ISMP Publishes Top Medication Errors and Hazards for 2021

The Institute for Safe Medication Practices (ISMP) published its list of top medication errors and hazards to help physicians and health systems effectively manage risks associated with medication administration. The compilation, says ISMP, highlights common errors that emerged over the past year and pose a significant threat to patient safety. Two of the ten problems are directly tied to the COVID-19 pandemic.

These concerns can be prevented with focused attention and prioritization that results in system and practice changes, says ISMP. The institute’s top medication errors, and the associated risk mitigation strategies, include, but are not limited to, the following:

1. Implementation of a standard process that prevents inappropriate distribution of extended-release opioid prescriptions to opioid-naïve patients;
2. Use of at least five letters of a drug name to ensure accuracy when searching electronic prescribing systems for Oxytocin;
3. Planning and periodic reassessments that reduce the risk of hazards linked to infusion pumps positioned outside of COVID-19 patients’ rooms;
4. Adoption of strategies that prevent common COVID-19 vaccine errors, including faulty dilution resulting in incorrect dosage, waste of dosages due to faulty preparation, incorrect syringe selection and more. (See our review of ISMP’s Safe Practices for Preventing COVID-19 Vaccine Error);

5. Regular updates to the “Do Not Use” medication abbreviation list to avoid misunderstandings and misinterpretations related to dosing, routes of administration and drug selection.

The complete list of medication errors and hazards is available on the ISMP website.

Additionally, MLMIC policyholders are encouraged to monitor our blog and review the following Risk Management Tips with recommendations for minimizing risks associated with medication mishaps:

• Prescription Medications and Patient Safety, a tip with recommendations for prescribing and monitoring the use of medications to promote patient health and safety;

• Managing Medication Samples, a tip on the safe management of medication samples to help prevent errors and subsequent patient injuries; and

• Promoting Adherence to a Medication Regimen, a tip on educating patients on the use of medications and potential drug interactions, side effects, and other related problems.