The Institute for Safe Medication Practices (ISMP) recently published a self-assessment for community pharmacies to help them identify potential safety issues. While the 216-question tool requires some time and considerable reflection to complete, asking just six questions can help ensure pharmacies take all the necessary steps to reduce errors when adding a new medication to their inventory.

1. If pharmacy staff use medical or pharmacy abbreviations (sig codes or speed codes) or mnemonics during order entry, are they standardized—and understood—within the pharmacy and across all stores in a chain? The ISMP reported that one pharmacy had coded “dys” to mean dyspepsia, but a technician thought it stood for dysmenorrhea, leading to an error in directions on a contraceptive.

2. Does pharmacy leadership follow a clear process for creating standardized abbreviations? The process should ensure that sig codes and mnemonics avoid abbreviations on the Joint Commission’s “do not use” list. These include using IU for international unit, which could be mistaken as IV for intravenous or the number 10, and using QOD or its variants for every other day, as it could be misread as QID or four times a day. For mnemonics, leadership should consider possible confusion caused by shortening drugs with similar names, such as Humalog and Humulin.

3. Is there a process and designated person responsible for identifying potential safety issues with every new medication added to the pharmacy inventory? Risks might include confusion with other medication names, similar packaging that could lead to a mix-up in dispensing, unusually complex usage instructions that might pose a problem for patients, unusual dosing parameters, and requirements for monitoring.

4. Does a pharmacist review recent literature to understand common errors associated with every new medication?

5. After identifying potential issues, does a pharmacist develop strategies to mitigate the risk of those occurring in the pharmacy before adding a new drug? Safety plans might include alerts, check systems, reminders, restrictions, separate storage, or location.

6. A few months after a medication has been added, does a pharmacist review internal safety records and external reports to determine whether other concerns have arisen? A pharmacist could consult store records for medication errors or adverse reactions, as well as review the most recent published literature in journals and on pharmacy websites and forums.

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