In hospitals, medication errors represent some of the most dangerous mistakes that can be made, endangering patients and, in many cases, resulting in significant mortality and morbidity. The Institute for Safe Medication Practices (ISMP), a non-profit organization that monitors medication usage internationally, recently published their 2024-2025 Targeted Medication Safety Best Practices for Hospitals, highlighting the gaps in care among hospitals regarding medication administration. Below are three of their best practices that focus on using advanced identification technologies to mitigate the risk of medication errors, with a special emphasis on barcode verification.
Expand the use of barcode verification beyond inpatient care
Inpatients are typically well looked after, with the Bar Code Medication Administration (BCMA) used as a platform that integrates barcode labels to verify the appropriate administration of medication to patients. It ensures that patients receive the correct medication at the right time by electronically validating and documenting medications as they are prescribed and dispensed.
However, in the assessment performed by ISMP, they clearly weren’t just focused on inpatients. In their report, they found numerous instances of errors occurring for medications prescribed to outpatients due to look-alike packaging and labels, resulting in “wrong patient” errors. They continued to expand on the idea that while barcodes are commonly adopted for inpatient services, they are not often used for outpatients. They suggested that barcodes should be used in areas with increased likelihood of a short or limited patient stay, like the emergency department, and that compliance and other metric data should be regularly reviewed to assess the utilization and effectiveness of barcoding.
Safeguard against vaccine errors
Vaccines reside in a very particular space within medicine; since the COVID-19 pandemic, fears have been stoked regarding the safety of vaccines, resulting in a record number of infections related to not just COVID-19 but other diseases that were once largely removed from society, such as measles and whooping cough. Therefore, to safeguard public safety, encourage patient confidence, and ensure those who require it receive effective protection from harmful pathogens, it is critical to prevent any potential vaccination errors in both inpatient and outpatient settings. In the ISMP’s report, the following were listed as frequently occurring errors:
- Errors with age-specific formulations
- Wrong patient errors due to confusion between siblings
- Invalid doses (given too soon) or missed opportunities to vaccinate
- Wrong route errors cause by unfamiliarity with the vaccine
- Errors with combination vaccines or vaccines with diluents
- Wrong vaccines related to vaccine nomenclature
- Errors related to labeling and packaging
- Errors related to unsafe vaccine storage
- Administration of expired vaccines
- Failure to involve the patient in the verification process
In their assessment, the ISMP also suggested several steps to improve vaccine administration and mitigate potential errors, chief among them being barcode scanning to verify the correct vaccine and dose are administrated to the correct patient. They also suggest verifying the patient’s identity using two unique identifiers and documenting the vaccine’s national drug code (NDC) number, lot number, and expiration date prior to administration, all of which can be tracked using barcode technology.
Prevent wrong-route errors with tranexamic acid
In the ISMP’s best practice report, they reserve tranexamic acid its own spot due to the fact that its vial cap looks similar to the anesthetics bupivacaine and ropivacaine. Typically, tranexamic acid is either administered intravenously or given orally; however, because of the mix-up with these anesthetics, some patients had received intraspinal injection, which in 50% of cases is fatal. Even if the patient survives, it can lead to permanent neurologic injury. Vials of tranexamic acid are also often found in areas that do not utilize barcode scanning, making it doubly problematic. To prevent errors in tranexamic administration, the ISMP has implored the use of point-of-care barcode-assisted safety checks prior to administration in both surgical and obstetrical locations. They also suggest storing tranexamic acid away from anesthetics in a downward position, so that the caps cannot be seen readily, and for practitioners to use premixed intravenous bags of tranexamic acid instead of vials, when appropriate. Additionally, they recommend adding a label around the cap that states, “Contains Tranexamic Acid.”
