Building Safer Medication-Use Systems
Resources from ISMP & ECRI
On August 14, 2026, according to a public statement by the Ascension Saint Thomas Hospital Midtown in Nashville, “an isolated medication error occurred in the pharmacy impacting four joint replacement patients. The patients mistakenly received potassium phosphate, instead of the intended anesthetic medication, mepivacaine.”
On August 21, Centers for Medicare & Medicaid Services (CMS) generated a survey report outlining safety concerns in the hospital including storage of high-alert medications and staff overriding pharmacy safety systems.
In the aftermath of these tragic cases of patient harm, our thoughts and sympathies are with the patients impacted and their loved ones, as well as the healthcare workers at this difficult time.
The following resources from ECRI and ISMP are designed to help healthcare organizations and practitioners take action to address safety gaps, mitigate risks and improve patient safety.
Targeted Medication Safety Best Practices for Hospitals
The ISMP Targeted Medication Safety Best Practices for Hospitals were developed to identify and mobilize widespread, national adoption of consensus-based Best Practices for specific medication safety issues that continue to cause fatal and harmful errors in patients. The recommendations are based on error reports received through the ISMP National Medication Errors Reporting Programs. They address many safety issues, including:
- Preventing errors during sterile compounding of medications (Best Practice 11).
- Enacting layered strategies to reduce risk of harm with high-alert medications (Best Practice 19). For additional information, see Implement High-Leverage and Layered Risk-Reduction Strategies Using ISMP’s Hierarchy of Effectiveness.
- Optimizing the use of barcode scanning and verification (Best Practice 24), which includes:
- Proactively scanning the barcode on new products received by the pharmacy to ensure there are no issues with scanning for end users.
- Develop an escalation process for barcode scanning failures and include steps for users to follow if a barcode will not scan.
- 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). - Technology vendors should optimize barcode scan alert language and sound for warnings and ensure end users are educated about the meaning of each alert generated when using barcode technology.
Additional resources are available to help hospitals implement the Best Practices:
- For each of the Best Practices, this Worksheet allows hospitals to document their implementation status, detail their plan for full implementation, and identify gaps in their safety practices.
- Frequently Asked Questions are available to help hospitals address challenges that may be raised when implementing the Best Practices.
Safe Sterile Compounding
The ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology were created to address safe practices related to the use of sterile compounding workflow management systems, automated compounding devices, and robotic compounding automation.
High-Alert Medications
The ISMP List of High-Alert Medications in Acute Care Settings was developed to raise awareness about high-alert medications, drugs that bear a heightened risk of causing significant harm when they are used in error.
Organizations should use this list to determine which medications require special safeguards to reduce the risk of errors, including potassium phosphates injection and any drugs administered via the epidural and intrathecal route. This includes strategies such as:
- Standardizing the ordering, storage, preparation, and administration of these products; improving access to information about these drugs
- Limiting access to high-alert medications
- Using auxiliary labels
- Employing clinical decision support and automated alerts
- Using redundancies such as automated or independent double checks when necessary (Note: manual independent double checks are not always the optimal error-reduction strategy and may not be practical for all medications on the list)
Medication Use in Perioperative and Procedural Settings
ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings were developed to address identified national gaps in perioperative and procedural medication safety, providing support for implementation of specific action plans to reduce harmful patient events.
Among other recommendations, the guidelines call for organizations to use an interdisciplinary team (e.g., pharmacy, nursing, anesthesia) to transition to the ISO 80369-6 design standards for neuraxial (NRFit) connectors to reduce the risk of misconnections. NRFit connectors are 20% smaller in diameter than luer connectors and prevent medications in medical devices meant for neuraxial administration from connecting to devices used for IV, enteral, and other applications and vice versa.
Education and Role of Simulation
The academic curricula for many healthcare practitioners often do not sufficiently cover topics such as medication safety, medication-use systems, and basic medication prescribing, preparation, and administration. Simulation is an evidence-based teaching method that can help facilitate the learning of important safety and quality aspects of patient care by replicating a process or system (e.g., preparing a medication using an intravenous workflow management system [IVWMS]) in a safe environment to gain insight.
ISMP has published several articles for members exploring education and competency development in medication preparation and sterile compounding practices. To learn more about member access, contact ClientServices@ECRI.org.
- Ensuring competency and safety when onboarding newly hired professional staff—Part I. ISMP Medication Safety Alert! Acute Care. 2023;28(8):1-4.
- The role of simulation when onboarding healthcare professionals—Part II. ISMP Medication Safety Alert! Acute Care. 2023;28(9):1-3.
- Another article, Advancing Medication Safety Through Simulation, along with a survey, is coming soon. Errors reported to ISMP mostly involve multiple system failures rather than a single point of breakdown. Contributing factors commonly include unclear communication, incomplete drug information, workflow challenges, and vulnerabilities in system design. This article will show how using real-world cases can help uncover system vulnerabilities that allow errors to occur.
- ISMP Foundations in Medication Safety program includes additional resources.
IV Workflow Management
Coming Soon: Evaluating IV Workflow Management Systems Through a Safety Lens | Current Capabilities, Persistent Gaps, and Unmet Needs: Med Safety Board (MSB), an ISMP company powered by ECRI, will be publishing a white paper on safe IVWMS practices.
Proactive Safe System Design
Preventable harm remains one of the most persistent challenges facing healthcare today. Consistently safe outcomes require systems proactively designed to support safe, reliable care and a just culture that prioritizes safety at every level. Learn more:
- Healthcare is a System
- Understanding Healthcare as a System: Video Series on Safer, Smarter Care
- Preventing the Preventable: How System Design and Safety Culture Transform Healthcare
- Creating a Culture of Safety in Healthcare: What It Really Takes
Contact: Yvonne Rhodes, YRhodes@ECRI.org, 484-531-5400