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News Release

First ISMP Targeted Medication Safety Best Practices for Community Pharmacy Released

Focus Areas Include Wrong-Patient Errors, Barcode Verification, and Oral Methotrexate Dosing

The Institute for Safe Medication Practices (ISMP) has developed the first set of specific, consensus-based guidance to help prevent persistent medication safety issues in community pharmacy and the potential patient harm that can result. The 2023-2024 ISMP Targeted Medication Safety Best Practices for Community Pharmacy identify areas where greater action is needed.

To best protect public health, ISMP encourages community pharmacies to focus their medication safety efforts for the next two years on these best practices, which are designed to be practical and have already been successfully adopted by numerous organizations. While targeted for the community pharmacy setting, some best practices are applicable to other healthcare settings, such as ambulatory, mail order, specialty pharmacy, long-term care, and home infusion.

“Many types of errors recur in community pharmacies, and more can be done to implement technology and procedures to prevent them,” says ISMP’s Michael J. Gaunt, PharmD, Senior Manager, Error Reporting Programs. “There is a natural human tendency to ‘normalize’ errors that happen in other facilities, but community pharmacy leaders have a role to play in conveying that errors present learning opportunities and steps should be taken to prevent them from happening in their own organization.”

The 2023-2024 community pharmacy best practices address the following issues:

  • Preventing wrong patient errors when filling prescriptions, responding to questions, and administering vaccines

  • Expanding and maximizing the use of barcode scanning during medication and vaccine dispensing

  • Avoiding errors involving inadvertent daily dosing of methotrexate for non-cancer indications

  • Standardizing the use of metric (milliliter--mL) units of measure when prescribing, dispensing, and measuring oral liquid medications

  • Using information about medication safety risks and errors that have occurred in other organizations to take preventative action

ISMP launched its medication safety best practices for hospitals in 2014; as with the acute care version, the community pharmacy best practices will be updated as needed every two years. Best practices are reviewed by an outside Expert Advisory Panel. The development of the 2023-2024 ISMP Targeted Medication Safety Best Practices for Community Pharmacy was supported by Novartis, Name Creation & Regulatory Strategy.

For a copy of the new best practices and an implementation worksheet tool, click here


Renee Brehio, Medication Safety Analyst and Editor,

About the Institute for Safe Medication Practices

The Institute for Safe Medication Practices (ISMP) is the nation’s first 501c (3) nonprofit organization devoted entirely to preventing medication errors. ISMP is known and respected for its medication safety information. For more than 30 years, it also has served as a vital force for progress. ISMP’s advocacy work alone has resulted in numerous necessary changes in clinical practice, public policy, and drug labeling and packaging. Among its many initiatives, ISMP runs the only national voluntary practitioner medication error reporting program, publishes newsletters with real-time error information read and trusted throughout the global healthcare community, and offers a wide range of unique educational programs, tools, and guidelines. In 2020, ISMP formally affiliated with ECRI to create one of the largest healthcare quality and safety entities in the world, and ECRI and the ISMP PSO is a federally certified patient safety organization by the U.S. Department of Health and Human Services. As an independent watchdog organization, ISMP receives no advertising revenue and depends entirely on charitable donations, educational grants, newsletter subscriptions, and volunteer efforts to pursue its life-saving work.


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About ISMP

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