getting your feet wet with ismp’schristopher walsh, pharmd, fismp medication safety pharmacist st....

Christopher Walsh, PharmD, FISMP

Medication Safety Pharmacist

St. Joseph Medical Center

Reading, Pennsylvania

Getting your feet wet with ISMP’s Targeted Medication Safety Best Practices

Disclosure

• The presenter for this activity has been required to disclose all relationships with any proprietary entity producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies.

• No significant financial relationships with commercial entities were disclosed by any of the speakers.

Learning Objectives

• Discuss the background of the Institute for Safe Medication Practice’s (ISMP) Targeted Medication Safety Best Practices (TMSBP)

• Review the ISMP’s TMSBP’s for 2020-2021 and how they can prevent serious patient harm when fully implemented

• Discuss how to use ISMP’s TMSBP’s to improve the safety of your medication use process

Targeted Medication Safety Best Practices Purpose

• Promote adoption of consensus-based best practices

• Specific medication safety issues that continue to cause fatal and harmful errors in patients,

• Repeated warnings in ISMP publications

Institute for Safe Medication Practices (ISMP). ISMP Targeted Medication Safety Best

Practices for Hospitals; 2020 (accessed at https://www.ismp.org/guidelines/best-practices-hospitals.)

https://www.ismp.org/guidelines/best-practices-hospitalshttps://www.ismp.org/guidelines/best-practices-hospitalshttps://www.ismp.org/guidelines/best-practices-hospitalshttps://www.ismp.org/guidelines/best-practices-hospitalshttps://www.ismp.org/guidelines/best-practices-hospitals

Targeted Medication Safety Best Practices Background

• 14 practices identified

• Focus over next 2 years

• Realistic and actionable

• Mainly for hospitals but can be applied to other settings

• Reviewed by an external Expert Advisory Panel and approved by the ISMP Board of Trustees.




Best Practice #1 vinCRIStine

• Dispense vinCRIStine and other vinca alkaloids in a minibag of a compatible solution and not in a syringe. – Safety Risk

• Over 130 fatalities reported due to wrong route administration into spinal fluid vs intravenously

• Mix-ups with cytarabine, methotrexate or hydrocortisone

– Prevention Strategy • Dispense in volume too large for intrathecal

administration




Best Practice #2 Methotrexate

• Use a weekly dosage regimen default for oral methotrexate in electronic systems when medication orders are entered.

• Require a hard stop verification of an appropriate oncologic indication for all daily oral methotrexate orders.

• Provide specific patient and/or family education for all oral methotrexate discharge orders. – Free copy of ISMP’s high-alert medication consumer

leaflet on oral methotrexate (found at: www.ismp.org/ext/221 ).



http://www.ismp.org/ext/221https://www.ismp.org/guidelines/best-practices-hospitalshttps://www.ismp.org/guidelines/best-practices-hospitalshttps://www.ismp.org/guidelines/best-practices-hospitalshttps://www.ismp.org/guidelines/best-practices-hospitalshttps://www.ismp.org/guidelines/best-practices-hospitals

Best Practice #2 Methotrexate

• Safety Risk – Harmful and fatal errors have been reported

involving the accidental daily dosing of oral methotrexate that was intended for weekly administration. • Daily sig on prescriptions much more common than

weekly

• Daily selected vs weekly during medication history or order entry




Best Practice #3 Patient Weights

• 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.

• Measure and document patient weights in metric units only.




Best Practice #3 Patient Weights

• Safety Risk – Relying on a stated, estimated, or historical weight

can cause inaccurate dosing (both under- and overdosing).

– Numerous mistakes have been reported in which practitioners • Made a mistake in calculations while converting a

weight from one measurement system to another, or • Weighing a patient in pounds, but accidentally

documented the weight value as kilograms, resulting in more than a two-fold dosing error.




Assessment Question #1

Which of the following is/are false regarding ISMP’s TMSBP’s 2020?

A. Dispensing vinCRIStine in a syringe is recommended to prevent inadvertent intrathecal administration.

B. Oral methotrexate for rheumatoid arthritis is usually dosed daily vs weekly

C. Patient weights should be documented using the metric system

D. A and B

E. All of the above

Best Practice #4 Oral Liquid Medications

• Ensure 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.” • Ensure that the oral/enteral syringes used do not connect

to any type of parenteral tubing used within the organization.




Best Practice #4 Oral Liquid Medications

• Safety Risk – Patients given oral liquid medications intravenously

– Oral liquid is prepared or dispensed in a parenteral syringe that connects to vascular access lines.

– Such errors have resulted in patient death or major harm. • Contents of liquid-filled capsules (e.g., niMODipine) were

withdrawn for oral administration with a parenteral syringe and then inadvertently administered intravenously.




Best Practice #5 Measuring Devices

• Purchase oral liquid dosing devices (oral syringes/cups/droppers) that only display the metric scale.

• Educate patients upon discharge to request appropriate oral dosing devices to measure oral liquid volumes in milliliters (mL) only.

• Safety Risk – More than 50 reports of mixups between milliliters

(mL) and household measures such as drops and teaspoonfuls, some leading to injuries requiring hospitalization.




Best Practice #7 Neuromuscular Blocking Agents

• 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 locklidded ADC pockets/drawers.




Best Practice #7 Neuromuscular Blocking Agents

• 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, IV bags)

• Safety Risk – Over 100 reports received since 1996 of accidental administration of NMBs to

patients not receiving proper ventilator assistance.

• 2014 - NMB instead of a fosphenytoin solution compounded

• 2017 - vecuronium vs midazolam




Best Practice #8 Infusion Pumps

• Administer medication infusions via a programmable infusion pump utilizing dose error-reduction systems.

• Maintain a 95% or greater compliance rate for the use of dose error-reduction systems.

• Monitor compliance with use of smart pump dose error-reduction systems on a monthly basis.

• If your organization allows for the administration of an 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.




Best Practice #8 Infusion Pumps

• Safety Risk

– Infusion-related medication errors expose patients to a higher risk of harm.

• Rationale

– “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.




Best Practice #9 Antidotes, Reversal and Rescue Agents

• Ensure all appropriate antidotes, reversal agents, and rescue agents are readily available.

• Standardized protocols and/or coupled order sets in place

• Directions for use/administration readily available in clinical areas

• Safety Risk – reports of death and serious harm due to delay in

administration




Best Practice #10 Sterile Water

• Eliminate all 1,000 mL bags of sterile water (labeled for “injection,” “irrigation,” or “inhalation”) from all areas outside of the pharmacy. – Replace all 1,000 mL (1 liter) bags of sterile water with 2,000 mL (2

liter) bags – Pharmacy to work with other departments on safest ways to provide

sterile water

• Safety Risk – 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. • mix-ups between the 1 liter bags of sterile water with 1 liter bags of dextrose

5% (D5W) and 0.9% sodium chloride due to similar labeling




Best Practice #11 Compounded Sterile Preparations

• Independent verification to ensure that the proper ingredients are added

• Confirmation of the proper amount (volume) of each ingredient prior to its addition to the final container. – Eliminate the use of proxy methods of verification (i.e. syringe pull

back) – Perform verification in all locations including patient care units – Use technology to assist (barcode scanning, gravimetrics, etc.)

• Safety Risk – Multiple serious compounding errors reported that caused patient

harm or death – Due to preparation of the wrong concentration/strength or using the

wrong product or diluent.




Best Practice #13 Promethazine

• Eliminate injectable promethazine from the formulary. – Therapeutic substitution to another antiemetic.

– Remove from all order screens, order sets and protocols

• Safety Risk – Serious tissue injuries and amputations from the

inadvertent arterial injection or IV extravasation of injectable promethazine.




Best Practice #14 External Risk

• Use information about medication safety risks from other organizations

• Take action to prevent similar errors – Identify one person responsible – Identify reputable resources – Establish a formal process for review

• Rationale – A medication error reported in one organization is also

likely to occur in another. – Prompts the evaluation of similar risks within the

organization that may be hidden




Best Practice #15 Opioids

• Verify and document a patient’s opioid status 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 – Alert practitioners when extended-release and long-acting opioid dose

adjustments are required – Eliminate the prescribing of fentaNYL patches for opioid-naïve patients and/or

patients with acute pain – Limit the storage of fentaNYL patches in Automated Dispensing Cabinets

• Safety Risk – 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.

– Harmful errors, including fatalities, due to the use of fentaNYL patches to treat acute pain in opioid-naïve patients continue to be reported.




Best Practice #16 Automated Dispensing Cabinets

• Limit the variety of medications that can be removed from an automated dispensing cabinet (ADC) using the override function.

• Require a medication order prior to removing any medication from an ADC, including those removed using the override function.

• Monitor ADC overrides to verify appropriateness, transcription of orders, and documentation of administration.

• Periodically review for appropriateness the list of medications available using the override function.

• Safety Risk – Reports of harmful and fatal medication errors that involved

practitioners removing medications using the override feature of an automated dispensing cabinet.




Assessment Question #2

Which of the following is/are true regarding ISMP’s TMSBP’s 2020?

A. It is ok to dispense an oral liquid medication in an IV syringe as long as you have a “For Oral Use Only” auxiliary label on it.

B. It is appropriate to use a fentanyl patch to treat severe acute pain in an opioid naïve patient if the patient requests it.

C. According to TMSBP #8, the goal compliance rate for programmable infusion devices is 95%.

D. A and B E. All of the above

Gap Analysis

Gap Analysis

Available at https://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitals (accessed 9/11/2020)

https://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitalshttps://www.ismp.org/resources/worksheet-ismp-targeted-medication-safety-best-practices-hospitals

Summary

• Institute for Safe Medication Practice’s (ISMP) Targeted Medication Safety Best Practices (TMSBP) 2020 represent ongoing, harmful medication errors

• Focusing on addressing these issues can significantly reduce the risk of medication-related preventable harm in your organization

• A gap analysis is a useful tool that can help organizations identify opportunities for improvement in their medication use process

Link for CE Credit

• https://www.papharmacists.com/surveys/?id=2020AnnualCE_ISMPSurvey

• Complete Survey Evaluation by October 19
https://www.papharmacists.com/surveys/?id=2020AnnualCE_ISMPSurveyhttps://www.papharmacists.com/surveys/?id=2020AnnualCE_ISMPSurveyhttps://www.papharmacists.com/surveys/?id=2020AnnualCE_ISMPSurvey

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