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News Release

ISMP Adds Three New Best Practices to Its 2022-2023 List for Hospitals

Healthcare organizations that are deciding on the focus for their medication safety efforts during the year can now rely on updated recommendations from the Institute for Safe Medication Practices (ISMP). ISMP has issued its 2022-2023 Targeted Medication Safety Best Practices for Hospitals to help identify, inspire, and mobilize widespread national action to address recurring problems that continue to cause fatal and harmful errors despite repeated warnings in ISMP publications.

The current list includes new Best Practices on preventing errors with oxytocin and high-alert medications as well as maximizing the use of barcode verification by expanding beyond inpatient areas. In addition, five best practices were archived this year or incorporated into other items. “The Best Practices address safety issues that ISMP continues to receive numerous reports about,” says Christina Michalek, BS, RPh, FASHP, Medication Safety Specialist and Administrative Coordinator for the Medication Safety Officers Society (MSOS). “Although targeted for the hospital setting, they can be applicable to other areas of healthcare as well.”

The new Best Practices that have been added for 2022-2023 are:

Safeguard against errors with oxytocin use.

  • Require the use of standard order sets for prescribing oxytocin antepartum and/or postpartum that reflect a standardized clinical approach to labor induction/augmentation and control of postpartum bleeding.

  • Standardize to a single concentration/bag size for both antepartum and postpartum oxytocin infusions (e.g., 30 units in 500 mL Lactated Ringers).

  • Standardize how oxytocin doses, concentration, and rates are expressed. Communicate orders for oxytocin infusions in terms of the dose rate (e.g., milliunits/minute) and align with the smart infusion pump dose error-reduction system (DERS).

  • Provide oxytocin in a ready-to-use form. Boldly label both sides of the infusion bag to differentiate oxytocin bags from plain hydrating solutions and magnesium infusions.

  • Avoid bringing oxytocin infusion bags to the patient’s bedside until it is prescribed and needed.


Maximize 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., emergency department, perioperative areas, infusion clinics, dialysis centers, radiology, labor and delivery areas, catheterization laboratory, outpatient areas).

  • 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).


Layer numerous strategies throughout the medication-use process to improve safety with high-alert medications.

  • For each medication on the facility’s high-alert medication list, outline a robust set of processes for managing risk, impacting as many steps of the medication-use process as feasible.

  • Ensure that the strategies address system vulnerabilities in each stage of the medication-use process (i.e., prescribing, dispensing, administering, and monitoring) and apply to prescribers, pharmacists, nurses, and other practitioners involved in the medication-use process.

  • Avoid reliance on low-leverage risk-reduction strategies (e.g., applying high-alert medication labels on pharmacy storage bins, providing education) to prevent errors, and instead bundle these with mid- and high-leverage strategies.

  • Limit the use of independent double checks to select high-alert medications with the greatest risk for error within the organization. (e.g., chemotherapy, opioid infusions, intravenous [IV] insulin, heparin infusions).

  • Regularly assess for risk in the systems and practices used to support the safe use of medications by using information from internal and external sources (e.g., Food and Drug Administration (FDA), The Joint Commission, ISMP).

  • Establish outcome and process measures to monitor safety and routinely collect data to determine the effectiveness of risk-reduction strategies.


ISMP began issuing Best Practices in 2014. The recommendations are based on error reports received through the ISMP National Medication Errors Reporting Program (ISMP MERP) and are reviewed by an external expert advisory panel and approved by the ISMP Board of Directors. They are designed to set realistic goals, which have already been adopted by numerous organizations.

For a copy of the 2022-2023 ISMP Targeted Medication Safety Best Practices for Hospitals, visit: Access may require free registration.


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