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New ISMP 2020-2021 Targeted Medication Safety Best Practices for Hospitals (Part 1)
By Yashar Rafi, PharmD, 2019-2020 ISMP Safe Medication Management Fellow
On February 21, 2020 ISMP released its 2020-2021 Targeted Medication Safety Best Practices for Hospitals. The purpose of this resource is to mobilize widespread adoption of consensus-based Best Practices to address recurring problems that continue to cause harmful errors. The Best Practices, which are reviewed by an external expert advisory panel and approved by the ISMP Board of Trustees, are designed to be realistic and have already been successfully adopted by numerous organizations. Their implementation can vastly improve medication safety and reduce the risk of significant patient harm.
The 2020-2021 list now comprises 16 Best Practices, including 2 new ones. Best Practice 15 is described below, and Best Practice 16 will be discussed in a future blog.
Best Practice 15: Opioid Prescribing
Verify and document a patient’s opioid status (naïve versus tolerant) and type of pain (acute versus chronic) before prescribing and dispensing extended-release and long-acting opioids.
This Best Practice replaces and expands on Best Practice 12 which referred specifically to fentanyl patches and called on practitioners to eliminate their use for acute pain and in opioid-naïve patients. A review of adverse drug events (ADEs) reported to the US Food and Drug Administration (FDA) revealed that between 2008 and 2010, fentanyl patches were the leading drug involved in serious ADEs. During the preparation of the 2020-2021 Targeted Medication Best Practices document, reviews of ISMP’s Medication Error Reporting Program (MERP) database and consultations with experts confirmed that extended-release and long-acting opioids continue to be used inappropriately and to cause serious harm and fatality. It made sense, therefore, to add a new Best Practice with an expanded scope to cover all extended-release and long-acting opioids.
To eliminate inappropriate use of long-acting and extended-release opioids it is essential to verify and document the indication for use along with the patient’s opioid status. The order entry system should protect against the use of fentanyl or other long-acting or extended-release opioids for an indication of acute pain. In addition, there should be a hard stop for use of fentanyl patches in an opioid-naïve patient.
In order to make the inappropriate use of fentanyl patches less likely, the Best Practice also recommends eliminating fentanyl patches from automated dispensing cabinets and as unit stock in those units which primarily treat acute pain (for example, the emergency department, operating room, postanesthesia care unit, procedural areas). While this may not eliminate all inappropriate use, it will require pharmacy review and help promote safe use of these high-alert medications.
Other suggestions for implementing this Best Practice focus on electronic order entry systems. When initiating an order for extended-release or long-acting opioids, the system should default to the lowest starting dose and frequency. In addition, when the patient is at increased risk of oversedation – for example due to age, renal or liver impairment, or when they are taking other sedating medications – the system should alert practitioners to the added risk. Both measures are intended to help reduce oversedation and other side effects from overdosing of opioid medications, measures that are all the more important when dealing with long-acting or extended-release formulations.
ISMP is conducting a short survey to get a sense of the baseline level of implementation of the 2 new Best Practices. We would appreciate your participation in this survey regardless of whether you have implemented the Best Practices. The online survey will remain open until July 17, 2020.
For more information, including a link to a list of Frequently Asked Questions please refer to the full article: https://ismp.org/acute-care/medication-safety-alert-february-27-2020.
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