ISMP Highlights Top Medication Safety Issues of 2018


Pharmacists have a crucial role to play in identifying medication safety issues and implementing best practices to prevent errors, according to the ISMP.

Pharmacists have a crucial role to play in identifying medication safety issues and implementing best practices to prevent errors, according to the Institute for Safe Medication Practices (ISMP).

During a presentation at the 2018 ASHP Summer Meetings and Exhibition in Denver, Colorado, ISMP medication safety specialist Christina Michalek, RPh, stated that 2.5% of nearly 2000 medication safety events reported to the organization were found to have caused patient harm. Specific harmful events described by Michalek included:

  • An elderly patient with Alzheimer disease who presented to the hospital after being given a daily dose of both donepezil 5 mg and donepezil 10 mg instead of 5 mg daily for 4 weeks followed by 10 mg daily
  • A pediatric patient who presented with Parkinson-like symptoms after being given risperidone 1 mg/ml instead of risperidone 1 mg/10 ml
  • A patient who experienced fatigue after receiving hydralazine 25 mg instead of hydroxyzine 25 mg

“Reported harmful events occurred at different points throughout the entire patient care process, but similarities exist in the causes of all these harmful events,” Michalek said. “Patient education and follow-up may help prevent harm.”

Michalek highlighted medication errors related to hyperkalemia treatment as one of the ISMP’s top safety issues of the year. Because hyperkalemia requires prompt treatment with IV insulin and dextrose 50%, she explained, there is a high potential for error and patient harm, usually as a result of incorrect dose or administration via the wrong route. To reduce the risk of such errors, Michalek recommended that hospitals establish treatment protocols, create a standard order set, and prepare hyperkalemia kits.

Medication errors related to drug shortages, vaccines, insufficient drug allergy alerts, and unlabeled or improperly labeled syringes were also deemed to be among the most noteworthy safety issues of the past year by the ISMP.

Additionally, Michalek discussed 3 new best practices for hospitals encouraged by the ISMP to reduce the risk of common errors:

  • Best Practice 12: Eliminate the prescribing of fentanyl patches for opioid-naïve patients and patients with acute pain
  • Best Practice 13: Eliminate the use of injectable promethazine
  • Best Practice 14: Seek information about and take action to prevent medication safety risks and errors that occur in other facilities

Co-presenter Kelly Besco, PharmD, a member of ISMP’s Clinical Advisory Board and a medication safety officer for OhioHealth, noted that providers often resist implementing new medication safety practices due to barriers in knowledge, attitude, and behavior. She added, however, that hospital pharmacists by seeking to understand their colleagues’ perspective and engaging in dialogue based upon shared values.

“Choice is guided by existing assumptions, beliefs, and attitudes,” Dr. Besco said. “To make others buy into your solutions, you have to know what they value.”


  • Cohen M, Michalek C, Besco K. ISMP Updates 2018. Presented at: 2018 ASHP Summer Meetings and Exhibition. June 2-6, 2018. Denver, Colorado.

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