New 2022 ISMP guidelines focuses on perioperative and procedural settting medication safety

BD Institute for Medication Management Excellence

New 2022 ISMP Guidelines Focus on Medication Safety in Perioperative & Procedural Settings

PUBLISHED: May 1, 2023

Shannon Johnson, PharmD, CPHIMSS
Associate Director, Medical Affairs, Becton, Dickinson and Company (BD)


Perioperative and procedural settings are high-risk environments for medication errors1.  When medication errors occur, they are often the result of complexity of care, numerous handoffs, fast pace, and medication related issues2, 3.  To help address this, the Institute for Safe Medication Practices (ISMP) has developed guidelines on medication safety in perioperative and procedural settings3.

Released in 2022, these guidelines aim to provide healthcare professionals within hospitals, ambulatory surgery centers, and other procedural locations with a comprehensive framework for proactively recognizing and prioritizing gaps in their medication systems and practices.   A proactive approach to error prevention is particularly helpful because many of the issues may not otherwise be recognized through voluntary medication error reporting and analysis1.

Comprised of ten recommendations (called “Key Elements”, see Table 1 below), each includes detailed statements (developed through expert consensus) that describe proven safety practices that support each element.  This is particularly interesting from the standpoint that technology solutions currently exist that can be extremely valuable in helping to meet elements #4 and #10 which state:

  • 4.3:  Eliminate the use of handwritten labels by 2025
  • 4.4:  Include a machine-readable code on all syringe & infusion labels by 2025
  • 4.5:  Full name, concentration/dose of the drug, name or initials of the preparing practitioner, expiration date and time. Color coded labels not sufficient.
  • 10.11:  Use machine-readable coding to verify patients and medications
  • 10.12:  Implement machine-readable coding to confirm medication/solution selection prior to administration.
  • 10.13:  Implement and integrate machine-readable coding to support real-time EHR documentation of medication doses and fluid administration


Medication labeling systems can be an effective way to help meet the consensus based key elements within the ISMP Guidelines3, 5.  And because new functionality exists to enable the medication labeling system to be connected to your Electronic Health Record (EHR), the tenth element statements (10.11, 10.12, and 10.13 shown above) are now able to be addressed rather effectively whereas in times past this may not have been the case.

In conclusion, the ISMP 2022 Guidelines on Medication Safety in Perioperative and Procedural Settings provide a valuable resource for healthcare professionals working in these complex environments. By following these guidelines and adopting a multi-disciplinary approach to medication safety, healthcare organizations can help to reduce the risk of medication errors and improve patient outcomes.




Ten Key Elements that Make up the ISMP Guidelines on Medication Safety in Perioperative & Procedural Settings3

1)Patient Information - Essential patient information is obtained, readily available in useful form, and considered when prescribing, dispensing, and administering perioperative medications, and when monitoring the effects of these medications.
2)Drug Information - Essential drug information is readily available in useful form and considered when prescribing, preparing, dispensing, and administering perioperative medications, and when monitoring the effects of these medications.
3)Communication of Drug Orders and Other Drug Information - Methods of communicating drug orders and other drug information in the perioperative setting are streamlined, standardized, and automated to minimize the risk of error.
4)Drug labeling, packaging, and nomenclature - Strategies are undertaken to minimize the possibility of perioperative errors with manufacturer-prepared, pharmacy-prepared, or commercially prepared (e.g., from a compounding pharmacy or outsourcing facility) drug products that have similar or confusing labeling/packaging and/or drug names that look and/or sound alike.
5)Drug standardization, storage, and distribution - IV and regional anesthesia solutions, drug concentrations, doses, and administration times are standardized whenever possible.
6)Medication delivery device acquisition, use, and monitoring - The potential for human error is mitigated through careful procurement, maintenance, use, and standardization of devices used to prepare and administer medications in the perioperative setting.
7)Environmental factors, workflow, and staffing patterns - Medications are prescribed, transcribed, prepared, dispensed, and administered in the perioperative setting within an efficient and safe workflow and in a physical environment that offers adequate space and lighting, and allows practitioners to remain focused on the medication use process without distractions.
8)Staff competency and education - Perioperative practitioners receive sufficient orientation to the perioperative medication use process and undergo baseline and annual competency evaluations of knowledge and skills related to safe medication practices.
9)Patient education - Patients are included as active partners in their perioperative care and are educated about their medications and ways to avert errors.
10)Quality processes and risk management - A safety-supportive culture (e.g., just culture) and model of shared accountability for safe system design/redesign and safe behavioral choices are in place and supported by perioperative leaders, managers, and the associated Board of Trustees/Directors.


  1. Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of perioperative medication errors and adverse drug events.  Anesthesiology. 2016;124(1):25-34.
  2. ISMP launches New Perioperative Medication Safety Guidelines (2022) Institute For Safe Medication Practices. Available at: (Accessed: May 3, 2023).
  3. Guidelines for Safe Medication Use in Perioperative and Procedural Settings. Institute For Safe Medication Practices (ISMP) (2022).
  4. Flynn E, Barker K, Pepper G, Bates D, Mikeal R. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm. 2002; 59(5):436–46. [PubMed: 11887410]
  5. Safe label system (SLS) Codonics. Available at: