The Dirty Dozen 12 persistent safety gaffes that we need to resolve!

Transcription

1 October 9, 2014 Volume 19 Issue 20 The Dirty Dozen 12 persistent safety gaffes that we need to resolve! ISMP seeks stronger Chantix warnings. As we enter into the last quarter of 2014, our thoughts have been with the many exceptional efforts that have been undertaken in the past year to improve medication safety. We have been busy selecting our most worthy ISMP CHEERS Award winners this year and reflecting on the strength and resolve of many across the nation who have demonstrated an unparalleled commitment to keeping patients safe. Despite the many safety accomplishments in 2014, we can t help but mull over persistent medication safety gaffes that continue unresolved and doggedly test our tenacity, often landing in our Worth repeating... newsletter feature, over and over again. We would like to share our Dirty Dozen safety gaffes of 2014 with ISMP newsletter readers with the hope that you will join us in bringing attention to these crucial issues and the compelling need for their resolution. Changing PhRMA business models: 1 Negative financial impact on providers supply chain costs Whether it s discontinuation of a low-volume but medically necessary drug leading to critical shortages, or increases in the cost of longstanding medications, such as U-500 insulin, when the demand increases, the cost of pharmaceuticals has been highly unpredictable. This has become more of an issue in the last 5 years, wreaking havoc on healthcare providers operational budgets. The latest offense comes from the pharmaceutical giant Genentech. The company has changed its distribution methods for three widely used cancer drugs to maximize business efficiencies for the company, but the change will result in negative consequences for everyone downstream. Effective October 1, 2014, AVASTIN (bevacizumab), HERCEPTIN (trastuzumab), and RITUXAN (rituximab) are only being shipped to healthcare providers via six authorized specialty distributors instead of the usual wholesalers. Genentech s choice to not contract for cost relief on any of its continued on page 2 Dirty Dozen > Scanning issue during Meditech bedside barcode verification Ahospital notified us recently about what they characterize as a flaw in the Meditech Bedside Medication Verification (BMV) system that occurs when nurses administer IV base solutions with additives. Normally, when a compounded IV product is administered, a nurse scans the pharmacy label barcode to verify that the base solution and additives in the bag match what has been ordered. However, when administering a compounded IV product using Meditech, if a nurse incorrectly scans the base solution barcode instead of the pharmacy label barcode, the medication is accepted without verification of the additives. It is documented in the patient s electronic medication administration record (emar) as given but not recorded as being scanned, making it impossible to monitor scanning compliance rates accurately. Based on input from other Meditech hospitals that are using the BMV system, not all were aware of this issue. Meditech is aware, and in some cases, has provided inquiring hospitals with a workaround that includes activating a point-of-care compounding verification function in the emar for bedside scanning. The compounding verification function, which continued on page 4 (right column) Scanning issue > ISMP and four other nonprofit organizations have filed a Citizen Petition asking the US Food and Drug Administration (FDA) to clarify and strengthen the Boxed Warning about psychiatric side effects of the smoking cessation aid, varenicline (CHANTIX). The four other organizations include Consumer Reports, the National Center for Health Research, the National Physicians Alliance, and Public Citizen. We are also seeking restrictions against varenicline use in sensitive and hazardous occupations. In our view, the existing Boxed Warning should be clarified to describe the 4 related psychiatric side effects of varenicline: suicidal behavior, aggression/violence, psychosis, and depression. In addition to these risks, varenicline is associated with sudden blackouts, seizures, and impaired vision, making this drug unsuitable for use by individuals in hazardous occupations, such as pilots, air traffic controllers, military missile crews, and emercontinued on page 2 SAFETY briefs > Take Our Survey ISMP is repeating a short survey to get a general sense of the current progress in implementing the ISMP Targeted Medication Safety Best Practices for Hospitals. We would appreciate your participation regardless of whether you have or have not implemented any or all of the practices. A copy of the survey can be found on page 6, and you can take the survey by visiting: The survey will be open until November 30, For a detailed description and exact wording of the targeted best practices, visit: We sincerely appreciate your participation!

2 October 9, 2014 Volume 19 Issue 20 Page 2 > Dirty Dozen continued from page 1 products means that hospitals will now lose any prior cost savings based on wholesaler contracts and frequently incur higher costs to manage their drug distribution process, requiring more products in stock and less just-in-time ordering. For a large cancer center, the change will add $1 million or more annually in pharmaceutical costs with little advanced warning, reducing the dollars available to provide care to patients. While Health and Human Services (HHS) is trying to contain the costs of healthcare on the provider end, there seems to be little effort to contain costs on the supply end. The budgets needed for pharmaceuticals crucial to patient care appear to be increasing at the financial whim of big pharmaceutical companies. Clear Care: 2 Still causing severe eye injuries 5 years later Since early 2010, ISMP has received scores of reports of painful eye injuries from patients using CLEAR CARE Cleaning & Disinfecting Solution for contact lenses, by Alcon (formerly CIBA VISION), a Novartis company. Hundreds more can be found on Internet listservs. Located on store shelves near other lens disinfectants and solutions, Clear Care differs from other commonly used solutions in that it must be used with a special lens case to neutralize the 3% hydrogen peroxide component of the solution over at least 6 hours before putting the lenses back into the eyes. However, many have used the solution inadvertently to soak their lenses in a standard lens case, or thought the solution was saline and instilled it directly into their eyes. This has caused severe eye burning, leading many to seek out emergency medical care for corneal burns. In 2012, the company made a minor label enhancement to warn customers to use the special lens case, but the label change has been ineffective. Neither the company nor the US Food and Drug Administration s (FDA) device division have been persuaded to make effective label improvements before permanent eye injury or blindness occurs. If the labeling and packaging cannot be improved to reduce the harm being reported, perhaps this dangerous product should be pulled from the market or available only behind the pharmacy counter? Patient counseling: 3 Still only a veiled offer in many states The effectiveness of patient counseling in a community pharmacy to detect and prevent medication errors, and its link to improved medication adherence and positive clinical outcomes, have been well documented in the literature.yet, studies have placed patient counseling rates at only 8% to 42%. An increase in the frequency and quality of patient counseling has been linked to state-specific regulations that require patient counseling for new prescriptions coupled with strict enforcement surveillance. States that require an offer to counsel have very low patient counseling rates. Patients often fail to recognize an offer to counsel when simply asked, Do you have any questions? or told to Sign here. They may not even know what to ask. This means that, with few exceptions, pharmacies in states that require only an offer to counsel will likely dispense a powerful opioid such as fentanyl patches, for example, and allow the patient or caregiver to walk out of the pharmacy without so much as a brief discussion about safe use and disposal. ISMP has long promoted mandatory patient counseling in community pharmacies for targeted high-alert medications, with less emphasis on current ineffective regulations that require an offer to counsel for all medications. Patients impacted by dispensing errors: 4 Callous response from pharmacists When patients report dispensing errors to ISMP, they are usually more upset about the response they received when contacting the pharmacist or pharmacy manager than the actual error itself. All too often, consumers tell us that pharmacy staff have responded in continued on page 3 Dirty Dozen > This slight delay means that all items are pushed back, so the general timeline will begin the first quarter of 2015 with the in- continued on page 3 SAFETY briefs > cont d from page 1 gency medical personnel. ISMP wants to replace existing bans by various federal agencies with a clear label restriction. ISMP will also testify about these safety concerns on October 16, 2014, at a joint meeting of two FDA advisory committees, which will reconsider the Boxed Warning based on new scientific evidence acquired since the current warnings were required in July The manufacturer of varenicline, Pfizer, has said it wants the Boxed Warning removed. The 24-page petition ( documents the scientific evidence that has expanded our understanding of the substantial risks of this smoking cessation drug. Appropriate warnings and careful monitoring can prevent many of these potentially catastrophic adverse drug events. Delay in introducing new feeding tube connectors. Due to some uncertainties and circumstances beyond manufacturers control, the introduction of the new ISO standard ENFit connectors on the administration set side (along with the ENFit Transition Connector) will be delayed until the first quarter of There has been a purposeful sequential launch planned for the new connectors starting with administration sets, and then new enteral-specific syringes, ENFit female connectors. Once both of those are in use, the new feeding tubes with ENFit male connectors will be introduced. The introduction was originally planned to begin this month; however, product manufacturers are awaiting US Food and Drug Administration (FDA) 510(k) clearance. Once manufacturers receive their respective 510(k) clearance, they will be in a position to manufacture the product, provide further details about their new products, and be able to offer product samples. Join ISMP in recognizing National Hospital and Health-System Pharmacy Week: October 19-25, 2014.

3 October 9, 2014 Volume 19 Issue 20 Page 3 > Dirty Dozen continued from page 2 a callous manner when confronted with the possibility of a dispensing error, demonstrating a lack of empathy and concern for the adverse effects the patient might have experienced. The patients are often asked to return the erroneous medication to the pharmacy (relinquishing key evidence if legal remedy is sought) and then given the correct medication. Some pharmacies also offer a $25 discount coupon or refund for the cost of the erroneous prescription, but a signature may be required to document that the patient has accepted the coupon or refund as full restitution of the mistake. While pharmacy staff may want to be more responsive to patients who report errors, they are often following corporate policies that are focused on legal concerns. As patients are continually encouraged to be active participants in their healthcare, they want and deserve honest disclosure of errors and knowledge that there s an action plan to reduce the risk of it happening again. Manufacturers prefilled syringes: 5 Misuse spanning at least 7 years Based on surveys, observations, and error reports, ISMP is aware that many practitioners misuse prefilled syringes in a manner that renders them unsafe. First, the prefilled drug cartridges are often used as single- or multiple-dose vials, by removing all or part of the contents through the rubber diaphragm or the small hole at the top of the needleless system connector. However, the cartridge is not intended for puncture, and the contents do not include preservatives or antimicrobial agents; thus, the risk of contamination is high, and measurement errors are also possible. While the prefilled cartridges include a barcode, the final practitioner-prepared syringes do not and are rarely labeled. Practitioners have also misused prefilled syringes of saline flushes when drawing a drug into the saline flush syringe to dilute the medication, or when the saline is used to reconstitute a lyophilized powder and then drawn back into the saline flush syringe. This dangerous practice, which we first reported in 2007, leads to a syringe labeled as saline but actually containing both saline and the drug. In 2007, one company that makes saline flushes had widened the gradations on the syringes to discourage this practice, as more precise gradations are usually needed to measure doses accurately. Unfortunately, this measure has not stopped the practice. Single-dose vials of saline or sterile water for injection must be provided and used if drugs require reconstitution or dilution in a patient care area. Syringe pull-back method for verifying IV admixtures: 6 Overreliance on a weak strategy Many hospital IV admixture processes rely on the syringe pull-back method as the method the pharmacist uses to check the admixture and assess how much medication or diluent was added to the infusion container. The empty syringe is accompanied by the actual drug or diluent container displayed next to the syringe. For years, ISMP has discouraged reliance on this method, particularly for chemotherapy, complex electrolyte solutions, or compounded sterile products with other high-alert medications. The method, now prohibited by some State Boards of Pharmacy, is prone to errors when pulling back the plunger to the volume of product one believes was included in the admixture, and when placing the syringes near the corresponding vials. Also, for the person checking the products, it may not be clear which syringe goes with which vial. Pardon our skepticism about such a longstanding pharmacy practice, but this method of verification is weak in comparison to manual or automated checking of the products and volumes in syringes before addition to the admixture container. Compounded pain creams: 7 High profit margin and danger Some compounding pharmacies have been heavily marketing compounded pain creams directly to consumers via unsolicited calls, suggesting that the creams are more effective continued on page 4 Dirty Dozen > cont d from page 2 troduction of administration sets with the new ENFit female connector and ENFit Transition Connector (to allow fitment into current feeding tubes). In the second quarter of 2015, the new enteral specific syringes with ENFit female connectors will be released, and in the third quarter, new feeding tubes (e.g., G-tubes, NGtubes, J-tubes, extension sets) with ENFit male connectors will be released. VisionBlue confused with methylene blue. VISIONBLUE (trypan blue) ophthalmic solution is used during cataract surgery to stain the anterior lens capsule, helping the ophthalmologist see the capsule as it is cut and removed. During a cataract extraction procedure, staff accidentally substituted methylene blue for VisionBlue. Methylene blue can damage the iris and corneal endothelium. In this case, it led to blindness and, eventually, a successful lawsuit ( sc?id=403). Methylene blue may be stored in perioperative areas for use during endoscopic polypectomies or for visualizing fistulae. If you stock VisionBlue and methylene blue, you may want to consider the potential for a mix-up and implement strategies to avoid potentially harmful events, as appropriate. Clarification regarding insulin vials. A statement in the June 16, 2014, Sentinel Event Alert (Issue 52) from The Joint Commission, Preventing infection from the misuse of vials, mentions that Only vials clearly labeled by the manufacturer for multiple-dose use can be used more than once. Since insulin vials are not labeled as multiple-dose containers, we ve asked each of the three major US manufacturers, Lilly, Novo Nordisk, and Sanofi, to clarify that insulin vials are in fact multiple-dose containers. We ve posted the letters on our website at: The Joint Commission said it would accept manufacturer verification.

4 October 9, 2014 Volume 19 Issue 20 Page 4 > Dirty Dozen continued from page 3 and safer than oral or injectable pain medications. Many of the creams contain drugs that can cause central nervous system depression or adverse cardiac effects, and most have not been FDA-approved for use in combination with each other or for topical use. Patients are charged per ingredient, with many creams containing numerous, expensive medications. Toxicity from the creams has been reported to poison control centers, including cases of accidental child exposures and intentional use for multiple family members. Patients are often unaware of the dangers with using the creams, including unsafe packaging in containers without child-resistant closures. We are specifically concerned about some statements that may be unproven, such as the products safe use with children. Compounded pain creams need prominent warnings on labels that describe the potential for toxicity, and physicians and pharmacists who prescribe and dispense the creams must provide patients with instructions about possible adverse effects, safe storage, and proper use. We believe regulatory or licensing oversight is necessary. Disrespectful behavior: 8 A history of tolerance in healthcare Bullying, incivility, and other forms of disrespectful behavior are still rampant in healthcare and allowed to exist while we tolerate the behavior, remain silent, or make excuses in an attempt to minimize the profound devastation that disrespectful behavior causes. An ISMP survey conducted in 2003 clearly demonstrated the scope of disrespectful behavior among many levels of interdisciplinary staff, and an ISMP survey a decade later demonstrates little progress. Our slow progress is not due to lack of resources or know-how but to a dysfunctional culture, central to which is an ethos that favors a sense of privilege, status, and autonomy, thus impairing teamwork and communication. Disrespect diminishes a person s ability to think clearly, make sound judgments, speak up regarding questions, or avoid at-risk behaviors. Disrespectful behaviors also underlie a resistance to collaborate with others, follow procedures that promote safe practices, or implement new safety practices. While a culture of disrespect is harmful on many levels, its effect on patient safety makes it a matter of national urgency. Independent double-checks: 9 Undervalued and misused Manual independent double-checks of high-alert medications is a strategy that has been widely promoted to help detect potentially harmful errors before they reach patients. However, their value has been disputed, and their use has been a source of stress for busy prescribers, pharmacists, and nurses who are short on time. Their impact on safety has been questioned by those who rarely find mistakes during the checking process. Their inconsistent use, variability in how the task is carried out, and overuse for all high-alert medications has rendered them incapable of detecting many errors. Failed checking processes can often be traced to: auto-processing in which the person checking the work does so in a habitual manner with little real appraisal; deference to authority in which the person checking the work of someone who outranks them may not ask questions; reduction of responsibility in which staff believe someone else will catch any mistakes; and lack of time. What is often missing in the double-check process is a more cognitive review of all components of the medication, beyond verification of the 5 rights, that require purposeful thought. Additionally, independent double-checks must be strategically placed for just a few select high-alert medications, and they should never serve as the only safety net in place to prevent or detect errors with these medications. continued on page 5 Dirty Dozen > > Scanning issue continued from page 1 pharmacies may already be using, allows pharmacy staff to scan each additive when preparing compounded sterile preparations. Once prepared, the solution s barcode label should be obscured with the pharmacy label or by other means to protect against accidental scanning. This may be difficult since the barcodes are sometimes located in areas difficult to cover. Meditech s compounding verification is standard functionality that can be enabled by the customer. It adds a layer of safety because it requires barcode scanning of additives instead of just visual verification. We know of at least one serious error that was prevented with use of this software feature when a pharmacy technician was about to use amphotericin B instead of liposomal amphotericin B, the latter of which is given in a much higher dose. When the compounding verification system is made available for bedside scanning, if an IV bag barcode is scanned in error, the nurse gets an alert to scan the additive vial s barcode. The nurse generally won t have this vial unless the admixture was nurse-prepared or when using an ADD-Vantage container or a similar medication delivery system. Without the vial label, the nurse needs to know to back out and properly scan the pharmacy prescription number barcode, which then allows a proper match. We have discussed this issue with Meditech, which plans to work with clients on existing functionality and is looking toward expanded capabilities. For now, Meditech BMV hospitals should confirm whether this issue exists at their location. (Other hospitals using BMV should test their systems as well, as the issue may exist with other systems.) Also, we recommend activating the compounding verification system for pharmacy use and bedside scanning; otherwise, none of the additives in the bag will be verified as correct if the base solution barcode is scanned instead of the pharmacy label barcode. Compounding verification is available in the software but may require working with the vendor to turn it on.

5 October 9, 2014 Volume 19 Issue 20 Page 5 > Dirty Dozen continued from page 4 Beyond-use dating of drugs: 10 CMS standards lead to costly waste To avoid the use of outdated drugs, the Centers for Medicare & Medicaid Services (CMS) requires pharmacists to follow the manufacturer s directions regarding storage, stability, and beyond-use dating in the official FDA-approved prescribing information. The Joint Commission (TJC) and other accrediting organizations follow guidance from CMS on this issue. However, this has proven difficult and wasteful especially in cases of critical drug shortages for two primary reasons: 1) complete information on storage, stability, compatibility, and beyond-use dating is often not provided in the official prescribing information, and 2) newer, evidence-based information on these matters can sometimes be found in peer reviewed scientific journals and compendia fully endorsed by national pharmacy organizations. If information on storage, stability, and beyonduse dating is not available in the manufacturer s directions, CMS and accrediting agencies defer to recommendations available in nationally recognized sources. ISMP and the American Society of Health-System Pharmacists (ASHP) have brought the issue to CMS, but the government agency is confronted with a dilemma if the official, FDA-approved manufacturer s directions differ from newer, evidence-based recommendations in national compendia. CMS has been reviewing this matter since However, surveyors from CMS and accrediting agencies are still citing organizations for not following the explicit directions in the manufacturer s package insert despite newer, reliable evidence, unless they have a letter of support from the manufacturer. Vaccine errors: 11 Repetitive errors reported in the last decade How often do DTaP (diphtheria and tetanus toxoids, and acellular pertussis) and Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccine mix-ups need to occur before regulatory action is taken to prevent confusion? Whatever the number, we can say that we have probably met that threshold! Yet, vaccine errors like this continue to occur at an alarming rate (based on those reported to ISMP alone). Vaccine mix-ups occur often due to age-dependent formulations of the same vaccine, similar vaccine abbreviations, similar vaccine containers and labels, and storage near each other. Confusion between the diluent and vaccine has led to administration of the diluent alone, or use of the wrong diluent (which happened in Syria last month, causing the death of 15 children). With an unfortunate rise in parents choosing not to vaccinate their children or themselves, we cannot continue to make errors when vaccinating those who choose to be immunized the impact on both individual and community immunity may be far-reaching. Wrong patient errors: 12 Not opening the bag at the point-of-sale Community pharmacies are vulnerable to dispensing correctly filled prescriptions to the wrong patient (or family member, friend, or caregiver) at the point-of-sale, a risk that is well substantiated in the literature. This error is not influenced by the attributes of a specific medication; thus, dispensing any prescription medication to the wrong patient at the point-of-sale carries a similar level of risk. Based on an ISMP study, the error happens frequently at an estimated rate of 1.22 per 1,000 prescriptions. Among approximately 56,000 community pharmacies in the US, this error rate suggests that 332,755 prescriptions will be dispensed to the wrong patient each month, or about 6 every month per pharmacy. One of the most effective ways to prevent this error is to open the bag of filled prescriptions at the point-of-sale to verify that the drugs are for the correct patient. With this simple step, the risk of error is reduced by 56%, according to the ISMP study. Yet, few pharmacies follow this practice. ISMP webinar Join us on October 23, 2014, for Smart Pump Integration: A Giant Step for IV Infusion Safety. This webinar will describe how smart pump integration can improve safety by linking the medication order directly to the infusion device and prepopulating the pump with infusion parameters contained in the order, thereby eliminating programming errors. Efficiencies are also gained as a 17-step manual programming process is reduced to 7 steps with integration. For details about the webinar, visit: educational/webinars.asp. Help with product safety testing If you are a pharmacist, nurse, unit clerk, pharmacy technician, or other healthcare practitioner who is interested in furthering medication safety, you can make a difference! Med-ERRS (a subsidiary of ISMP) is looking for assistance to help evaluate medication labels, drug packaging, and proposed drug names prior to submission by pharmaceutical and biotech companies for approval by FDA. The process is simple and fun, and a small honorarium is paid. For details, visit: and click on Become A Reviewer. To subscribe, visit: ISMP Medication Safety Alert! Acute Care (ISSN ) 2014 Institute for Safe Medication Practices (ISMP). Permission is granted to subscribers to reproduce material for internal communications. Other reproduction is prohibited without permission. Report medication errors to the ISMP National Medication Errors Reporting Program (ISMP MERP) at FAIL-SAF(E) or online at Unless noted, published errors were received through the ISMP MERP. ISMP guarantees confidentiality of information received and respects the reporters' wishes as to the level of detail included in publications. Editors: Judy Smetzer, RN, BSN, FISMP; Michael R. Cohen, RPh, MS, ScD; Russell Jenkins, MD. ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA ismpinfo@ismp.org; Tel: ; Fax: This is a peer reviewed publication

6 October 9, 2014 Volume 19 Issue 20 Page 6 ISMP Resurvey on the Targeted Medication Safety Best Practices for Hospitals ISMP is repeating a short survey to get a general sense of the current progress in implementing the Targeted Medication Safety Best Practices for Hospitals as a baseline measure. We would appreciate your participation regardless of whether you have or have not implemented any or all of the practices. Please complete this survey by November 30, 2014, at: The survey questions are in the tables below for your review prior to taking the online survey. For a detailed description and exact wording of the targeted best practices, visit: 1 Please select the best option that reflects the status of the best practices in your hospital using the KEY that follows. Do not guess at the answers; choose Don t Know if you are uncertain. For A, B, C, D, or E answers, provide the additional information requested in the Comments section. KEY: A. There has been no activity to implement this best practice. B. This best practice has been formally considered, but we have decided not to implement it. C. This best practice is planned but has not been implemented yet. D. This best practice has been partially implemented in some or all areas of the organization. E. This best practice is fully implemented in some areas of the organization. F. This best practice is fully implemented throughout the organization. Best Practices (See Key Above) A B C D E F Don t Know Comments Please Provide Reason Not Fully Implemented 1 2a 2b Dispense vincristine (and other vinca alkaloids) in a minibag of compatible solution, and not in a syringe. Use a weekly dosage regimen default for oral methotrexate. If overridden to daily, require a hard stop verification of an appropriate oncologic indication. For manual systems, require verification of an oncologic indication before dispensing daily oral methotrexate. Provide patient education by a pharmacist for all weekly oral methotrexate discharge orders. Explain to the patient that taking extra doses is dangerous and that the drug should not be used as needed for symptom control. Provide patients with a drug information leaflet that contains clear instructions about weekly dosing, such as the free ISMP consumer leaflet. Measure and express patient weights in metric units only. Scales used for weighing patients are set and measure only in metric units (i.e., kilograms [kg] and grams [g]). If scales can measure in pounds and kg/g, modify the scale to lock out the ability to weigh in pounds. Computer systems and medication device (e.g., pumps) screens, printouts, and preprinted order forms should list or prompt for weights only in g (neonates) or kg. Document weights using metric designations only. Use measured weight, not a stated, historical, or estimated weight. Ensure that all oral liquids that are not commercially available as unit dose products are dispensed by the pharmacy in an oral syringe. Use only oral syringes marked Oral Use Only. Use of an auxiliary label For oral use only on syringes is preferred, if it does not obstruct critical information. Ensure that oral syringes do not connect to parenteral tubing in the hospital. Purchase and use oral liquid dosing devices (oral syringes/cups/ droppers) that only display the metric scale. Patients discharged on an oral liquid medication should be provided with oral syringes (or a prescription for oral syringes) to measure volumes in ml. Eliminate glacial acetic acid from all areas of the hospital. This includes all clinical areas of the hospital (e.g., pharmacy, clinics, physician offices, patient care areas). Replace glacial acetic acid with vinegar (5% solution) or commercially available, diluted acetic acid 0.25% (for irrigation) or 2% (for otic use). Laboratory use excluded if lab purchases directly from an external source. 2 Please select one answer in each category that best describes your hospital, the number of inpatient beds, and your professional designation. Hospital: Non-academic/non-governmental/not-for-profit Investor-owned/for-profit Academic Government (state/local) Military Veterans Affairs Critical access Other: Hospital inpatient beds: 25 beds or less beds beds beds 500 beds and over Profession: Nurse Pharmacist Physician Administrator Other: 3 Prior to receiving this survey, were you aware of ISMP s Targeted Medication Safety Best Practices for Hospitals? No Yes If yes, how did you hear about the best practices?