This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate.

The Institute for Safe Medication Practices (ISMP) has launched the 2023-24 Targeted Medication Safety Best Practices for Community Pharmacy (Best Practices). The purpose of these Best Practices is to identify, inspire, and mobilize widespread, national adoption of consensus-based best practices in community pharmacies to address recurring problems that continue to cause fatal and harmful errors, despite repeated warnings. These best practices, which are reviewed by an external expert advisory panel, represent high-leverage error-reduction strategies, many of which have already been successfully adopted by some pharmacies. While Best Practices might be challenging for some organizations to achieve, they are designed to be practical and realistic. Their value in reducing medication errors is grounded in scientific research and expert analysis of medication errors and their causes. Their implementation can vastly improve medication safety and reduce the risk of significant patient harm. 

Each best practice is accompanied by a rationale and references, as well as related issues of ISMP’s newsletters for additional background and information. While targeted to the community pharmacy setting, some best practices are also applicable to other health care settings, such as ambulatory, mail order, specialty pharmacy, long-term care, and home infusion. 

The 2023-24 Targeted Medication Safety Best Practices for Community Pharmacy include the following: 

  • Use a standard protocol to verify a patient’s identity, utilizing at least two patient identifiers, when receiving a prescription to be filled, responding to patient-specific questions, providing filled prescriptions to patients at the point of sale, when delivering prescriptions to the patient’s home, and prior to administering vaccines or other treatments. 
  • Install and use barcode verification during production (ie, the prescription-filling process) to scan each drug or vaccine package or container (eg, bottle, carton) used to fill a prescription, including manufacturer cartons or bottles that may be dispensed to a patient. 
  • Use a weekly dosage regimen default for oral methotrexate in electronic systems when medication orders are entered. Require verification and entry of an appropriate oncologic indication in order-entry systems for daily orders. Create a forcing function (for instance, an electronic stop in the sales register that requires intervention and acknowledgment by a pharmacist) to ensure that every oral methotrexate prescription is reviewed with the patient or a family member when a prescription is presented or refills are processed. Provide specific patient and/or family education for all oral methotrexate prescriptions. 
  • Standardize the use of the milliliter (mL) unit of measure when prescribing, dispensing, and measuring oral liquid medications. 
  • Seek out and use information about medication safety risks and errors that have occurred in organizations outside of your pharmacy, including other affiliated pharmacies, and take action to prevent similar errors. 

To best protect public health, ISMP encourages all United States community and ambulatory care pharmacies to focus their medication safety efforts for the next two years on these Best Practices. The Best Practices are fully described on ISMP’s website. In addition, there is a worksheet that pharmacies can use to identify gaps in implementation of the Best Practices and develop an action plan to address vulnerabilities. Pharmacies can also view a recording of the NABP educational session Exploring Medication Safety: New ISMP Best Practices for Community Pharmacy to learn more about the new Best Practices.