ISMP releases Top 10 list of medication errors and hazards in 2020

A list of the Top 10 most persistent medication errors and hazards with extended-release opioids and use of infusion pumps in acute care has been published in an ISMP1 Newsletter.

The ISMP − a US-based nonprofit organisation that is devoted entirely to preventing medication errors − stated that it "believes that these issues merit attention and priority if action has not already been taken to mitigate risk, and the newsletter article provides specific prevention recommendations".

In addition, the ISMP noted that "two of the top 10 categories identified are closely associated with the pandemic−errors with COVID-19 vaccines and risks associated with positioning infusion pumps outside COVID-19 patients' rooms".

The ISMP's Top 10 list of medication errors and hazards for 2020 are as below:

• prescribing, dispensing and administering extended-release opioid analgesics to opioid-naïve patients;

• not using smart infusion pumps with dose error-reduction systems (DERS) in perioperative settings;

• errors associated with administration of oxytocin;

• hazards associated with positioning infusion pumps outside of the rooms of COVID-19 patients;

• errors associated with administration of COVID-19 vaccines;

• use of the retrospective, proxy "syringe pull-back" method of verification during pharmacy sterile compounding;

• combining or manipulating commercially available sterile products outside the pharmacy;

• medication loss in the tubing when administering small-volume infusions via a primary administration set;

• wrong route (intraspinal injection) errors with tranexamic acid; and

• use of error-prone abbreviations, symbols, or dose designations.

The ISMP said that it hoped that the above-mentioned medication errors and hazards "become an essential part of healthcare organizations' strategic medication safety improvement plans this year".