ISMP Targeted Medication Safety Best Practices: A Hospital Self-Assessment Checklist

ISMP publishes several kinds of guidance for hospitals, and it is easy to conflate them.
The Targeted Medication Safety Best Practices for Hospitals (TMSBP) is not the same
document as ISMP’s general guideline library — its sterile compounding guidelines,
high-alert medication guidance, or standard order set recommendations — and it is not
the ISMP Medication Safety Self Assessment for Hospitals either. TMSBP is narrower
and more targeted by design: a consensus set of specific, high-severity practices built
directly from fatal and harmful error reports submitted through the ISMP National Medication
Errors Reporting Program (ISMP MERP), reviewed by an external expert advisory panel, and
approved by the ISMP Board of Trustees. Where the general guideline library covers broad
practice areas and the self-assessment survey benchmarks a hospital’s overall medication-use
system, TMSBP calls out a specific list of recurring, well-documented failure modes —
the kind that keep recurring in MERP reports despite years of prior warnings — and asks
hospitals to implement a specific, named control for each one.

That distinction matters for how you should use this page. This is a working
self-assessment checklist built around TMSBP’s documented target-practice areas, organized so
a patient-safety officer, pharmacy director, quality director, or risk manager can walk
through it with the relevant service leads and mark each item covered, partially covered, or
not yet addressed. It is not a substitute for ISMP’s own published document. ISMP updates
TMSBP on a recurring cycle, and the exact wording, inclusion criteria, and numbering shift
edition to edition — before citing a specific item number in a policy, order set, or
survey-readiness binder, pull the current PDF directly from ISMP/ECRI and confirm the wording
matches. Treat the numbering below as CASRAI’s own organizing scheme for the checklist, not a
claim about ISMP’s current official numbering.

Who this self-assessment is for

TMSBP spans pharmacy, nursing, anesthesia, and clinical informatics, which is exactly why it
tends to fall through the cracks of any single department’s ownership. In practice, running
this checklist works best as a joint exercise between the patient-safety or quality
department (which owns root-cause-analysis and event-reporting data), the pharmacy
department or Pharmacy and Therapeutics (P&T) committee (which owns formulary and
order-set controls), and clinical informatics (which owns the electronic health record
build, automated dispensing cabinet configuration, and barcode scanning workflows). No single
item on this list is purely a pharmacy problem or purely a nursing problem — most
combine a system control (an EHR hard stop, a cabinet restriction, a barcode requirement)
with a documented clinical practice, and both halves need a named owner before the item can
honestly be marked “covered.”

How to use this checklist

For each item below: (1) identify whether your hospital has a specific, documented control
in place — not just a general policy that happens to touch the topic; (2) confirm the
control is actually enforced in the system your staff use day to day, not only written down;
and (3) note the gap and an accountable owner for anything not fully in place. A short,
recurring cadence (annually, or after any related serious safety event) works better than a
one-time pass, because EHR builds, cabinet configurations, and staff turnover erode controls
over time even when the underlying policy hasn’t changed.

The checklist

High-severity, drug-specific errors

1. Vincristine and other vinca alkaloids: intrathecal-route prevention. Do
   you dispense vinca alkaloids only in a minibag (never a syringe) for administration outside
   oncology-designated areas, and does your system carry an explicit warning or physical barrier
   against intrathecal administration?
2. Oral methotrexate: accidental daily dosing. For patients on weekly
   oral methotrexate (rheumatologic/dermatologic dosing, not oncology treatment protocols), does
   your EHR flag or hard-stop a daily frequency, and does pharmacy verify indication before
   dispensing?
3. Glacial acetic acid. Has glacial (undiluted) acetic acid been removed
   from patient-care areas and pharmacy stock entirely, with only appropriately diluted
   formulations available where acetic acid is clinically needed?
4. Oxytocin. Is oxytocin administration standardized to a protocol-driven,
   weight-based or unit-based infusion with a hard maximum, rather than left to individual
   titration judgment?
5. Injectable promethazine. Does policy restrict IV promethazine to the
   most dilute concentration available, delivered through a running IV line into a large vein,
   with an explicit prohibition on intra-arterial or subcutaneous administration and a
   documented preference for alternative antiemetics where clinically appropriate?
6. Neuromuscular blocking agents (NMBAs). Are NMBAs stored and labeled with
   a distinct, hard-to-miss warning restricting use to monitored/ventilated settings, and
   excluded from automated dispensing cabinet override lists outside those settings?

Route and measurement mix-ups

7. Oral-to-IV mix-ups. Do oral liquid dispensing devices (oral syringes,
   tips, adapters) use a connector standard that is physically incompatible with IV tubing
   ports, so an oral dose cannot be pushed into a line even by mistake?
8. Milliliters vs. household units. Are all oral liquid doses on discharge
   instructions, MARs, and patient-facing labels expressed in milliliters only, with teaspoon/
   tablespoon measurements eliminated, and is a milliliter-marked dosing device supplied with
   every oral liquid?
9. Sterile water administered as an IV infusion. Is sterile water for
   injection/irrigation stored separately from IV fluids and excluded from areas where it could
   be selected as a diluent or infused directly, given the hemolysis risk of free water given
   intravenously?
10. Tranexamic acid wrong-route errors. Is IV tranexamic acid stored and
    labeled to prevent confusion with local anesthetics intended for spinal, epidural, or
    intrathecal use, particularly in obstetric and surgical areas where both are stocked nearby?
11. Patient weight accuracy. Are all inpatient weights captured in metric
    units only (kilograms, not pounds converted on the fly), measured rather than
    stated/estimated on admission, and is weight-based dosing software validated against the
    actual documented weight rather than a default or carried-forward value?

High-alert medication and technology controls

12. High-alert medication strategy, not just a list. Beyond maintaining a
    list of high-alert medications, does each entry on your list carry a specific, documented
    safeguard (independent double check, smart-pump dose-error-reduction library entry, ADC
    restriction, or standardized concentration), rather than the list existing as a reference
    document alone? See our companion guide on
    attaching a real safeguard to every high-alert medication list entry.
13. Automated dispensing cabinet overrides. Have overrides been removed or
    sharply restricted for high-alert medications, with any remaining override list reviewed on
    a fixed schedule rather than left to accumulate?
14. Barcode verification coverage. Does barcode medication administration
    extend beyond inpatient units into the emergency department, perioperative areas, and other
    lower-compliance settings where it is often skipped? See our guide on
    barcode medication
    administration implementation, overrides, and workaround patterns.
15. Barcode scanning workaround reduction. Have you audited scan-override and
    workaround rates by unit and shift, and addressed the workflow friction driving them, rather
    than treating a low scan-compliance rate as a training problem alone?
16. Smart-pump infusion safeguards. Are dose-error-reduction software limits
    enabled and enforced (not just installed) on IV infusion pumps, with compliance monitored and
    overrides reviewed?
17. IV push medication safety. For medications given by direct IV push, are
    concentration, dilution, and administration-rate instructions standardized and available at
    the point of care, rather than left to individual practice?

Program and process practices

18. Extended-release/long-acting opioids and fentanyl patches. Are
    extended-release and long-acting opioid formulations, including fentanyl patches, restricted
    from use in opioid-naive patients for acute pain, with an EHR or order-set check for opioid
    tolerance before dispensing?
19. Opioid status verification. Is a patient’s opioid-tolerant vs.
    opioid-naive status verified and documented before an opioid order is placed, not inferred
    after the fact from the order itself? See our related guide on
    opioid stewardship programs, prescribing
    defaults, and naloxone triggers.
20. Antidote and reversal agent readiness. Are antidotes and reversal agents
    (naloxone, flumazenil, vitamin K, protamine, and others relevant to your formulary) stocked
    where they will be needed and covered by a policy that prevents delay in retrieval and
    administration?
21. Sterile compounding error prevention. Does your sterile compounding
    process include an independent verification step (barcode-assisted, gravimetric, or visual
    by a second qualified person) before a compounded product leaves the pharmacy?
22. Care-transition medication errors. Is medication reconciliation
    performed and documented at every transition point — admission, transfer, and discharge
    — rather than only on admission? See our guide on the
    medication reconciliation five-step process.
23. Vaccine administration errors. Are vaccine storage, product selection,
    and dose/age verification steps built into the ordering and administration workflow, with
    distinct handling for look-alike vaccine products stored near one another?
24. Learning from external events. Does your patient-safety program have a
    standing process for reviewing external ISMP alerts, MERP-derived safety bulletins, and
    other health systems’ reported events, and translating relevant ones into a local practice
    change — not only responding to your own internal events after the fact?
25. Safety culture measurement. Do you measure and act on safety-culture
    survey results (event-reporting comfort, willingness to raise concerns, non-punitive response
    to good-faith reporting) as a standing program metric, rather than a one-time survey?

From checklist to corrective action

A checklist only creates value once its gaps turn into tracked, owned corrective actions.
For any item marked partially covered or not addressed, route it through your existing event
and root-cause-analysis process rather than starting a separate parallel workstream —
see our guide on
building a hospital root-cause-analysis
fishbone diagram for a structured way to work from a gap to a specific system fix.
Prioritize items connected to your hospital’s own recent near-misses or events first; the
rest of the list still matters, but a gap tied to a real local event has both the clearest
justification for resourcing and the most institutional momentum behind fixing it.

How this relates to survey readiness

Several TMSBP items overlap directly with what accreditation surveyors and CMS Conditions
of Participation reviewers ask about — high-alert medication safeguards, look-alike/
sound-alike name controls, and tall man lettering consistency chief among them. Running this
checklist alongside your accreditation tracer preparation, rather than as a separate
exercise, avoids duplicating the evidence-gathering work. Related reading: our guides on
building and maintaining a LASA
medication list,
tall man lettering: the FDA and ISMP lists and the CD3
rule, and
The Joint Commission Do Not Use list and
how ISMP’s list differs.

Frequently asked questions

Is TMSBP a regulatory requirement?

No. TMSBP is ISMP’s own consensus guidance, not a federal regulation or a Joint Commission
standard in itself, though individual items frequently overlap with what accreditation
surveyors and CMS review. Hospitals adopt it voluntarily, and adoption is uneven across
individual practices — which is precisely why a periodic self-assessment against the
full list, rather than an assumption that “we probably do most of this,” is worth the time.

How is TMSBP different from the ISMP Medication Safety Self Assessment?

The Medication Safety Self Assessment is ISMP’s broader benchmarking survey covering the
full medication-use system across many more practice domains. TMSBP is narrower and more
prescriptive: a shorter list of specific, named failure modes with a specific expected
control for each, drawn directly from fatal and harmful MERP-reported errors rather than a
comprehensive system-wide self-audit.

How often should we run this self-assessment?

At minimum annually, and again after any serious safety event connected to one of these
practice areas or after a significant EHR, cabinet, or pump-library change that could have
quietly altered a control that was previously in place.

Who should lead it?

Typically the patient-safety officer or medication-safety pharmacist convenes it, but it
requires participation from pharmacy leadership, nursing, anesthesia (for NMBA and
IV-push-related items), and clinical informatics (for EHR- and technology-dependent
controls) to assess honestly rather than from one department’s partial view.

For the authoritative, current-edition wording and numbering, consult ISMP’s own
Targeted Medication Safety Best Practices for Hospitals document directly, and treat this
page as a working self-assessment tool built around its documented target areas rather than
a substitute for the primary source.