Seeking expertise from external sources and learning about errors that have occurred in other hospitals prompts the evaluation of similar risks within your own organization that may otherwise be hidden, lying dormant for years before they cause or contribute to an adverse outcome. Described below are five themes that ISMP consulting services staff frequently encounter during hospital consulting engagements, many of which relate to one of our ISMP Targeted Medication Safety Best Practices for Hospitals.
Theme 1: Patient Weights
There is a common practice to weigh patients in pounds rather than kilograms or grams in the United States. Some organizations’ digital scales do not default to metric units, or they allow practitioners to toggle between pounds and kilograms. In addition, some electronic health record (EHR) systems allow practitioners to enter weight in pounds/ounces or kilograms/grams, and the user is required to type “lb” or “kg.” This practice has been linked to errors, where the patient's weight in pounds was entered as kilograms and vice versa.
Organizations should measure and document patient weights in metric units only (Best Practice 3). If scales can measure in both pounds/ounces and kilograms/grams, modify the scale to lock out the ability to weigh in pounds/ounces, so only metric units are displayed. If purchasing or replacing scales, buy new scales that measure in, or can be locked to measure in, metric units only. Have resources (e.g., 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 EHR screen views and medication device screens (e.g., infusion pumps) prompt for the patient’s weight in metric units only.
Theme 2: Patient ID and BCMA
There are inconsistencies in patient identification (ID) processes across different patient care areas within an organization. In some locations, particularly in ambulatory settings, patients may not receive ID bands. There are also challenges with barcode scanning devices, including not having a sufficient number of wireless handheld devices available, leading to delays in medication administration. In addition, barcode medication administration (BCMA) is not consistently used for all medications and vaccines, especially in outpatient areas, emergency departments (EDs), and certain diagnostic and procedural areas.
Barcode scanning is critical for safe medication use. Standardize patient ID processes across all areas where patient encounters occur and ensure all patients receive and wear an ID band that is scanned before any test or procedure is initiated, or medication is administered. Regularly review compliance and other metrics to assess utilization and effectiveness of this safety technology (e.g., scanning compliance rates, bypassed or acknowledged alerts). Address challenges with barcode scanning compliance by improving scanner reliability and ensuring sufficient handheld devices are available. Best Practice 18 calls for maximizing the use of barcode verification prior to medication and vaccine administration by expanding use beyond inpatient care areas. Specifically target clinical areas with an increased likelihood of a short or limited patient stay (e.g., ED, perioperative areas, infusion clinics, dialysis centers, radiology, labor and delivery areas, catheterization laboratories, outpatient areas). Complete walk rounds to understand practices that lead to BCMA workarounds. BCMA may be suboptimally implemented due to issues with software (e.g., EHR configuration, connectivity) or hardware (e.g., broken or missing scanners). Develop and implement strategies that address system issues and support safe clinical workflow.
Theme 3: Medication Reconciliation
Medication reconciliation is inconsistently performed, particularly during transitions of care and at discharge. Organizations do not always allocate resources for completing accurate medication histories as close to the time of admission as possible. There is often a lack of clarity in the role of the prescriber, nurse, pharmacist, and pharmacy technician during the medication reconciliation process. For example, some organizations do not designate or have a clear expectation as to which practitioner is responsible for removing outdated medications from the patient’s home medication list.
Best Practice 21 specifies the need to assign dedicated and trained practitioners to obtain thorough medication histories. Ideally, this list would be available to providers before admission orders are written so that they can compare the planned medications to those on the medication history list to ensure they are appropriate and then resolve any discrepancies. Providers need to document reconciliation and modifications made to the current therapy upon admission, with each transition of care, and at discharge. Develop a system-wide medication reconciliation policy that addresses the steps in the reconciliation process, defines the specific roles of each practitioner (e.g., pharmacy technician, pharmacist, prescriber, nurse) in the process, and the expectations during transitions of care and at discharge. Utilize specific process measures to monitor the success of the medication reconciliation process.
Theme 4: Opioid Status Management
Organizations do not clearly define the terms "opioid-naïve" or "opioid-tolerant" and what each practitioner's role is regarding pain management. Most organizations that were visited do not require practitioners to assess and document the patient’s opioid status on admission or to assess if the patient is at high risk for opioid-induced respiratory depression before prescribing, dispensing, or administering opioid medications. Practitioners are not educated during orientation or annually on the treatment differences based on a patient's opioid status.
Organizations must ensure that a patient's opioid status and risk for opioid-induced respiratory depression is evaluated and documented in the EHR before ordering, verifying, or administering opioids. Establish a process to verify and document a patient’s opioid status (naïve versus tolerant) and the type of pain (acute versus chronic) before prescribing and dispensing extended-release and long-acting opioids (Best Practice 15). For adults, opioid-tolerance may be defined as 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. Patients who do not meet “opioid-tolerant” criteria are considered “opioid-naïve” and require lower starting doses of opioids or alternative analgesics for pain management. Default order entry systems to the lowest initial starting dose and frequency when initiating orders for extended-release and long-acting opioids. Build clinical decision support (CDS) to 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.
Theme 5: Clinical Decision Support (CDS)
There is an opportunity to enhance CDS during medication prescribing and verification. Collection of essential patient information, such as allergies and weight, is not enforced with hard stops during prescriber order entry or pharmacist verification. In addition, some EHR systems have safety gaps that allow critical warnings (e.g., anaphylactic reaction to a medication) to be easily bypassed by prescribers and pharmacists. Renal dose adjustments, drug-allergy interactions, and drug-diagnosis warnings often lack effective alerts or are easily overridden. Prescribers intending to order methotrexate for weekly administration may have an option to select an every 12-hour frequency from a dropdown list, or there may not be a hard stop to verify an appropriate oncologic indication for any daily oral methotrexate orders. Management of medications with specific formulary restrictions may rely on the verifying pharmacist to remember which drugs have restrictions and the medication-specific limitations for use.
Organizations must have a standardized process and build required fields to document essential patient information before prescribing or verifying medications. Enhance CDS systems by implementing critical medication warnings, including those related to dose range checking, renal dosing, drug-allergy interactions, and drug-disease state interactions. Hard stops should be used to prevent absolute contraindications or catastrophic errors. For example, require a hard stop verification of an appropriate oncologic indication for any daily oral methotrexate orders (Best Practice 2). Gather metrics regarding CDS override reasons to determine whether practitioner-documented reasons and/or overrides of warnings are appropriate. Monitor for nuisance alerts and refine system settings as needed. Additionally, move toward electronic management of formulary restrictions and Risk Evaluation and Mitigation Strategies (REMS) requirements instead of relying on pharmacists to manually recall specific drug limitations.
Summary
We encourage organizations to review and learn from these five commonly occurring risks and mitigation strategies. Whether you are an individual healthcare organization, pharmacy, ambulatory care practice site, long-term care facility, or represent a large multi-site healthcare enterprise, ISMP Consulting Services can help proactively identify hidden vulnerabilities and provide you with an unbiased analysis, a customized roadmap, and ongoing guidance to significantly reduce and prevent harm within your organization. For more information visit: Consulting Solutions.
Suggested citation:
Institute for Safe Medication Practices (ISMP). Take action on the top five themes identified during ISMP consultations. ISMP Medication Safety Alert! Acute Care. 2025;30(17):1-3.
