Strategies for Improving Medication Safety: A National Perspective From ISMP

Two representatives from the Institute for Safe Medication Practices (ISMP), a federally certified patient safety organization, presented information on strategies for improving medication safety at an educational session entitled “Strategies for Improving Medication Safety: A National Perspective From ISMP.”

Daryl S. Rich, PharmD, medication safety specialist at the ISMP, opened the session with an overview of the top 10 priority medication safety issues for 2013 based on reports to the ISMP in the past year. These include opioids, look-alike and/or sound-alike drugs, computer entry (CPOE-Pharmacy), vaccines, weight-based dosing, sterile compounding, sterility from injectables, bypassing technology safeguards, oral syringes, and glacial acetic acid. For each of these safety issues, Dr Rich identified the safety problems and recommendations to improve safety.

Dr Rich explained that most of the issues related to safety problems with opioids are the result of improper dosing and monitoring. Among the recommendations to promote safer use of opioids is better education on proper dosing, conversion, and monitoring of opioids. Establishing a clear protocol for opioid use that includes an accurate definition and assessment for opioid naïve versus tolerant patients is also important. Dr Rich cited the example of inaccurately labeling a surgical patient as opioid tolerant after the patient had received opioids for the first time for surgical reasons, and emphasized that opioid tolerance requires longer, more sustained use.

In another example, Dr Rich described safety issues related to bypassing of technology safeguards by staff including inaccurate use of smart infusion pumps (ie, not using pump libraries, not setting up enough soft or hard limits, or bypassing a library by using 2 pumps) and problems with bar code medication administration (ie, scanning duplicate patient bracelets). Overall, he emphasized the need to use data from technology to improve compliance not just on the individual level but on a global level as well.

Dr Rich also stressed the importance of establishing a “just culture,” a model proposed through the ISMP that includes fairness to workers who make errors. This model can be effective in reducing safety risks as described in the ISMP Medication Safety Alert (see, for example, http://www.ismp.org/newsletters/acutecare/showarticle.asp?id=22). He emphasized that bypassing technology is not a good idea and does not fit into that model.

Dr Rich summarized his talk by delivering several “general safety pearls” that organizations can adopt to improve medication safety. These include establishing both a safety and a “just” culture, appointing a medication safety officer (MSO) and medication safety committee/subcommittee, using the ISMP’s quarterly action agendas, and addressing medication safety in annual budgets and department plans.

Michael R. Cohen, RPh, president of ISP, followed with a more detailed discussion of how organizations can improve medication error reporting and evaluation to improve medication safety.

Dr Cohen emphasized that along with identifying and reporting actual errors, it is also important to identify and report potential risks and near misses as well as the underlying causes of errors. He noted that errors generally have multiple underlying factors, which highlights the need for a multidisciplinary approach to medication safety. As such, he stressed the need for cooperation among physicians, nurses, physician assistants, and pharmacists, who all need to participate in reporting errors.

Dr Cohen also stressed the importance of reporting errors to an external organization such as ISMP to ensure action. He said that any error reported to the ISMP is automatically reported to the US Food and Drug Administration, so filing to both organizations is not necessary. Dr Cohen also emphasized that reporting an error to the ISMP is much simpler than filing an incident report with an insurance company because the ISMP requires only a narrative of the incident. He said that reasons practitioners report errors to the ISMP include the desire to promote change and prevent harm, the opportunity to receive feedback on product and practice changes, and confidence that their identity will not be revealed.

Dr Cohen emphasized the need to be proactive instead of reactive when reporting errors, and referred participants to the ISMP Quarterly Action Agenda as a great tool (https://www.ismp.org/Newsletters/acutecare/actionagendas.asp).

Finally, Dr Cohen discussed the need for organizations to create a culture of safety in which errors are not seen as a measure of competency, those who bring up issues are valued, and patient safety and reporting are rewarded. Elements that encourage error reporting in an organization include trustworthiness (ie, leaders use errors to assess system performance and not staff performance), guaranteed confidentiality for reporters, clear and easy understanding of the types of errors that should be reported, simplicity of the reporting process, rewards for reporting, and evidence of the credibility and usefulness of reporting errors.