In our February 22, 2024 newsletter, we invited hospitals to participate in a short survey to establish a baseline of implementation for the three new Best Practices released in the 2024-2025 ISMP Targeted Medication Safety Best Practices for Hospitals. The three new Best Practices are associated with safeguarding against wrong-route errors with tranexamic acid (#20), implementing strategies to prevent medication errors at transitions in the continuum of care (#21), and safeguarding against errors with vaccines administered in the inpatient and associated outpatient settings (#22). We sincerely thank the hospitals that participated in our survey and shared their valuable lessons learned regarding the barriers and enablers for the new Best Practices. An overview of the survey findings is presented in Table 1 and detailed below.
Respondent Profile
More than four hundred (N = 427) respondents participated in our Best Practices survey. More than a quarter (26%) of them worked at hospitals with 500 beds or more; 18% with 300-499 beds; 28% with 100-299 beds; 13% with 26-99 beds; and 15% with 25 beds or less. Overall, nearly two-thirds (58%) reported employing one or more part- or full-time medication safety officer(s) (MSO). Most (85%) respondents were located in the United States/US territory, but we also heard from practitioners located in a US military foreign country/territory (1%) and other foreign countries/territories (14%).
New Best Practice 20: Safeguard against wrong-route errors with tranexamic acid
New Best Practice #20 consists of seven interventions designed to safeguard against wrong-route errors with tranexamic acid. Mix-ups with local anesthetics such as BUPivacaine and ROPivacaine have been reported due to similar cap color especially when the vials are stored upright near each other. When accidentally administered intrathecally, tranexamic acid injection is a potent neurotoxin with a mortality rate of about 50% and is almost always harmful to the patient. Survivors of intraspinal tranexamic acid often experience seizures, permanent neurological injury, and paraplegia. The first intervention recommends the use of point-of-care barcode-assisted medication safety checks prior to administering medications in surgical and obstetrical areas. More than a third (35%) reported full implementation, while another 47% reported partial implementation. Electronic health record (EHR) limitations and anesthesia staff resistance were the most frequently cited barriers to implementation. No enablers were reported.
The second intervention recommends, when appropriate, to use premixed intravenous (IV) bags of tranexamic acid, which are less likely to be confused with local anesthetic vials. Overall, 40% reported full implementation. Respondents reported shortages of premixed bags as a barrier. An enabler was having the pharmacy prepare and dispense premixed bags.
The third intervention recommends, if possible, not to store tranexamic acid in an anesthesia tray. For Best Practice #20, this intervention had the greatest number reporting full compliance (62%). The primary barrier to implementation was anesthesia providers' resistance to removing tranexamic acid vials from their trays. Some providers insisted the vials be readily available, or thought that mix-ups with other available vials were unlikely. No enablers were reported.
The fourth intervention recommends separating or sequestering tranexamic acid in storage locations (e.g., pharmacy, clinical areas) to avoid storing local anesthetics and tranexamic acid near one another. Sixty-one percent reported full implementation. Limited storage space was a barrier to implementation. An enabler was not storing tranexamic acid outside of the pharmacy.
The fifth intervention recommends avoiding storage of injectable medication vials in an upright position, especially when stored in a bin or drawer below eye level, to prevent misidentifying medications by viewing only the vial caps. Store medication vials in a way that always keeps their labels visible. Thirty-eight percent reported full implementation. Frequently cited barriers were that this process was reliant on humans to remember, users can still change the vial orientation, and space constraints do not always allow for this to occur. Enablers were continuous education to staff before and after implementation.
The sixth intervention recommends conducting a review to identify any look-alike ampules or vials (including caps) and determine if the risk of a mix-up will be reduced by purchasing them from different manufacturers. If so, purchase them from different manufacturers. One-third (33%) reported full implementation, while another 43% reported partial implementation. Frequently cited barriers to implementation included drug shortages, purchasing based on cost, and not having enough time or resources to complete a product review. An enabler was implementing a yearly review by the MSO.
The seventh intervention is to consider labeling vial caps with a label that states, “Contains Tranexamic Acid.” Of the seven interventions for Best Practice #20, this had the lowest reported full implementation (17%), with almost three-quarters (74%) reporting no implementation. Several respondents reported that they did evaluate this, but opted not to add auxiliary labels due to the concern about label fatigue resulting in staff not reading the labels, or because this was too labor-intensive and not feasible with the pharmacy workload. Others told us they did not know this was a recommendation and planned to review this with their team.
New Best Practice 21: Prevent medication errors at transitions in the continuum of care
New Best Practice #21 consists of six interventions to prevent medication errors at transitions in the continuum of care. The first intervention is to obtain the most accurate medication list feasible upon admission to the organization before the first dose of medication is administered (except in emergency or urgent situations). Nearly half (46%) reported full implementation, while another 52% reported partial implementation. Barriers were a lack of staff to obtain this information, not having a consistent policy or process, and lack of communication (e.g., staff, patients, pharmacies). Enablers included having a designated medication reconciliation technician team, and implementing widespread education for staff involved in medication reconciliation. One respondent said they turned to a remote medication reconciliation service to help ensure this was completed.
The second intervention recommends asking about allergies and associated reactions, prescription and over-the-counter medications (including herbals and dietary supplements), and non-enteral medications. Nearly two-thirds (63%) reported full implementation, and only 1% reported no implementation. Barriers included labor, budget, and time constraints. Enablers were implementing a standard checklist or scripting for staff to use as a tool.
The third intervention recommends listing the drug name, dose, route, frequency, indication, and time of the last dose. More than half (53%) reported full implementation, while another 45% reported partial implementation. The primary barriers to implementation were that this information was not readily available, and that the indication and last dose were not required fields in the EHR. However, those who were able to implement this reported an enabler was building these fields into the EHR to facilitate documentation.
The fourth intervention recommends considering assigning dedicated practitioners to obtain the medication histories. More than a third (36%) reported full implementation, while another 42% reported partial implementation. Respondents indicated that not having enough staff to complete this 24 hours a day was a barrier to implementation. Sometimes this was due to cost; with one respondent referring to this as an “unreimbursed expense.” Enablers included a robust 24/7 medication reconciliation technician program, or using a remote medication reconciliation service.
The fifth intervention recommends ensuring the medication and doses collected and subsequently ordered are the correct therapy for that patient, given their current state of health. More than half (57%) reported full implementation. Respondents acknowledged that pharmacy technicians and nurses obtaining the medication list were not able to determine the appropriateness of the medication for the patient’s condition as this is outside their scope of practice. Enablers were having prescribers or pharmacists evaluate appropriateness after the medication history was completed.
The sixth intervention recommends designating a provider to compare the prescribed medications to those on the medication history list and resolve any discrepancies. In addition, have providers document reconciliation and modifications made to the current therapy upon admission, with each change in level of care, and at discharge. Forty percent reported full implementation, while another 47% reported partial implementation. Reported barriers included the cost to monitor compliance, resources, and time to complete this in a quality manner. Some said physicians are not required to do this. Enablers were building this into the EHR at the required transitions of care, and establishing and maintaining collaborative relationships between providers and pharmacy.
New Best Practice 22: Vaccine safety
New Best Practice #22 consists of 10 interventions to safeguard against errors with vaccines administered in the inpatient and associated outpatient settings. The first intervention recommends using standard order sets to prescribe vaccines; requiring an order prior to administration of any vaccine; utilizing the full generic name and brand name (if applicable); and avoiding vaccine abbreviations, which some staff may confuse or not even be familiar with. Full implementation was reported by more than half (52%) of the respondents. Barriers were that order sets were not available for all vaccine orders, and that abbreviations were used in the EHR. Some respondents told us they were compliant for inpatient vaccine orders, but not outpatient vaccine orders. Enablers were building order sets, and using generic/brand names without abbreviations in the EHR.
The second intervention recommends verifying a patient’s immunization status (in the EHR as well as vaccine registries) prior to providing vaccines. These systems track the vaccines that patients have received and can prevent duplication or omission errors. Forty-eight percent reported full implementation, and another 41% reported partial implementation. Some respondents reported that in its current state, their EHR system did not have the capability to pull in the vaccine registry for automatic screening upon order entry, while others said this is being addressed by an upcoming EHR upgrade.
The third intervention recommends providing patients and/or caregivers with vaccine information (e.g., Vaccine Information Statement [VIS]) in their primary language prior to vaccination. Sixty-five percent reported full compliance. Respondents reported budget, workforce, and availability of interpretation services as barriers. Similar to other interventions, enablers included having this prebuilt in the EHR.
The fourth intervention recommends storing vaccines in separate bins or containers based on type and formulation, and storing two-component vaccines together to assist with proper mixing. Nearly three-fourths (72%) reported full implementation. The most frequently reported barrier was not having enough space, along with inconsistencies in storage among locations.
The fifth intervention recommends using prefilled syringes when available; and if not available, preparing each vaccine dose immediately prior to administration and labeling with the vaccine name, dose, and, if appropriate, the indicated age range. Sixty-nine percent reported full implementation. Barriers included time constraints, lack of staff education about how to label syringes, and space limitations that prevent the ability to store prefilled syringes. An enabler was the organization evaluating which vaccines are available in prefilled syringes and purchasing them, when possible.
The sixth intervention recommends that when multiple adults and children are being vaccinated at the same time, patients should be separated into distinct treatment areas; bringing only one patient’s vaccines into the area at a time. Just over one-half (51%) reported full implementation. The most frequent barrier was not having enough space or patient rooms to allow for this. One respondent told us this is feasible in the inpatient setting, but presented safety challenges in the outpatient setting. As an example, they stated a child cannot be left alone during the clinic visit if a parent brings multiple young children to be vaccinated. An enabler was including this in the organization’s policy and procedure.
The seventh intervention recommends verifying the patient’s identity using two unique identifiers. This intervention had the greatest number reporting full compliance (89%). A barrier was that although some outpatient pharmacies have built this into their systems and processes prior to dispensing medication prescriptions, this was not built into the process prior to vaccine administration. Other respondents said that room numbers were still used rather than unique patient identifiers. An enabler was analyzing and learning from barcode medication administration (BCMA) data.
The eighth intervention recommends using barcode scanning technology to verify the correct vaccine and dose are administered to the correct patient. Sixty percent reported full implementation, with over a quarter (27%) reporting partial implementation. The most frequent barrier to implementation was that outpatient areas did not have the technology to do this (e.g., barcode scanners). Others shared that frontline staff did not understand the benefits of using BCMA. Although enablers were not reported, organizations should consider sharing and learning from internal and external errors that could have been avoided had BCMA been used, as well as close calls (i.e., good catches) that demonstrate how the use of BCMA prevented patient harm.
The ninth intervention is to document the vaccine’s national drug code (NDC) number, lot number, and expiration date prior to administration; document administration in the EHR; and ensure information is sent to the local or state vaccine registry. More than three-quarters (76%) reported full implementation. Barriers and enablers were opposed, meaning those who did not implement this told us this was not a required field in the EHR, versus those who were doing this consistently, had this built as a required field in the EHR.
The tenth intervention is to provide vaccinators with ongoing education and competency assessment about vaccines and their appropriate storage, selection, administration, and monitoring. Fewer than half (49%) reported full implementation. Barriers included not having resources to educate staff or to create and complete competency assessments. An enabler was having a dedicated clinical educator to oversee this process.
Conclusion
These survey results suggest there is room for improvement with the three new Best Practices. We hope that hospitals will use these survey results to prompt interdisciplinary discussions that take note of the barriers and enablers while implementing these Best Practices. Notably, the most frequently reported enabler among all interventions was building the particular requirement into the EHR. An Implementation Worksheet (www.ismp.org/node/1506) for all of the Best Practices is available and might be helpful to document your assessment of implementation status, actions required, and assignments.
Suggested citation:
Institute for Safe Medication Practices (ISMP). Survey shows room for improvement with three new best practices for hospitals. ISMP Medication Safety Alert! Acute Care. 2024;29(12):1-6.
