Michael J. Gaunt, PharmD

The FDA and the Institute for Safe Medicaiton Practices have received numerous reports of errors related to Paxlovid (nirmatrelvir and ritonavir).

Paxlovid is indicated for the treatment of mild to moderate COVID-19 in patients 12 years or older who weigh at least 40 kg, have tested positive for SARS-CoV-2, and are at elevated risk for progression to severe COVID-19, including hospitalization or death. The reports have mentioned pre- scribing or dispensing the wrong strength, improper renal dosing, and self-administration errors.

Paxlovid is available in 2 configurations. For patients with normal renal function (estimated glomerular filtration rate [eGFR] ≥90 mL/min) or mild renal impairment (eGFR <90 mL/min but ≥to 60 mL/min), Paxlovid is available in a carton of 30 tablets contained in 5 daily-dose blister cards. Each blister card contains 4 nirmatrelvir tablets (150 mg each) and 2 ritonavir tablets (100 mg each). Patients should take 2 tablets of nirmatrelvir (150 mg each for a total of 300 mg) and 1 tablet of ritonavir (100 mg) in the morning and the same dose in the evening. Patients with severe renal impairment (eGFR <30 mL/min) should not receive the drug.

When Paxlovid first became available, pharmacists had to remove 1 of the 2 nirmatrelvir tablets for morning and eve- ning doses from each of the blister cards before dispensing the drugs to patients with moderate renal impairment. In some cases, extra tablets were not removed or pharmacies removed ritonavir instead of nirmatrelvir. To mitigate these risks, in April 2022, cartons of Paxlovid for patients with moderate renal impairment became available with reduced-dose blister packages designed to provide just 1 tablet of nirmatrelvir (150 mg) and 1 tablet of ritonavir (100 mg) for twice-daily administration. Each carton contains 20 tablets in 5 daily-dose blister cards.

Many of the errors reported occurred when patients took the medication and generally involved taking the wrong tablets (eg, 3 of nirmatrelvir but no ritonavir, 1 of nirmatrelvir and 2 of ritonavir, or the entire day’s dose at one time). Dispensing errors involved giving the carton with reduced-dose blister packages to patients with mild renal impairment or normal renal function. Several reported errors involved improper renal dosing, such as prescribing or dispensing Paxlovid to patients with severe renal impairment. Other errors included ordering the standard dose for patients with moderate renal impairment, not checking concomitant drug use or renal function to avoid drug-drug interactions, prescribing the incorrect quantity (eg, 30 tablets for moderate renal impairment dosing), and providing directions to take 2 tablets twice a day in conflict with the instructions on the package prescribed.

 Educate physicians about the availability of reduced-dose blister packages for patients with moderate renal impairment. Remind them to avoid prescribing and dispensing Paxlovid to patients with severe renal impairment.

Check the electronic health record (EHR) and prescribing system configuration.

 Check EHR or prescribing system to see how the dose- and tablet-strength fields are displayed. On drop-down menus, it is safest to list the strength of Paxlovid as a 300-mg and 100-mg dose pack for normal renal function and as a 150-mg and 100-mg dose pack for moderate renal impairment.

 Include dose guidance for Paxlovid in prescribing systems. For instance, mention the reduced dosing required for patients with moderate renal impairment.

Check the patient’s renal function before dispensing Paxlovid. Use the FDA’s Paxlovid Patient Eligibility Screening Checklist Tool for Prescribers to support clinical decision-making and screen for significant drug interactions (fda.gov/media/158165/ download). Document the patient’s most recent eGFR and date on prescriptions. Pharmacists without access to the patient’s medical record must contact the prescriber if this information is not included.

Avoid communicating the dose by tablet or blister color.

 Do not refer to the tablets as pink (nirmatrelvir) and white (ritonavir) or by the color of the blister package because this can cause patients to misunderstand which medications they should take.

 Designate Paxlovid prescriptions as needing mandatory patient education. Show patients how the drug is labeled on the blister pack and teach them about the 2 medications they’ll be taking. Encourage them to remove each tablet just prior to taking it (ie, do not transfer to pillbox). Give patients the Fact Sheet for Patients, Parents, and Caregivers (fda. gov/media/155051/download).

 is a senior director of error reporting programs and editor at the Institute for Safe Medication Practices (ISMP) in Horsham, Pennsylvania. He also serves as the editor of the monthly ISMP Medication Safety Alert! Community/Ambulatory Care newsletter.

Articles

Take steps to safeguard prescribing, dispensing, and patient use of the COVID-19 antiviral medication.

Mitigate Risk for Errors Involving Paxlovid

In the safety briefs below, we look at drug interactions with the combination of nirmatrelvir and ritonavir (Paxlovid) and wrong route errors with topical drugs.

A physician prescribed Paxlovid for a patient aged 34 years with flulike symptoms who tested positive for COVID- 19. On day 3 of treatment, the patient visited the prescribing physician and presented with fatigue and bradycardia, with a heart rate below 40 beats per minute. The physician referred the patient to the emergency department (ED) for further evaluation, where it was discovered that the patient had been taking ivabradine for premature ventricular contractions. Ivabradine is metabolized by the CYP3A4 enzyme, and the ritonavir component of Paxlovid is a strong cytochrome P450 (CYP) 3A4 inhibitor. Thus, concomitant use of ivabradine and Paxlovid is contraindicated because of the risk of ivabradine accumulation and toxicity, which could lead to bradycardia, heart failure, and hypotension. Increased plasma concentrations of ivabradine may also exacerbate bradycardia and conduction disturbances. Fortunately, the patient was monitored in the ED for 24 hours, recovered, and was discharged.

The practitioner who reported this event to the Institute for Safe Medication Practices (ISMP) mentioned that the prescriber was not familiar with the patient’s medical history. Paxlovid should not be prescribed without reviewing the patient’s medication list for potential drug interactions. Pharmacists and prescribers should test their computer systems to ensure they provide alerts for this and other drug interactions. The FDA’s Paxlovid Patient Eligibility Screening Checklist Tool for Prescribers (fda.gov/ media/158165/download) can be used for screening but does not list ivabradine as a drug with potentially significant interactions.

Educate patients, pharmacy staff members, and prescribers about the potential for Paxlovid drug interactions. In addition to the FDA’s tool, other resources that practitioners can use to learn about Paxlovid drug interactions include the following:

COVID-19 Drug Interactions (www.covid19-druginteractions.org/checker) from the University of Liverpool in England

Drug-Drug Interactions Between Ritonavir-Boosted Nirmatrelvir (Paxlovid) and Concomitant Medications (www.covid19treatmentguidelines.nih.gov/therapies/antiviral-therapy/ritonavir-boosted-nirmatrelvir--paxlovid-/paxlovid-drug-drug-interactions/) from the National Institutes of Health

Management of Drug Interactions with Nirmatrelvir/Ritonavir (Paxlovid): Resource for Clinicians (www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/management-of-drug-interactions-with-nirmatrel- virritonavir-paxlovid/), from the Infectious Diseases Society of America

Topical Gel Dispensed in an ENFit Syringe Given Via G-Tube

A chronic pain service provider prescribed a topical gel containing amitriptyline 1% and ketamine 1% for an inpatient with a gastrostomy tube (G-tube). The pharmacy-compounded gel (1 mL) was packaged in ENFit syringes, which were labeled with the ingredients and topical route of administration. While administering several oral liquid medications packaged in ENFit syringes via the patient’s G-tube, a nurse accidentally administered the topical gel that way, too. The topical gel was scheduled for application at the same time as the enteral liquid medications. Fortunately, there were no systemic effects from the drug and the patient was not harmed.

Although it may not be considered “unit dose,” it would be safer to package compounded topicals in available tubes or jars. Yet, packaging topical products in oral syringes appears to be a widespread practice at many compounding pharmacies, facilities, and outsourcers. After conversion to ENFit, oral syringes may no longer be available, because ENFit syringes can be used in place of oral syringes. Such was the case at the facility that reported this error.

The facility is exploring unit dose blister packs that are typically used for repackaged solid oral dosage forms for packaging and dispensing of low-volume topical ointments and gels.

Still, whenever a substance meant for one route is placed in packaging meant for another, the chance of administering the medication by the wrong route is increased. For example, the ISMP previously reported errors related to accidental injection of topical thrombin that was placed in a parenteral syringe.

Topical medications should never be placed in a parenteral syringe because the consequences of administering a topical medication by a parenteral route could be devastating.

The primary strategy for preventing this type of error is to package a topical medication in a container that practitioners would expect, such as jars or tubes.

But if a facility must use an ENFit or oral syringe to package a topical product, affix a prominent auxiliary label stating “For External Use Only” over the syringe cap, as well as on the immediate container, to cover any incorrect route-specific instructions.

Note that some syringes state “For Enteral Use” or “For Oral Use,” which would communicate the wrong route.

Pharmacies should track patients who have feeding tubes, which will soon all be ENFit.

When possible, avoid scheduling topical medications packaged in an oral or ENFit syringe at the same time enteral or oral drugs
are administered.

 is a senior director of error reporting programs at the Institute for Safe Medication Practices in Horsham, Pennsylvania.

Accidental injection of topical thrombin continues. Institute for Safe Medication Practices. January 12, 2017. Accessed June 11, 2022. https://www.ismp.org/resources/accidental-injection-topical-thrombin-continues

Resources for health care professionals include FDA’s patient eligibility screening checklist tool for prescribers.

Prevent Drug Interactions With Paxlovid

The Institute for Safe Medication Practices (ISMP) has received reports about patients swallowing desiccant tablets that are packaged within blister cards holding everolimus tablets from Biocon Biologics.

Everolimus is used primarily to prevent rejection after liver or renal transplant and to treat certain forms of breast or renal cancer and noncancerous fat and muscle tumors in the kidney (renal angiomyolipoma). The medication is available in 2.5-, 5-, 7.5-, and 10-mg tablets. Each strength is packaged as a carton of 4 blister cards, and each blister card has 4 blisters containing desiccant tablets and 7 blisters containing everolimus tablets. The desiccant blisters are labeled with “Desiccant Do Not Eat” (Figure), but this warning is printed on only 1 side of the blister card; the other side contains no wording. Patients viewing the blank side of the blister may push a desiccant tablet through without realizing it. Although the desiccant tablets look different from the everolimus tablets, they can still be easily mistaken for medication-containing tablets. Thus, patients have accidentally ingested a desiccant tablet instead of an everolimus tablet.

Since February 1, 2021, the ISMP National Medication Errors Reporting Program and the FDA Adverse Event Reporting System have received 13 reports related to this issue. Although at least 8 manufacturers provide everolimus tablets in blister packaging, all the reports submitted to the FDA and ISMP involve the product from Biocon Ltd, which is the only company that packages desiccants with the tablets in blister cards. The cases frequently involved older patients for whom poor vision may have contributed to the confusion. Furthermore, the small font size and light tan color of the drug name and dose on the labeled side of the card are difficult to see on the foil blisters (Figure).

Two patients almost ingested the desiccant. In one case, a non–English-speaking patient became confused about the desiccant blisters and thought he was supposed to swallow them along with the medication. Luckily, he called the pharmacy, and the pharmacist was able to communicate with the patient to avert an error. The other 11 patients ingested the desiccant, often for several doses. In 2 cases, parents administered the desiccants to their children. One mother questioned whether her child’s recent facial erythema was related to ingesting the desiccant after discovering she had administered the desiccant to her child at least 6 times. Another patient took all 4 desiccants in the blister pack and went to the emergency department for chest pain. It is worth noting that the everolimus product labeling and the information that accompanies the medication dispensed to patients provide no information about the desiccants or what to do if they are swallowed.

Biocon told the ISMP that the desiccants in everolimus blisters are chemically inert, nonhazardous, and nontoxic. They are a moisture-absorbing mixture of molecular sieve, polypropylene resin, white colorant, and a trade-secret binder.

The desiccant tablets are not absorbed or digested, passing through the body as is, according to the manufacturer. Still, keep in mind that patients swallowing a desiccant tablet may also miss a dose of their scheduled cancer or immunosuppressant medication, which could affect treatment.

Because many practitioners will never open the Biocon everolimus carton to see the individual blister cards, it is important to alert them to the blister-card labeling issue so that they are aware of the potential for patients to ingest the desiccant tablets.

In the pharmacy computer system and on the cartons, mark these products for mandatory patient education. When educating patients upon discharge, it is critical to tell them that these blister cards contain desiccants that might be mistaken for tablets. Consider opening the carton to show patients the blister cards. Warn patients to never eat or swallow a desiccant.

Additionally, remove desiccant cylinders from medication bottles when possible; if the desiccant must remain in the bottle, warn patients about the hazards associated with swallowing it.

The ISMP has reached out to Biocon Ltd and the FDA to express concern with everolimus labeling so that they can take steps to properly address the above issues.

is a senior director of error reporting programs at the Institute for Safe Medication Practices in Horsham, Pennsylvania.

Mark these products for mandatory patient education on the cartons and in the pharmacy computer system.

Patients Swallow the Desiccants in Everolimus Blister Cards

Oral propranolol liquid was prescribed for a 7.2-kg, 3-month-old baby with infantile hemangioma, which is a rapidly growing benign vascular tumor.

The pharmacy contacted the physician’s office to clarify the order.

When the patient’s mother picked up the prescription, propranolol 20 mg/5 mL (4 mg/mL) was dispensed with the following instructions: “Administer 3.5 mL once on day 1, administer 3.5 mL twice daily for the next 6 days, then administer 7.5 mL twice daily for a maintenance dose.”

Based on the concentration dispensed, this would equate to 14 mg once on day 1 (1.9 mg/kg/day), 14 mg twice daily for the next 6 days (3.9 mg/kg/day), followed by 30 mg twice daily (8.3 mg/kg/day) for the maintenance dose. This maintenance dose is much higher than the typical daily oral maintenance dose (1 to 3 mg/kg/day) for children and infants for this indication.

At the pharmacy, the mother was neither counseled nor provided with an oral syringe to administer the medication to her infant. After the mother returned home, she called the pharmacist to question the dose. The pharmacist confirmed that the dose was higher than recommended for a 7.2-kg infant with infantile hemangioma.

However, the pharmacist stated, “It should be fine if this is how the doctor wanted it.”

If the mother was still concerned about the dose, the pharmacist suggested calling the physician’s office herself. The mother called the prescriber to express her concerns. The prescriber confirmed the dosing directions provided on the pharmacy label by the pharmacy were incorrect. The prescriber told the mother that, when the pharmacist called for clarification, the dosing directions were mistakenly communicated to the pharmacist in mL, not mg.

The intended instructions were “3.5 mg (0.88 mL) for the first day (0.49 mg/kg/day), 3.5 mg (0.88 mL) twice daily for the following 6 days (0.97 mg/kg/day), followed by 7.5 mg (1.88 mL) twice daily (2.1 mg/kg/day) for the maintenance dose.”

Fortunately, the infant’s mother kept questioning the directions, and the error was caught before the infant was given the medication.

There are 3 propranolol oral liquid concentrations available, including 2 concentrations of generic products, 20 mg/5 mL (4 mg/mL) and 40 mg/5 mL (8 mg/mL), and a different concentration for a brand product, Hemangeol
4.28 mg/mL. Hemangeol is the only liquid propranolol approved by the FDA for the treatment of proliferating infantile hemangioma requiring systemic therapy. The generic products are used off label for this indication. In the United States, the existing generic propranolol solutions are expressed in terms of propranolol hydro- chloride, and the FDA had previously requested that Hemangeol concentration and dosages be communicated similarly. Outside the United States, the Hemangeol concentration is expressed as 3.75 mg/mL of propranolol base, which is equivalent to 4.28 mg/mL. Unfortunately, the Hemangeol 4.28 mg/mL concentration can add to the risk of dosage calculation errors compared with the available generic 4- or 8-mg/mL concentrations.

To avoid confusion among the multiple concentrations and between mg and mL doses, propranolol oral liquid doses should always be prescribed in mg. Prescribers should include the patient’s weight in metric units on the prescription. Otherwise, pharmacists will need to confirm the weight so they can calculate and verify the mg/kg dose. If the dose is outside the normal range, pharmacists should clarify the order directly with the prescriber, referring to the mg dose. Once the drug has been prescribed in mg, pharmacists may need to calculate and transcribe the mL dose based on the drug’s concentration for the patient’s instructions if the electronic prescribing system does not calculate the volume automatically. Then, if the volume amount must be entered manually, an independent double check of the calculation should be required.

Labels on prescription oral liquids should specify the dose in mL in the instructions for use for the patient/parent to measure each dose, and then the product’s concentration should be listed elsewhere on the label. Weight-based medication doses should be rounded or standardized automatically at the time of prescribing to a dose that is not greater than or less than 10% of the originally prescribed dose. For example, 3.5 mg (0.88 mL) of propranolol 4 mg/mL should be rounded to 3.6 mg (0.9 mL) to facilitate the ease of measuring doses. Pharmacies should provide patients with an appropriately sized, metric-only oral syringe or dosing cup for safe dose measurement and administration of oral liquids. Pharmacists should employ the “teach-back” method, which incorporates a return demonstration by the patient or parent to confirm their ability to measure each dose. Importantly, when patients or parents express a safety concern, stop, listen, and investigate to confirm that there are no errors.

, is a senior director of error reporting programs at the Institute for Safe Medication Practices in Horsham, Pennsylvania.

Case highlights the need to stop, listen, and investigate when patients or parents express a safety concern.

Infant’s Mom Discovers Wrong Directions on Pediatric Propranolol Oral Liquid Label

Copying old prescriptions can expedite the dispensing process, but be careful when editing and verifying new or updated prescriptions. The Institute for Safe Medication Practices continues to receive reports of dispensing errors occurring when a previous prescription was copied in a pharmacy computer system.

In one case, a pharmacy dispensed the incorrect strength of hydrocodone/acetaminophen. The error was discovered when investigating why the patient needed to have the prescription filled several days early. The pharmacy had incorrectly dispensed hydrocodone/acetaminophen 5 mg/325 mg. Upon discovery, the provider was contacted and informed of the error. A new prescription for hydrocodone/acetaminophen 7.5 mg/325 mg was then filled. The error was thought to have been caused by copying an old prescription from the previous month without the correction in strength being made.

Another case involved a patient with a new prescription for oxycodone 5 mg. A few months earlier, this patient had received a prescription for oxycodone 30 mg. To expedite the dispensing process, the pharmacist chose to copy the previous oxycodone 30 mg prescription but failed to change the dosage strength. The patient received oxycodone 30 mg and used this strength for a month. The patient’s physician discovered the error and notified the pharmacy. The pharmacy’s analysis of the event found that the pharmacist conducted the final prescription verification immediately after he completed the order entry and filled the prescription, which limited the effectiveness of the checking process.

In a third case, a community pharmacy dispensed Adderall XR 20 mg (dextroamphetamine sulfate, dextroamphetamine saccharate, amphetamine sulfate, and amphetamine aspartate monohydrate extended release) to a patient instead of the prescribed Adderall XR 10 mg. The patient discovered the error at the point of sale when he looked at the pharmacy label. The patient had previously taken Adderall XR 20 mg, but his doctor was switching him to Adderall XR 10 mg. One of the contributing factors was the computer system’s functionality, which allowed the individual conducting order entry to copy a previous prescription for the same drug.

In a recent case, a patient received a new prescription for chlordiazepoxide 10 mg. The patient had previously been taking chlordiazepoxide 25 mg. The pharmacy technician generated a “new from old” prescription when the new one was dropped off but did not change the capsule strength to 10 mg from 25 mg. As a result, chlordiazepoxide 25 mg was dispensed. The prescriber discovered the error and contacted the pharmacy to ask about the lower dose of medication.

Copying and Placing a Presciption On Hold

The copy function can also be used when placing a prescription on hold to fill later. When the computer system’s prescription copy or linking functionality is used in these cases, there is a risk that the order entry verification may be skipped or not done with the same attentiveness. The pharmacist may think it will be double-checked when the prescription is eventually processed and dispensed to the patient.

Evaluate the computer system’s prescription copy or linking functionality. Some
systems may prompt users to link new prescriptions to those already on patient profiles. Although this functionality can increase order entry efficiency, any changes on the new prescription may be missed. If this functionality is used, review the workflow, process, and prompts when copying or linking to old prescriptions. Consider ways to have the computer system guide the individual conducting order entry in verifying whether each piece of information, such as drug name or strength, directions, quantity, strength, or suffix, on the new prescription matches the one already on the patient’s profile before accepting the copy. Even if the computer system cannot incorporate this change, the manual process used to verify prescriptions should include these additional steps. Educate practitioners about the importance of verifying each piece of information.

Additionally, when using this functionality to place a prescription on hold, it is critical that the order entry undergoes the same verification process used when a prescription is dispensed. This includes rechecking the order entry by comparing the prescription information entered in the computer system with that on the original prescription. When the prescription is dispensed, verification against the original prescription or its scanned image should be done again. Final verification should include a review of the patient’s profile and a prospective drug use review. Engaging the patient as a final check at the point of sale also can help catch errors.

, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care newsletter at the Institute for Safe Medication Practices in Horsham, Pennsylvania.

Expediting the dispensing process makes sense, but take care when entering and verifying script.

Copying an Old Prescription May Lead to Trouble

The Institute for Safe Medication Practices (ISMP) has released its 2022-2023 Targeted Medication Safety Best Practices for Hospital, with which it aims to address problems that continue to cause fatal and harmful errors despite repeated warnings in ISMP publications.

Although the best practices might be challenging for some organizations to achieve, they are all practical and realistic and their value in reducing medication errors is grounded in expert analysis and/or scientific research on medication errors and their causes. Their implementation can vastly improve medication safety and reduce the risk of significant patient harm.

Although created for hospitals, the best practices are often applicable to other health care settings.

First released in 2014, the list, which originally included 6 best practices, is updated every 2 years and now comprises 19 best practices, including 3 newly introduced:

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

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.

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

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

Standardize to a single bag or concentration size for both antepartum and postpartum oxytocin infusions, such as 30 units in 500 mL lactated Ringer’s.

Maximize the use of barcode verification prior to medication and vaccine administration by expanding the use beyond inpatient care areas.

Regularly review compliance and other metric data to assess effectiveness and use of this safety technology, such as acknowledged or bypassed alerts and scanning compliance rates.

Specifically target clinical areas with an increased likelihood of a limited or short patient stay, such as catheterization laboratories, dialysis centers, emergency departments, infusion clinics, and labor and delivery, outpatient, perioperative, and radiology areas.

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

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

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

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

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

Limit the use of independent double-checks to select high-alert medications with the greatest risk for error within the organization, such as chemotherapy, heparin and opioid infusions, and intravenous insulin.

Regularly assess for practices used to support the safe use of medications and risk in the systems by using information from external and internal sources, such as The Joint Commission and the ISMP.

The following supplemental information is included in the rationale section of Best Practice 1: Dispense vincristine and other vinca alkaloids in a minibag of a compatible solution and not in a syringe. This was added: “In 2020, the US Food and Drug Administration (FDA) changed the prescribing information (package insert) to call for dilution in a minibag only (www.ismp.org/ node/18548). The labeling for vincristine now states: To reduce the potential for fatal medication errors due to incorrect route of administration, vincristine sulfate injection should be diluted in a flexible plastic container and prominently labeled as indicated ‘For intravenous use only—fatal if given by other routes.’ Preparation and administration of the drug in a syringe has been removed from the package insert.”

Health systems and hospitals should focus their medication safety efforts over the next 2 years on these 2022-2023 best practices, and other health
care providers can learn from them. The rationale for recommending the best practices, along with related ISMP guidelines and publications for additional information, is found in the full best practices document.

 Related documents that might be helpful to hospitals include frequently asked questions

 that can help these institutions identify gaps in implementation of these best practices and develop an action plan to address vulnerabilities.

, is a medication safety analyst and the editor of ISMP Medication 

 Community/Ambulatory Care Newsletter at the Institute for Safe Medication Practices in Horsham, Pennsylvania.

1. Targeted medication safety best practices for hospitals. Institute for Safe Medication Practices. February 9, 2022. Accessed February 14, 2022. www.ismp.org/guidelines/best-practices-hospitals

2. Frequently asked questions - targeted medication safety best practices for hospitals. Institute for Safe Medication Practices. Accessed February 14, 2022. www.ismp.org/tmsbp/faq

3. Worksheet for the targeted medication safety best practices for hospitals. Institute for Safe Medication Practices. February 9, 2022. Accessed February 14, 2022. www.ismp.org/resources/worksheet- ismp-targeted-medication-safety-best-practices-hospitals

Although the ISMP created the guidelines for hospitals, they are applicable in other health care settings.