ISMP High Alert Medications 2023

ismp high alert medications

Each year, ISMP receives many reports of errors involving high-alert medications. These drugs have the potential to cause severe patient harm if they are used incorrectly.

Despite the high risk, hospitals are not implementing effective safeguards for these drugs. A new ISMP best practice encourages hospitals to perform an independent double-check before administering a medication or vaccine.

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ISMP Pharmacy

The Institute for Safe Medication Practices is a global leader in medication safety, providing information and guidance to healthcare practitioners, regulatory agencies, professional organizations and the pharmaceutical industry. ISMP publishes newsletters containing real-time error information that is widely read and trusted throughout the world-wide healthcare community, and develops comprehensive educational programs and tools to prevent and reduce errors.

ISMP’s Medication Reconciliation Best Practices and Getting Started Kits have helped many healthcare organizations avoid errors when dispensing medications in acute care, long term care and home health settings. These tools are used to help ensure accurate and complete medication histories for each patient.

ISMP is concerned about reports of medication errors (including fatalities) involving the use of the override feature on Automated Dispensing Cabinets (ADC). The override feature allows a practitioner to remove a prescription from an ADC without waiting for pharmacist review. This process is risky and should be used only when it is clear that the delay in dispensing a medication will not adversely affect the patient’s outcome. ISMP has developed a Best Practice “archive” designation in order to focus attention on new and other existing Best Practices that have lower adoption rates.

ISMP Best Practices

The Institute for Safe Medication Practices (ISMP) publishes a series of medication safety best practices to help hospitals assess their systems and implement improvement strategies. These best practices are based on real-world data from error reports submitted to the ISMP National Medication Error Reporting Program. ISMP also distributes urgent medication advisories through several national distribution channels that highlight serious or potentially dangerous medications.

These advisories and best practices should not be considered a substitute for a facility’s internal error reporting system or for participating in root cause analysis to identify underlying issues and make changes that can prevent future errors. Hospitals should avoid reliance on low-leverage risk-reduction strategies, such as applying high-alert labels to pharmacy storage bins or staff education, and instead focus on layering numerous strategies throughout the medication-use process.

Managing high-alert drugs involves establishing a comprehensive set of procedures that cover all aspects of the medication-use process and applies to nurses, pharmacists, and prescribers. This includes identifying high-alert medications in the hospital’s formulary, implementing an effective handoff protocol for continuity of care between departments, and setting clear medication-related expectations during training.

ismp guidelines

ISMP Guidelines

Institute for Safe Medication Practices (ISMP) is an independent nonprofit watchdog organization that focuses on patient safety and the medication use process. It relies on charitable donations, educational grants, newsletter subscriptions, and volunteer efforts to pursue its lifesaving mission.

ISMP’s advocacy work has helped to change medical practices, drug packaging and labeling, and sterile field requirements in ambulatory care and hospital settings. ISMP was instrumental in changing the abbreviations used on Tylenol packaging to help reduce the risk of accidental overdoses. ISMP also partnered with FDA and McNeil Consumer & Specialty Pharmaceuticals to make changes to the labeling of liquid oral anticoagulants.

ISMP’s national error reporting program provides information on medication errors reported by hospitals and other facilities. In addition, ISMP publishes guidelines based on best practices that can be used in healthcare settings to prevent errors. ISMP’s guidelines should be reviewed by facility staff in conjunction with internal error reports and root cause analysis reports to ensure effective strategies are developed for each type of high-alert medication or class of medications.

ISMP List of Confused Drug Names

Medications with similar names present an additional risk for medication errors. In an effort to address this issue, the Institute for Safe Medication Practices created a list of medications that should be distinguished using tall man letters. The list contains both look-alike and sound-alike drug names that are often confused.

Depending on the type of drug, effective strategies may include separating them on storage shelves, requiring an order form that includes the indication or purpose of the medication and specifying a route when possible, affixing tall man lettering to prescription bottles and bins, highlighting the drug name in boldface or colored font, or incorporating it into electronic ordering systems.

While it is not known if medication errors are more common with high alert medications, they do carry a greater potential for serious harm when mistakenly used. As a result, healthcare facilities should consider a proactive risk assessment to develop error reduction strategies. This should include reviewing internal medication error reporting data and conducting a root cause analysis. The assessment should also be updated as new medications are introduced.

ISMP High Risk Medications

When errors occur with high-risk medications, the consequences are typically more serious. That’s why it’s so important for hospitals to have a well-thought-out list of high-alert medications and effective, high-leverage strategies that mitigate the risk of error with these drugs. To create such a list, it’s helpful to review internal medication error reporting data and any available root cause analysis findings. A search of the external literature can also uncover reports of errors with specific high-alert medications or classes of medication.

A hospital should develop a list of high-risk medications based on these data and a thorough assessment of the facility’s systems, practices, and procedures. Then, implement a comprehensive set of risk-reduction strategies that impact as many steps of the medication-use process as possible. Finally, ensure that everyone who touches the process is aware of the list and understands how it will help prevent medication errors and patient harm. This includes pharmacists, nurses, physician assistants, and nursing students. To make sure that the high-alert medication list is effective, it should be reassessed regularly.

ISMP Automatic Stop Orders

While mistakes with any medication can be fatal, they are often more serious and costly when high alert drugs are involved. A new ISMP best practice suggests that facilities layer numerous strategies throughout the medication-use process for these medications.

These include standardized processes, auxiliary labels and alerts, limited access, employing redundancies, and requiring a physician’s order to discontinue or restart an order (e.g., methotrexate, concentrated morphine oral solution). A second suggestion is to use weekly dosage regimen defaults for medications that require frequent monitoring or dosing (e.g., insulin).

A third recommendation involves using a high-alert drug list, establishing a comprehensive set of risk-reduction strategies for the list, and communicating these to all staff members who touch the medication-use process. This is especially important during patient transfer/discharge, when a hospital needs to confirm the medication history with the receiving facility. For example, a death occurred when an IV dose of fosphenytoin (non-high alert) was accidentally given to the wrong patient with a neuromuscular blocking agent called rocuronium (high alert). IV workflow technology that includes bar code scanning of ingredients would have prevented this error.

ISMP Careers

Institute for Safe Medication Practices (ISMP) is the nation’s first 501c(3) nonprofit organization devoted to preventing medication errors. ISMP’s advocacy work has resulted in numerous necessary changes in clinical practice, public policy and drug labeling and packaging.

ISMP collects and analyzes reports of medication errors (including close calls) submitted to its voluntary ISMP National Medication Error Reporting Programs for healthcare practitioners and consumers. ISMP then disseminates these reports through a variety of communication channels to share emerging information, lessons learned and prevention strategies with the entire healthcare community.

Participate in ISMP membership activities, consultation engagements and other organizational programs to advance patient safety. Perform research and analysis, develop a project plan and prepare and present findings and recommendations to ISMP leadership and external audiences. Author, contribute or edit content for ISMP newsletter publications, research and grant proposals, medication safety projects, self-assessment tools, guidelines and other resources. Provide advice and guidance to healthcare practitioners, consumers, ISMP Fellows, residents and students.

ISMP Certification

ISMP certification is a great way to prove your pharmacy skills and knowledge. The exam covers a wide range of topics and will prepare you for many different roles in the industry. You’ll be able to understand medication error reporting, identify common mistakes and learn how to prevent them from happening again. In addition to certification, you can also take advantage of ISMP’s many resources and events.

ISMP offers a high-risk medication self assessment program that helps pharmacies identify medications that are particularly susceptible to errors and develop systems for preventing them. The self-assessment tool also allows pharmacists to compare their processes with those of other hospitals and find opportunities for improvement.

Hospitals should have their own list of high-alert medications and effective processes for managing these drugs. Whether the drugs are on the ISMP list or not, each hospital should have its own set of criteria for choosing these medications. These medications should be the subject of a comprehensive risk-reduction plan, including standardized dispensing, auxiliary labels and automated alerts, reducing distractions and limiting access to these drugs.

ISMP Questions and Answers

A nonprofit organization called the Institute for Safe Pharmaceutical Practices (ISMP) was founded to assist medical professionals in comprehending medication errors from a systems viewpoint, gathering reports of errors, and disseminating suggestions to help prevent similar incidents.

Institute for Safe Medication Practices.

The Institute for Safe Pharmaceutical Practices (ISMP), which focuses on enhancing medication safety and minimizing mistakes in healthcare settings, is significant. By investigating pharmaceutical errors, creating plans to stop them in the future, and offering teaching materials and recommendations to medical professionals, ISMP plays an important role. They support reporting errors and learning from them, support pharmaceutical safety, and increase public knowledge of potential hazards. Through its work, ISMP advances patient safety, enhances healthcare procedures, and promotes a culture of pharmaceutical safety.

ISMP is a non-profit organization that focuses on increasing pharmaceutical safety and minimizing prescription errors. They accomplish this by activities such as reporting and analyzing drug errors, educating and training healthcare personnel, producing standards and recommendations for safe pharmaceutical practices, and raising public awareness about medication safety issues. ISMP aims to improve patient safety by decreasing medication mistakes and promoting medication management best practices.

The Institute for Safe Medication Practices (ISMP) is a non-profit organization whose mission is to help healthcare practitioners understand medication errors from a systems perspective, collect reports of errors, and distribute advice to prevent repeat incidents.