale:
The first goal of this Best Practice is to ensure, as much as possible, that the
patient’s actual weight is obtained upon each admission or appropriate
encounter. Many medication doses are based on the patient’s weight.
Relying on a stated, estimated, or historical weight can cause inaccurate
dosing (both under- and overdosing).
The second goal is to standardize the measurement and communication
of a patient’s weight using only metric units of measure (grams [g]
and kilograms [kg]). Official product labeling for medications provides
weight-based dosing using only the metric system (e.g., mg/kg, units/kg).
Significant medication errors have occurred when the patient’s weight
was communicated and/or documented in non-metric units of measure
(pounds and ounces) and was confused with kilograms or grams. Numerous
mistakes have been reported in which practitioners converted a weight
from one measurement system to another, or weighed a patient in pounds,
but accidentally documented the weight value as kilograms in the medical
record, resulting in more than a two-fold dosing error.
Best Practice 3
First Introduced:
2014-2015
Related ISMP Medication
Safety Alerts!:
December 1, 2011; August
26, 2010; January 15, 2009;
November 17, 1999.
BEST PRACTICE 3:
a) Weigh each patient as soon as possible on admission and during each appropriate* outpatient or
emergency department encounter. Avoid the use of a stated, estimated, or historical weight.
• Have metric scales available in all areas where patients are admitted or encountered. Ensure the metric
weight is documented in the medical record.
• Do not rely on a patient’s stated weight, a healthcare provider’s estimated weight, or a documented weight
from a previous encounter.
* Appropriate encounters include all encounters where the patient is being seen by a licensed independent practitioner, excluding life-threatening
situations where the delay involved in weighing the patient could lead to serious harm (e.g., major trauma). Encounters that involve laboratory and
other services where medications are not prescribed or administered would be considered an exclusion to this definition.
b) Measure and document patient weights in metric units only.
• If scales can measure in both pounds/ounces and kilograms/grams, modify the scale to lock out the ability to
weigh in pounds/ounces.
• If purchasing or replacing scales, buy new scales that measure in, or can be locked to measure in, metric
units only.
• Have charts that convert from kilograms (or grams for pediatrics) to pounds available near all scales, so that
patients/caregivers/parents can be told the weight in pounds, if requested.
• Ensure that electronic health record screen views, medication device screens (e.g., infusion pumps), printed
patient information documents, and printed order and/or communication forms, list or prompt for the
patient’s weight in metric units only.
• Document the patient’s weight in metric units only in all electronic and written formats.
BEST PRACTICE 2 – continued from page 4

6
BEST PRACTICE 4 (ARCHIVED)
See page 18
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.
See page 19
Purchase oral liquid dosing devices (oral syringes/cups/droppers) that only display the metric scale.
See page 20
Eliminate glacial acetic acid from all areas of the hospital.
ARCHIVED Best Practice

BEST PRACTICE 7:
Segregate, sequester, and differentiate all neuromuscular blocking agents (NMBs) from other medications,
wherever they are stored in the organization.
• Eliminate the storage of NMBs in areas of the hospital where they are not routinely needed.
• In patient care areas where they are needed (e.g., intensive care unit), place NMBs in a sealed box or,
preferably, in a rapid sequence intubation (RSI) kit.
• Limit availability in automated dispensing cabinets (ADCs) to perioperative, labor and delivery, critical care, and
emergency department (ED) settings; in these areas, store NMBs in a rapid sequence intubation (RSI) kit, or
locked-lidded ADC pockets/drawers.
• Segregate NMBs from all other medications in the pharmacy by placing them in separate lidded containers in
the refrigerator or other secure, isolated storage area.
• Place auxiliary labels on all storage bins and/or ADC pockets and drawers that contain NMBs as well as all
final medication containers of NMBs (e.g., syringes, intravenous (IV) bags) that state: “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 communicate that respiratory paralysis will occur and ventilation is required.*
Exception: The auxiliary label practice excludes anesthesia-prepared syringes of NMBs.
* Other acceptable alternatives to labeling storage bins and/or ADC pockets are to affix an auxiliary warning label (in addition to the manufacturer’s
warning on the caps and ferrules) directly on all vials and/or other containers stocked in storage locations, or by displaying a warning on the ADC
screen, (e.g., “Patient must be intubated to receive this medication”) that interrupts all attempts to remove a neuromuscular blocker via a patient’s
profile or on override. The warning should require the user to enter or select the purpose of the medication removal (“other” should not be a
choice) and verify that the patient is (or will be) manually or mechanically ventilated.
Rationale:
The goal of this Best Practice is to prevent errors related to accidental
administration of NMBs to patients, especially those not receiving
proper ventilator assistance. Because the respiratory muscles are
paralyzed by these agents, errors in the compounding, dispensing, and
administration of these medications instead of other drugs have resulted
in death or serious, permanent injury. Even with patients requiring
ventilator assistance, severe psychological trauma can occur if the NMB is
accidentally administered prior to sedation.
ISMP has received well over 100 reports concerning accidental
administration of NMBs and has been discussing the hazards of these
agents since 1996. Most errors with the use of these agents have been the
result of using or compounding a NMB in error instead of the intended
drug. In 2014, a widely publicized death caused by compounding a NMB
solution instead of a fosphenytoin solution received national attention.
A few years later, in 2017, due to several system failures, the accidental
administration of a NMB in place of midazolam resulted in another
patient’s death. Inadequate labeling or unsafe storage has been the root
cause of most of these errors. Segregation in storage areas and the use
of proper warning labels can be an effective means of preventing mix-ups
with NMBs.
Best Practice 7
First Introduced:
2016-2017
Safety Alerts!:
June 4, 2020; January 17, 2019;
June 16, 2016; December 18,
2014; September 25, 2014; January
30, 2014; November 15, 2012;
January 14, 2010; December 4,
2008; May 30, 2007; September
22, 2005; April 4, 2003; January 9,
2003; December 18, 2002; May 1,
2002; August 25, 1999; October 7,
1998; May 20, 1998; April 9, 1997;
October 23, 1996; June 5, 1996.

8
BEST PRACTICE 8:
a) Administer medication infusions via a programmable infusion pump utilizing dose error-reduction
systems*
.
b) Maintain a compliance rate of greater than 95% for the use of dose error-reduction systems.
c) Monitor compliance with use of smart pump dose error-reduction software on a monthly basis.
d) If your organization allows for the administration of an intravenous (IV) bolus or a loading dose from a
continuous medication infusion, use a smart pump that allows programming of the bolus (or loading dose)
and continuous infusion rate with separate limits for each.
• Allocate resources for ongoing maintenance, updating, and testing of the software and drug library for all
smart infusion pumps.
• Ensure drug library content is consistent with the drug information and nomenclature (e.g., drug name, dosing
units, dosing rate) in the electronic health record.
• Plan for the implementation of bi-directional (i.e., auto-programming†
and auto-documentation‡
) smart
infusion pump interoperability with the electronic health record.
This Best Practice applies to all hospital settings, both inpatient and outpatient (e.g., magnetic resonance imaging
[MRI] department, emergency department, outpatient infusion clinics), and to all situations in which medications
are infused by the IV or epidural route, including anesthesia use and patient-controlled analgesia (PCA). The only
exception is for small volume vesicant infusions (i.e., chemotherapy vesicants) which, when administered via the
peripheral route, should only be infused by gravity and NOT by an infusion/syringe pump.
* Dose error-reduction systems (DERS): Refers to the integral computer software in smart infusion pumps intended to aid in prevention of infusion
programming-related errors and warn users of potential over- or under-delivery of a medication or fluid by checking programmed doses/rates
against facility configurable preset limits specific to a medication, fluid, and to a clinical application (e.g., epidural administration) and/or location
(e.g., neonatal intensive care unit, medical/surgical unit).
† Auto-programming: Automatic programming of infusion parameters from the electronic health record system to the smart infusion pump (which
are then verified, and the infusion is started manually by the practitioner) after use of the barcode medication administration system to associate
the patient, fluid container (e.g., bag, bottle, syringe), and pump channel.
‡ Auto-documentation (also known as auto-charting or infusion documentation): Sending infusion information such as intake data, dose/rate
changes, and infusion stop time, to the electronic health record system for manual clinician confirmation to enable accurate recording of this
information to the patient’s record after the infusion is started.
Rationale:
The goal of this Best Practice is to ensure the use of dose error-reduction
technology to prevent infusion-related medication errors, which can
cause harm to patients. Infusion-related medication errors expose
patients to a higher risk of harm. Programmable infusion pumps with
dose error-reduction systems help to avert these potentially harmful
errors by “remembering” the large number of “rules” (hospital-defined
dosing limits and other clinical advisories) entered into the drug library,
and applying those “rules” during pump programming to warn clinicians
about potentially unsafe drug therapy. Implementation of bi-directional
interoperability connecting the smart infusion pump and the electronic
health record will further reduce the risk of programming errors and
provide a mechanism for more accurate documentation of infusing
medications.
Best Practice 8
First Introduced:
2016-2017
Safety Alerts!:
July 12, 2018; May 31, 2018; April
5, 2018; April 9, 2015; February
23, 2012; May 5, 2011; October
7, 2010; April 8, 2010; August
28, 2008; September 20, 2007;
August 23, 2007; June 14, 2007;
April 19, 2007; May 6, 2004; April
7, 2005; September 18, 2002.
See also: ISMP Guidelines for
Optimizing Safe Implementation
and Use of Smart Infusion Pumps
(2020). www.ismp.org/node/972

BEST PRACTICE 9:
Ensure all appropriate antidotes, reversal agents, and rescue agents are readily available. Have standardized
protocols and/or coupled order sets in place that permit the emergency administration of all appropriate
antidotes, reversal agents, and rescue agents used in the facility. Have directions for use/administration
readily available in all clinical areas where the antidotes, reversal agents, and rescue agents are used.
• Identify which antidotes, reversal agents, and rescue agents can be administered immediately in emergency
situations to prevent patient harm.
• Use this list to develop appropriate protocols or coupled order sets to ensure that the above Best Practice
is met.
Rationale:
The goal of this Best Practice is to ensure that when an antidote, reversal agent,
or rescue agent is known for a drug that has a high potential to cause an
adverse reaction, or if a toxic dose is inadvertently administered, the agent is
readily available and can be administered without delay. Some medications
have a high potential to cause an adverse reaction even when the appropriate
dose is administered (e.g., iron dextran). Adverse effects can also occur if
an overdose of a medication is accidentally administered. In both cases, the
reaction can be life-threatening, and sometimes immediate intervention is
needed. For some drugs, an antidote, reversal agent, or rescue agent may
exist to counteract the reaction. For example, naloxone counteracts the
effects of opioids, flumazenil counteracts benzodiazepines, lipid emulsions
counteract the cardiotoxic effects of local anesthetics, and uridine triacetate
counteracts the toxic effects of fluorouracil.
ISMP has received reports of death and serious harm because there was
a delay in the administration of the appropriate antidote, reversal agent,
or rescue agent (e.g., EPINEPHrine for anaphylaxis). Known antidotes,
reversal agents, and rescue agents must be routinely available and, in
certain situations, stored in areas where these high-risk medications are
administered. In addition, it is important to have standardized protocols or
coupled order sets so qualified staff can treat the reaction/overdose without
waiting for an order from the prescriber. Also, the directions for use should be
available near where these agents are stored to avoid a delay or improper use
and administration of the agent.
Best Practice 9
First Introduced:
2016-2017
Safety Alerts!:
July 1, 2010; April 8, 2010;
March 11, 2010; February
22, 2007; January 11,
2007; December 14,
2006; November 3, 1999;
September 10, 1999.

10
See page 21
Eliminate all 1,000 mL bags of sterile water (labeled for “injection,” “irrigation,” or “inhalation”) from all areas
outside of the pharmacy.
BEST PRACTICE 11:
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 (volume) of
each ingredient prior to its addition to the final container.
• Specifically, eliminate the use of proxy methods of verification for compounded sterile preparations of
medications (e.g., the “syringe pull-back method,” checking a label rather than the actual ingredients).
• Except in an emergency, perform this verification in all locations where compounded sterile preparations are
made, including patient care units.
• Use technology to assist in the verification process (e.g., machine-readable coding [e.g., barcoding scanning,
radio frequency identification] of ingredients, gravimetric verification, robotics, intravenous [IV] workflow
software) to augment the manual processes. When technology is in use, it is important that processes are in
place to ensure it is maintained, the software is updated, and that the technology is always used in a manner that
maximizes the medication safety features of these systems.
Rationale:
The goal of this Best Practice is to prevent medication errors during sterile
compounding of drugs, that are not detected with proxy checks, such
as the “syringe pull-back method” or other retrospective verification
processes. ISMP has reported multiple serious compounding errors that
caused patient harm or death mostly due to preparation of the wrong
concentration/strength or using the wrong product or diluent. Many of
these would have been identified prior to dispensing if preproduction
checks or sterile processing technology would have been utilized.
ISMP has received reports of errors that were specifically attributed to
a failed check system when using the “syringe pull-back method.” This
error-prone method has been used in pharmacies during the sterile
compounding process for years. Using this method, an ingredient is
injected from the syringe into the final container, and the plunger is
then pulled back to the amount on the syringe that was injected. It is
this “pulled-back” syringe that is checked to determine the accuracy of
the amount injected. Errors may not be detected if the syringe does not
reflect the actual amount added or when the pulled-back syringes are
partnered with the wrong container of medication.
Best Practice 11
First Introduced:
2016-2017
Safety Alerts!:
January 28, 2021; August 13,
2020; January 15, 2015; March 12,
2015; December 18, 2014; October
9, 2014; July 11, 2013; October
18, 2012; June 2, 2011; April 21,
2011; July 1, 2010; April 23, 2009;
August 23, 2000.
See also: ISMP Guidelines for Safe
Preparation of Compounded Sterile
Preparations (2016).
www.ismp.org/node/101

BEST PRACTICE 12:
(Incorporated into Best Practice 15)
Eliminate the prescribing of fentaNYL patches for opioid-naïve patients and/or patients with acute pain.
BEST PRACTICE 13:
Eliminate injectable promethazine from the formulary.
• Remove injectable promethazine from all areas of the organization including the pharmacy.
• Classify injectable promethazine as a non-stocked, non-formulary medication.
• Implement a medical staff-approved automatic therapeutic substitution policy to convert all injectable
promethazine orders to another antiemetic.
• Remove injectable promethazine from all medication order screens, and from all order sets and protocols.
This Best Practice includes not using intramuscular administration of promethazine because this can also cause
tissue damage if accidentally injected intraarterially.
Rationale:
The goal of this Best Practice is to eliminate the risk of serious tissue injuries
and amputations from the inadvertent arterial injection or intravenous
(IV) extravasation of injectable promethazine. ISMP brought attention to
this serious issue in August 2006 and conducted a survey to determine
the prevalence of the issue. Of the nearly 1,000 responses to the survey, 1
in 5 reported awareness of such an occurrence in their facility during the
prior 5 years. The US Food and Drug Administration (FDA) requires the
manufacturer to include strong warnings about the risk of inadvertent
intraarterial injection or perivascular extravasation of this drug in the
package insert. Injectable promethazine has been included on the ISMP
List of High-Alert Medications in Acute Care Settings (www.ismp.org/
node/103) since 2007.
In 2009, ISMP recommended removal of injectable promethazine from
an organization’s formulary, if possible, and use of safer alternatives
such as 5-HT 3 antagonists (e.g., ondansetron). However, these products
were significantly higher in cost at the time. Since then, these alternative
injectable antiemetics have become available as generic products and are
significantly less costly. Thus, injectable promethazine has been used less
frequently, and for safety, should now be removed from all formularies.
Best Practice 13
First Introduced:
2018-2019
Safety Alerts!:
June 27, 2013; October 8, 2009;
September 24, 2009; October 9,
2008; November 2, 2006; August
10, 2006.

12
BEST PRACTICE 14:
Seek out and use information about medication safety risks and errors that have occurred in other
organizations outside of your facility and take action to prevent similar errors.
• Appoint a single healthcare professional (preferably a medication safety officer) to be responsible for oversight
of this entire activity in the hospital.
• Identify reputable resources (e.g., ISMP, The Joint Commission, ECRI, patient safety organizations, state
agencies) to learn about risks and errors that have occurred externally.
• Establish a formal process for monthly review of medication risks and errors reported by external
organizations, with a new or existing interdisciplinary team or committee responsible for medication safety.
The process should include a review of the hospital’s current medication use systems (both manual and
automated) and other data such as internal medication safety reports to determine any potential risk points
that would allow a similar risk or error to occur within the hospital.
• Determine appropriate actions to be taken to minimize the risk of these types of errors occurring in the hospital.
• Document the decisions reached and gain approval for required resources as necessary.
• Share the external stories of risk and errors with all staff, along with any changes that will be made in the
hospital to minimize their occurrence, and then begin implementation.
• Once implemented, periodically monitor the actions selected to ensure they are still being implemented and are
effective in achieving the desired risk reduction. Widely share the results and lessons learned within the facility.
Rationale:
One of the most important ways to prevent medication errors is to learn from errors that
have occurred in other organizations and to use that information to identify potential
risk points or practices within your organization to prevent similar errors. Experience
has shown that a medication error reported in one organization is also likely to occur in
another. Seeking out external sources of risks and errors prompts the evaluation of similar
risks within the organization that may otherwise be hidden, lying dormant for years before
they cause an adverse outcome.
Because there’s a natural human tendency to “normalize” errors that happen elsewhere,
believing they will never happen within the organization, leaders must convey that these
external risks and errors offer valuable and necessary learning opportunities and must be
sought out and reviewed regularly. They must convey that the organization is vulnerable
to errors, and that they consider external errors to be a “clear and present danger” in their
organization for which steps must be taken to prevent a similar occurrence.
To establish a process for learning from external risks and errors, organization leaders
must identify reliable sources of information, establish a systematic way to review this
information, assess the organization’s vulnerability to similar events, and determine a
workable action plan to address any vulnerabilities. To facilitate such a process, ISMP
publishes the ISMP Medication Safety Alert! Action Agenda - Acute Care in January, April,
July, and October to summarize important topics published in the ISMP Medication
Safety Alert! Acute Care newsletters during the previous 3 months. The Action Agenda
is prepared for leadership to use at an interdisciplinary committee meeting and with
frontline staff to stimulate discussion and action to reduce the risk of medication errors.
Each Action Agenda item includes a brief description of the medication safety problem,
recommendations to reduce the risk of errors, and the issue number to locate additional
information.
Other credible sources of information about risks and errors that can be used to
proactively address known medication safety issues that could otherwise lead to harmful
BEST PRACTICE 14 – continued on page 13
Best Practice 14
First
Introduced:
2018-2019
Related ISMP
Medication
Safety Alerts!:
March 23, 2017;
February 9, 2017;
November 6,
2008; November
29, 2007; January
13, 2005; February
25, 1998.

patient outcomes include the following: The Joint Commission Sentinel Event Alert, advisories from
the US Food and Drug Administration (FDA), the Centers for Medicare & Medicaid Services (CMS),
patient safety organization publications, peer-reviewed journals, and newsletters. It should be
noted that CMS states that “Medication errors are a substantial source of morbidity and mortality risk
in the hospitalized setting. Therefore, hospitals must take steps to prevent, identify, and minimize these
errors. These steps must be based on accepted professional principles. This includes not only ensuring
that the pharmacy processes conform to accepted standards of pharmacy practice but also proactively
identifying and reviewing Adverse Drug Events (ADE) that occur. Pharmacies also need to be aware of
external alerts to real or potential pharmacy-related problems in hospitals.” 1
Reference:
1. Centers for Medicare and Medicaid Services. Revised Hospital Guidance for Pharmaceutical Services and Expanded Guidance
Related to Compounding of Medications. S&C 16-01-Hospital. October 30, 2015.
Best Practice 15 First Introduced:
2020-2021
Related ISMP Medication Safety
Alerts!:
January 28, 2021; March 11, 2021; January
26, 2017; October 20, 2016; November 6,
2014; October 9, 2014; October 17, 2013;
May 30, 2013; June 17, 2010; May 20,
2010; February 11, 2010; October 8, 2009;
November 6, 2008; July 12, 2007; June
28, 2007; August 11, 2005; May 20, 2004;
April 18, 2001.
Rationale:
The goal of this Best Practice is to support appropriate prescribing
of extended-release and long-acting opioid medications and
prevent death and serious patient harm from inappropriate use
of these medications. A secondary goal is to specifically prevent
the inappropriate use of fentaNYL patches to treat acute pain in
patients who are opioid-naïve. FentaNYL patches were the highest-
ranking drug involved in serious adverse drug events (ADEs) reported to
the US Food and Drug Administration (FDA) from 2008 through 2010.
ISMP continues to receive reports, including fatalities, due to the
prescribing, dispensing, and administration of fentaNYL patches to
treat acute pain in opioid-naïve patients.
BEST PRACTICE 15:
Verify and document a patient’s opioid status (naïve versus tolerant*) and type of pain (acute versus chronic)
before prescribing and dispensing extended-release and long-acting opioids.
• Default order entry systems to the lowest initial starting dose and frequency when initiating orders for
extended-release and long-acting opioids.
• Alert practitioners when extended-release and long-acting opioid dose adjustments are required due to age,
renal or liver impairment, or when patients are prescribed other sedating medications.
• Eliminate the prescribing of fentaNYL patches for opioid-naïve patients and/or patients with acute pain.
• Eliminate the storage of fentaNYL patches in automated dispensing cabinets or as unit stock in clinical locations
where acute pain is primarily treated (e.g., in the emergency department, operating room, postanesthesia care
unit, procedural areas).
FentaNYL patches are for the management of pain in opioid-tolerant patients, severe enough to require daily,
around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate.
Extended-release formulations are for the management of pain severe enough to require daily, around-the-clock,
long-term opioid treatment and for which alternative treatment options are inadequate.
* Opioid-tolerant patient: Opioid tolerance is defined by the following markers: Patients receiving, for 1 week or longer, at least:
60 mg oral morphine/day; 25 mcg transdermal fentaNYL/hour; 30 mg oral oxyCODONE/day; 8 mg oral HYDROmorphone/day;
25 mg oral oxyMORphone/day; 60 mg oral HYDROcodone/day; or an equianalgesic dose of another opioid, including heroin and/
or non-prescribed opioids.
BEST PRACTICE 14 – continued from page 12

14
BEST PRACTICE 16:
a) Limit the variety of medications that can be removed from an automated dispensing cabinet (ADC) using
the override function.
b) Require a medication order (e.g., electronic, written, telephone, verbal) prior to removing any medication
from an ADC, including those removed using the override function.
c) Monitor ADC overrides to verify appropriateness, transcription of orders, and documentation of
administration.
d) Periodically review for appropriateness the list of medications available using the override function.
• Restrict medications available using override to those that would be needed emergently (as defined by the
organization) such as antidotes, rescue and reversal agents, life-sustaining drugs, and comfort measure
medications such as those used to manage acute pain or intractable nausea and vomiting.
Rationale:
The goal of this Best Practice is to minimize risks associated with the
removal of medications from an ADC using the “override” feature. One
of the biggest challenges to the safe use of ADCs is the ease with which
medications can be removed upon override, many times unnecessarily
and with a lack of perceived risk. Practitioners often view the override
process as a routine, rather than a risky step, and fail to recognize that
use of the feature should be situation dependent and justifiable, and not
based merely on an approved list of medications that can be obtained
via override. Removing medications using the override feature should
be limited to emergent circumstances when waiting for a pharmacist
to review an order could adversely impact the patient’s condition, and
approved overridable medications should be limited to those that fit this
intended use.*
Sometimes, practitioners will obtain a medication from an ADC without
a specific verbal, telephone, written, or electronic order. This may be
incorrectly referred to as an “override;” however, all true overrides should
begin with an order (or protocol) and end with a decision not to wait for a
pharmacist review before obtaining the medication from the cabinet.
Another “override” safety concern involves the process that should be
in place for pharmacists and nurse managers to retrospectively review
medications removed using the override feature. Too often this step is
absent or inadequate, or important findings never reach nurse leaders
who have the oversight of nursing practice.†
ISMP has repeatedly received reports of harmful and fatal medication
errors that involved practitioners removing medications using the
override feature of an ADC.
* When selecting medications to be accessible using the override feature, avoid multiple use containers
and limit the number of drug concentrations and the quantity of vials/ampules/tablets available.
† When monitoring override activity, specifically look for situations where more than one dose or one
dosing unit was removed, the practitioner or practitioner type who is performing the override, and
use this and other organization-specific data when periodically reviewing the appropriateness of the
list of medications available.
Best Practice 16
First Introduced:
2020-2021
Safety Alerts!:
October 24, 2019; February
14, 2019; January 17, 2019;
December 19, 2019; August 1,
2019; June 20, 2019; March 14,
2019; February 28, 2019; February
22, 2018; January 11, 2018; June
2, 2016; January 13, 2011; March
10, 2011; September 9, 2010;
November 19, 2009; January 17,
2008; May 31, 2007; February 22,
2007.
See also: ISMP Guidelines
for the Safe Use of Automated
Dispensing Cabinets (2019).
www.ismp.org/node/1372

NEW BEST PRACTICE 17:
Safeguard against errors with oxytocin use.
a) 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.
b) Standardize to a single concentration/bag size for both antepartum and postpartum oxytocin infusions
(e.g., 30 units in 500 mL Lactated Ringers).
c) 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).
d) 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.
e) Avoid bringing oxytocin infusion bags to the patient’s bedside until it is prescribed and needed.
Rationale:
The goal of this Best Practice is to prevent errors associated with oxytocin
use. Intravenous (IV) oxytocin is used antepartum to induce labor in
patients with a medical indication, to stimulate or reinforce labor in
selected cases of uterine inertia, and as an adjunct in the management
of an incomplete, inevitable, or elective abortion. Used postpartum, IV
oxytocin is indicated to produce uterine contractions during expulsion
of the placenta and to control postpartum bleeding or hemorrhage.
However, improper administration of oxytocin can cause hyperstimulation
of the uterus, which in turn can result in fetal distress, the need for an
emergency cesarean section, or uterine rupture. A few maternal, fetal,
and neonatal deaths have been reported because of oxytocin errors.
Since the mid-1990s, ISMP has been publishing safety alerts related to
errors with oxytocin use. In February 2020, ISMP analyzed voluntary error
reports submitted to the ISMP National Medication Errors Reporting
Program (ISMP MERP) between 1999 and 2019. During that time, 52 reports
involved oxytocin. About 10% of the reports described more than one
oxytocin error that had occurred. About 44% of the reported events
originated during dispensing, about a quarter (23%) originated during
administration, and 13% during prescribing. A quarter (25%) of all events
resulted in maternal, fetal, or neonatal harm. Analysis of these reports
identified five event themes: prescribing errors, look-alike drug packaging
and names, preparation challenges, administration-associated errors, and
communication gaps; therefore, a Best Practice recommendation has been
created for each of these five event themes.
Best Practice 17
First Introduced:
2022-2023
Safety Alerts!:
January 28, 2021; November 5,
2020; February 13, 2020; January
30, 2020; July 26, 2018; April 19,
2018; August 9, 2012; September
9, 2010; June 3, 2010; June 18,
2009; September 11, 2008; June 15,
2006; March 23, 2006; November
3, 2005; October 20, 2005; July 14,
1999; June 30, 1999.
NEW Best Practice

16
Maximize the use of barcode verification prior to medication and vaccine administration by expanding use
beyond inpatient care areas.
a) 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).
b) 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).
Rationale:
The goal of this Best Practice is to expand the utilization of barcode
verification to care areas beyond inpatient care units. Implementation
of barcode medication administration is a well proven error prevention
strategy. Errors due to look-alike packages and labels are commonly
reported to the ISMP National Medication Errors Reporting Program
(ISMP MERP). Contributing factors in these events include the use of highly
stylized label graphics and similar cap and label colors. Products that
have similar names and dosages, are used in the same setting, and/or
are stored near one another, adds to the risk for mis-selection. Wrong
patient errors have also been reported to ISMP MERP. Barcode medication
administration systems are designed to catch medication errors at the
point of administration. Although this safeguard is commonly utilized
in inpatient care areas, adoption tends to lag in procedural settings and
other clinical areas where there is short or limited patient encounter.
ISMP has received numerous error reports where barcoding prior to
medication administration could have alerted practitioners to the wrong
drug, wrong dose, or wrong patient, thus preventing the error. Therefore,
implementing barcode verification prior to medication and vaccine
administration in care areas beyond the inpatient setting will help deliver
the maximum medication safety benefit to patients.
Best Practice 18
First Introduced:
2022-2023
Safety Alerts!:
April 11, 2019; November 29, 2018;
February 22, 2018; June 16, 2016;
November 5, 2015; June 5, 2015.
NEW Best Practice

Layer numerous strategies throughout the medication-use process to improve safety with high-alert
medications.
a) 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.
b) 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.
c) 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.
d) 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).
e) 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).
f) Establish outcome and process measures to monitor safety and routinely collect data to determine the
effectiveness of risk-reduction strategies.
Rationale:
Events continue to happen in hospitals with medications that are on the
hospital’s list of high-alert medications. High-alert medications are drugs
that bear a heightened risk of causing significant patient harm when they
are used in error. Although mistakes may or may not be more common
with these drugs, the consequences of an error with these medications
are clearly more devastating to patients. This is repeatedly borne out in
the literature and by reports submitted to the ISMP National Medication
Errors Reporting Program (ISMP MERP). High-alert medications top the list
of drugs involved in moderate to severe patient outcomes when an error
happens. Most facilities have defined a list of high-alert medications, but
some hospitals have neither a well-reasoned list of high-alert medications
nor a robust set of processes for managing the high-alert medications on
their list. Organizations’ attempts to prevent errors may be limited to low-
leverage risk-reduction strategies, rely on staff vigilance to keep patients
safe, or focus on a single step or single practitioner in the medication-use
process. The goal of this Best Practice is to engage hospitals to reassess
their current list of high-alert medications, enact robust error-prevention
strategies throughout the medication-use process, and monitor outcomes
to reduce the risk of harm with these drugs.
Best Practice 19
First Introduced:
2022-2023
Safety Alerts!:
June 4; 2020; June 6; 2019; August
23; 2018; October 23; 2014;
September 19; 2013; September 5;
2013; April 4; 2013; April 8; 2010;
January 11; 2007
NEW Best Practice

18
BEST PRACTICE 4:
(Moved to Archived Status in 2022)
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.
• Do not stock bulk oral solutions of medications on patient care units.
• Use only oral syringes that are distinctly marked “Oral Use Only.”
• When ISO 80369 compliant syringes (e.g., ENFit) are used for administration of oral liquid medications, always
highlight on the pharmacy label, or affix an auxiliary label, “For Oral Use Only” on the syringe.
• Ensure that the oral/enteral syringes used do not connect to any type of parenteral tubing used within the
organization.
Exception: If the pharmacy is employing unit dose packaging automation that does not use oral syringes, unit dose
cups/bottles may be provided in place of oral syringes. However, ensure that oral or ISO 80369 compliant syringes
(e.g., ENFit) are available on nursing units in case patients cannot drink the medication from the cup or bottle.
Best Practice 4
First Introduced:
2014-2015
Archived:
2022
Safety Alerts!:
September 20, 2018; May 30,
2013; August 23, 2012; August
12, 2010; May 31, 2007; July 27,
2006; June 15, 2006; July 28, 2005;
May 6, 2004; November 27, 2002;
August 25, 1999; January 13, 1999;
March 12, 1997; August 14, 1996;
May 8, 1996.
Rationale:
The goal of this Best Practice is to prevent the unintended administration
of oral medications via the intravenous route. Reports in which patients
were inadvertently given an oral liquid medication intravenously continue
to be reported. This happens most often when an oral liquid is prepared
extemporaneously or dispensed in a parenteral syringe that connects to
vascular access lines. Such errors have resulted in patient death or major
harm. Fatalities have also occurred when the contents of liquid-filled
capsules (e.g., niMODipine) were withdrawn for oral administration via a
nasogastric or other tube with a parenteral syringe and then inadvertently
administered intravenously. The oral and ISO 80369 compliant syringe
tip is designed to be incompatible with vascular lines so it cannot be
inadvertently attached.
ARCHIVED BEST PRACTICES
Reason for the change to archived status:
In 2020, ISMP created a new Best Practice designation of “archived.” While still important as a Best
Practice, compliance with recommendations for an archived Best Practice signal that focus can be
directed toward new and other existing Best Practices with lower adoption rates. Archived Best Practices
maintain their original Best Practice number but will be listed after the unarchived Best Practices.

BEST PRACTICE 5
Purchase oral liquid dosing devices (oral syringes/cups/droppers) that only display the metric scale.
• In addition, if patients are taking an oral liquid medication after discharge, educate patients to request
appropriate oral dosing devices to measure oral liquid volumes in milliliters (mL) only.
Rationale:
The goal of this Best Practice is to use liquid medication dosing devices
(specifically oral syringes, cups, and droppers) that only display volume
using the metric scale. ISMP has received more than 50 reports of mix-
ups between milliliters (mL) and household measures such as drops
and teaspoonfuls, some leading to injuries requiring hospitalization.
Oral syringes, dosing cups, droppers, and other measuring devices
have been involved. Use of the apothecary system has also caused
confusion with mix-ups between drams and mL and other non-metric
measurements such as ounces and tablespoons. ISMP first reported
confusion in the year 2000 and has continued to receive reports of
medication errors because of mix-ups between metric and non-metric
units of measure.
The purchase and use of the current commercially available oral
syringes, cups, and droppers that only display volume using an easy-to-
read printed (rather than embossed) metric scale will help prevent these
types of errors.
Best Practice 5
First Introduced:
2014-2015
Archived:
2022
Safety Alerts!:
November 1, 2012; September 20,
2012; June 14, 2012; December 1,
2011; September 22, 2011; March
22, 2007; March 6, 2003; June 28,
2000; February 26, 1997.
See also: ISMP Statement on
Use of Metric Measurements to
Prevent Errors with Oral Liquids.
ISMP News Release. September
29, 2011. www.ismp.org/node/496

20
BEST PRACTICE 6
Eliminate glacial acetic acid from all areas of the hospital.*
• Remove and safely discard this product from all clinical areas of the hospital (including the pharmacy, clinics,
and physician office practices), and replace it with vinegar (5% solution) or commercially available, diluted
acetic acid 0.25% (for irrigation) or 2% (for otic use).
* Laboratory use excluded if the laboratory purchases the product directly from an external source.
Rationale:
The goal of this Best Practice is to prevent harm from the use of glacial
acetic acid applied directly to patients. 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.
Of particular concern is glacial acetic acid. Accidental topical
application of “glacial” (greater than or equal to 99.5%) acetic acid has
repeatedly resulted in serious patient harm, including severe pain and
serious tissue damage, third-degree burns, and in one case, bilateral
leg amputation. Often in these cases, this item was either accidentally
purchased or used in place of a much more diluted form of acetic acid,
such as vinegar or a commercially available 0.25% acetic acid solution.
Best Practice 6
First Introduced:
2014-2015
Archived:
2020
Safety Alerts!:
January 24, 2013; May 5, 2005;
September 20, 2012; June 30, 2005.

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.
• Use alternatives to avoid the storage and use of 1,000 mL (1 liter) bags of sterile water for injection, irrigation,
or inhalation in patient care areas. For example, replace all 1,000 mL (1 liter) bags of sterile water for injection,
irrigation, or inhalation with 2,000 mL (2 liter) bags of sterile water for injection, irrigation, or inhalation, or
bottles of sterile water for irrigation, inhalation, or vials.
• Establish a policy that 1,000 mL bags of sterile water can only be ordered by the pharmacy.
• The pharmacy needs to work with respiratory therapy and other relevant departments of the hospital to
establish guidelines regarding the safest way to provide large volumes of sterile water when needed for
patient care.
Rationale:
The goal of this Best Practice is to prevent the accidental administration
of an intravenous (IV) infusion of sterile water to a patient. Administering
large quantities of hypotonic sterile water IV has resulted in patient
harm, including death, from hemolysis. ISMP has received reports of
mix-ups between the 1 liter bags of sterile water for injection, irrigation,
and inhalation with 1 liter bags of dextrose 5% (D5W) and 0.9% sodium
chloride (normal saline [NS]). These products look very similar in size,
shape, and type of flexible plastic bag used for distribution.
Respiratory therapy staff may need to use bags of sterile water for
inhalation in patient care units for humidification with ventilators or
continuous positive airway pressure (CPAP) devices. In addition, due
to the large volume of sterile water needed to reconstitute traditional
dantrolene, sterile water bags for injection may need to be stored in
malignant hyperthermia (MH) carts in the perioperative and procedural
areas of the hospital. Unfortunately, if the sterile water bag is not used, it
may be returned to the wrong storage area where IV bags are routinely
kept (e.g., medication rooms, on IV poles). Therefore, when large volume
bags of sterile water must be used outside of the pharmacy, the best
approach is to use 2 liter bags, or bottles of sterile water, to prevent mix-
ups because the larger volume or shape of the container will differentiate
these products from 1 liter bags of D5W and NS. Also, use of the
concentrated suspension of dantrolene, which can be reconstituted with
a small amount of sterile water from vials, eliminates the need for large
volume sterile water bags on the MH cart.
Best Practice 10
First Introduced:
2016-2017
Archived:
2022
Safety Alerts!:
April 3, 2020; September 11,
2014; November 30, 2006;
September 18, 2003.

22
2022-2023 EXPERT ADVISORY PANEL
Merissa Andersen, PharmD, MPH, FISMP
Medication Safety Officer
Mayo Clinic
Rochester, MN
Gregory P. Burger, PharmD, CPPS, FASHP, EMT
Pharmacy Facility Program Manager
Dwight D. Eisenhower VA Medical Center
Leavenworth, KS
David T. Caron, Jr., PharmD
Director of Pharmacy and Compliance Officer
Martha’s Vineyard Hospital
Mass General Brigham
Rabih Dabliz, PharmD, FISMP, CPPS, CPHQ
Senior Manager, Quality & Medication Safety
Services
Cleveland Clinic Abu Dhabi
Abu Dhabi, UAE
Michael C. Dejos, PharmD, BCPS, CHOP, DPLA
System Medication Safety Officer
Methodist Le Bonheur Healthcare
Bob Feroli, PharmD, FASHP
Medication-Use Safety, Armstrong Institute
Johns Hopkins
Baltimore, MD
Michael Ganio, PharmD, MS, FASHP
Senior Director, Pharmacy Practice and Quality
ASHP
Patricia C. Kienle, RPh, MPA, BCSCP, FASHP
Director, Accreditation and Medication Safety
Cardinal Health
Brigitta U. Mueller, MD, MHCM, MSJ, CPPS, CPHQ,
FISQua, FAAP
Executive Director, Patient Safety, Risk & Quality
ECRI
Plymouth Meeting, PA
MiKaela Olsen DNP, APRN-CNS, AOCNS, FAAN
Clinical Program Director- Oncology
Johns Hopkins Hospital and Johns Hopkins Health System
Baltimore, MD
Amy L. Potts, PharmD, MMHC, BCPPS, FPPA
Program Director, Quality, Safety and Education
Department of Pharmacy
Monroe Carell Jr. Children’s Hospital at Vanderbilt
Nashville, TN
Elizabeth Rebo, PharmD, MBA, CPPS
Executive Director, Pharmacy Quality and Medication
Safety
National Pharmacy Services
Kaiser Permanente
Downey, CA
Georgene Saliba, RN, BSN, MBA, CPHRM, FASHRM
Vice President, Insurance
UHS of Delaware, Inc.
King of Prussia, PA
Emily Holcomb, PharmD, BCPS
2021-2022 ISMP Safe Medication Management Fellow

23
ABOUT ISMP
The Institute for Safe Medication Practices (ISMP) is the only 501c (3) nonprofit
organization devoted entirely to preventing medication errors. During its more
than 25-year history, ISMP has helped make a difference in the lives of millions of
patients and the healthcare professionals who care for them.
ISMP is known and respected as the gold standard for medication safety
information. It also has served as a vital force for progress. ISMP’s advocacy work
alone has resulted in numerous necessary changes in clinical practice, public
policy, and drug labeling and packaging.
Among its many initiatives, ISMP runs the only national voluntary practitioner
medication error reporting program, publishes newsletters with real-time error
information read and trusted throughout the global healthcare community, and
offers a wide range of unique educational programs, tools, and guidelines.
In 2020, ISMP formally affiliated with ECRI to create one of the largest healthcare
quality and safety entities in the world. The affiliation will allow both organizations
to work more closely together for the benefit of providers, patient advocates,
governments, and most importantly, patients.
As an independent watchdog organization, ISMP receives no advertising revenue
and depends entirely on charitable donations, educational grants, newsletter
subscriptions, and volunteer efforts to pursue its life-saving work. For more
information or to donate to protect patients worldwide from harmful medication
errors, visit ISMP online at: www.ismp.org.

For more information about the ISMP Targeted Medication
Safety Best Practices for Hospitals including Frequently
Asked Questions, Educational Programs and Surveys, see:
www.ismp.org/guidelines/best-practices-hospitals.
Institute for Safe Medication Practices
An ECRI Affiliate
200 Lakeside Drive, Suite 200, Horsham, PA 19044
Phone: (215) 947-7797 Fax: (215) 914-1492
www.ismp.org

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