some ISMP accomplishments.

We’re proud of the following accomplishments made by ISMP staff and the health professionals and consumers who’ve taken the time to report errors, near misses and hazardous conditions to the ISMP medication Errors Reporting Program (ISMP MERP). As a result of their efforts, Americans are safer from harm from these conditions than ever before.

I. Early warning system

Nationwide hazard alerts
(description of the safety issue along with error-reduction recommendations)
In direct response to analysis of specific types of errors and hazards submitted to the MERP, ISMP electronically distributed timely, nationwide, hazard alerts to healthcare providers on the following topics:  

  • Fatal events involving concentrated electrolytes (1996)
  • Mix-ups between various protease inhibitors, some new to the market (1996)
  • Change in packaging of Clintec Nutrition 10% amino acid solution, which has led to mix-ups with look-alike containers of 10% dextrose solution (1996)
  • Errors from confusing dose labeling on Camptosar (irinotecan hydrochloride injection, CPT-11) (The alert leads to labeling changes) (1996)
  • Ambiguous presentation of a cisplatin regimen published in the Journal of Clinical Oncology (The alert leads to correction published in subsequent journal) (1997)
  • Fatal overdoses of cisplatin due to labeling and packaging similarity with carboplatin (The alert leads to labeling and packaging changes) (1997)
  • Fatal events involving magnesium sulfate overdoses (1997)
  • Fatal errors stemming from confusion between lipid-based products (amphotericin B, doxorubicin, daunorubicin) and their conventional counterparts (1998)
  • Repeated warnings about errors from confusing dose labeling on Cerebyx (fosphenytoin) (The alert leads to labeling changes) (1998)
  • Methotrexate overdoses due to inadvertent administration daily instead of weekly (2002)
  • The need for immediate, nationwide replacement of Brethine (terbutaline) ampuls with available vials to avoid potentially fatal mix-ups with look-alike ampuls of Methergine (methylergonovine) (2004)
  • Error alert on Heparin-insulin confusion after several reports of insulin being added to neonatal TPNs instead of heparin (2007)
  • Fatal overdoses with fentanyl transdermal patches (2007)
  • Warned about concentrated acetaminophen 100 mg/mL product similar to TYLENOL Infant Drops, but available in a pint bottle. FDA forced removal of product from market due to potential for confusion with lower concentration liquids also available in similar pint bottle (2008)
  • Warning about IV solutions administered post-op can cause low sodium levels and death in healthy children (2009)
  • Tamiflu oral suspension shortage contributing to dosing errors (2009)
  • Needlestick injury due to label issue with Lovenox Unit Dose injection (2010)
  • Press releases to the lay and healthcare media
    (description of the safety issue, error-reduction strategies, and link for additional information)
    In direct response to analysis of specific types of errors and hazards submitted to the MERP, ISMP electronically distributed timely, nationwide press releases to the lay and healthcare media on the following topics:  
  • The risk of accidental acetaminophen overdoses in children if parents or healthcare providers fail to recognize that there are different dosage strengths available on the market (2003)
  • Remind parents during the flu season about the risk of acetaminophen overdoses and that aspirin is not a suitable alternative for children who have fever, headaches, or other signs of a virus infection (2003)
  • The dangerous practice of “PCA by proxy” and other risks associated with pain control when using patient controlled analgesia (2003) 
  • Fatal errors that have occurred because medications or solutions were unlabeled in the sterile field (2004)
  • A call for definitive action by the FDA and manufacturers on longstanding labeling and packaging problems that have led to serious errors (e.g., vaccines with look-alike packaging, medications packaged in look-alike low density polyethylene containers, concentrated liquid morphine without a prominent warning) (2004)
  • Life-threatening tubing misconnections in hospitals, including the risk of fatal connections between IV ports and blood pressure device hoses, air supply hoses, oxygen tubing, and other forms of medical tubing (2004) 
  • The risk of methemoglobinemia associated with benzocaine spray products and the difficulty with detection of the potentially fatal reaction because arterial blood gas or pulse oximetry readings can be near normal (2004)
  • Improper and sometimes fatal intrathecal injection of ionic contrast media prior to diagnostic radiological tests (2004)
  • Fatal overdoses that have occurred when using transdermal fentanyl patches (2005) 
  • Warning that the same brand name may be used for different drugs in different countries, causing harm in some cases (2005)
  • Computer weaknesses compromise medication safety (2005)
  • A call for more action to safeguard pain patches (2005)
  • Myths still exist about hospital formularies (2005)
  • Survey shows need for improvement in safety practices for IV vincristine (2006)
  • Fatal overdoses with fentanyl transdermal patches continue (2007)
  • Archives of Internal Medicine issues a press release on ISMP Adverse Drug Reaction Study (2007)
  • Error-prone conditions can lead to student nurse-related medication mistakes (2007)
  • Product-related issues lead to potential errors with investigational drugs (2007)
  • Survey shows unnecessary risks still exist with automated dispensing cabinets (2008)
  • Recommendations on resolving conflicts when safety questions arise (2008)
  • Safe practice recommendations for basal opioid infusions given through patient-controlled analgesia (2009)
  • A call for immediate communication between industry and FDA on opioid product withdrawals (2009)
  • A call to remove the use of “teaspoonful” and other non-metric measurements in prescription directions in order to better protect patients (2009)
  • A call for safety improvements in use of elastomeric pain relief pumps (2009)
  • Economic downturn is impacting medication safety (2010)
  • Examination of fatal error supports system-based approach to safety (2010)

II.  Learning

Dissemination of error-prone trends and error-reduction strategies
In direct response to analysis of errors and hazards submitted to MERP, ISMP took the following actions to facilitate widespread dissemination of the error-prone trends uncovered and suggested error-reduction strategies: 

  • Published the fist list of dangerous drug abbreviations, as identified from voluntary practitioner reports of errors1 (1987)
  • Published the first mention in the medical literature of the dangers of free-flow infusion pumps (1992)
  • Published the first scholarly article on application of failure mode and effects analysis in healthcare settings (1994)
  • Surveyed U.S. hospitals about serious medication errors and drugs most prone to these errors; combined with data from the MERP, these findings become the source of the nation’s first high-alert drug list (1995)
  • Created a website for clinicians and consumers to access free medication safety information electronically, as learned from reports to the MERP (1995)
  • Launched the ISMP Medication Safety Alert!® newsletter; the biweekly publication shares blinded stories about errors reported to the MERP and recommendations for multidisciplinary prevention of medication errors in acute care settings (1996)
  • Held its first seminar for the pharmaceutical industry, Strategies for Error-Proofing Drug Labeling, Packaging & Nomenclature, in Princeton, NJ, based in large part on associated errors reported to the MERP; ISMP holds annual educational programs thereafter (1998)
  • Published in a peer-reviewed journal the first list of high-alert medications that are more likely to be involved in serious medication errors4 (1998)
  • Disseminated the first ISMP Medication Safety Self Assessment® for Hospitals, conducted in partnership with AHA and the Healthcare Research and Education Trust (HRET); the safety practices highlighted in the self-assessment are derived from analysis of hospital error reports submitted to MERP (2000); findings were later published5 (2003)
  • Launched the first certificate program in medication safety, offered as part of Temple University’s Doctor of Pharmacy program; blinded error reports from the MERP are used to teach students about medication safety (2000)
  • Issued a white paper on electronic prescribing calling for the elimination of handwritten prescriptions, which were clearly associated with harmful errors reported to the MERP6 (2000)
  • Conducted a Medication Safety Self Assessment® for Community/Ambulatory Pharmacy, cosponsored by the APhA Foundation and National Association of Chain Drug Stores; the safety practices highlighted in the self-assessment are derived from analysis of community practice error reports submitted to MERP (2001)
  • Launched the ISMP Medication Safety Alert! ® Community/Ambulatory Care Edition; the monthly publication shares blinded stories about errors reported to the MERP and recommendations for multidisciplinary prevention of medication errors in community settings (2002)
  • Launched the ISMP Medication Safety Alert! ® Consumer Edition and the ISMP Nurse Advise-ERR ®newsletters; the monthly nursing and bimonthly consumer publications share blinded stories about errors reported to the MERP and recommendations for prevention of medication errors in acute care and self-care (home) settings (2003)
  • Published a review of all medication errors associated with patient-controlled analgesia in ISMP Medication Safety Alert!, along with recommendations for its safe use; the findings are later used to brief FDA staff who evaluate medical devices, and to hold a 1-day educational meeting devoted to safety issues associated with patient-controlled analgesia (2003)
  • Conducted the second ISMP Medication Safety Self Assessment® for Hospitals; the safety practices highlighted in the self-assessment are derived from analysis of hospital error reports submitted to MERP (findings [to be published] show that hospitals have made improvement in virtually every category since the 2000 assessment) (2004)
  • Issued the ISMP Medication Safety Self Assessment® for Antithrombotic Therapy in Hospitals; many of the safety practices highlighted in the self-assessment are derived from analysis of errors submitted to MERP (2005)
  • Offered a Teleconference on the “Just Culture” model to help maximize safety and balance individual and system responsibility for errors (2005)
  • Redesigned website to provide easier access to medication safety information (2006)
  • Created, in collaboration with the Medical Group Management Association (MGMA) and the Health Research and Educational Trust (HRET), the Physician Practice Patient Safety Assessment (PPPSA), a unique Web-based tool that allows medical practices to evaluate daily processes that affect patient safety (2006)
  • Published patient-specific guidelines for injectable syringe labels for inpatient use (2007)
  • Launched a project to study medication reconciliation, through a grant from the Aetna foundation (2007)
  • Published an updated version of ISMP’s List of High-Alert Medications based on a 2007 practitioner survey and review by ISMP and other medication safety experts (2007)
  • Issued a white paper on inappropriate medication use and the role of the community pharmacist in helping Americans take their medications safely (2008)
  • Issued guidance on the interdisciplinary safe use of Automated Dispensing Cabinets following a 2007 ISMP-led forum which included key stakeholders (2008)
  • Collaborated with the Hematology Oncology Pharmacy Association (HOPA) and the International Society of Oncology Pharmacy Practitioners (ISOPP) to conduct an international survey that assesses three important areas related to cancer chemotherapy safety: Compliance with WHO vincristine recommendations; best practices related to IV chemotherapy safety and safe practices with oral chemotherapy (2008)
  • Released, in collaboration with the Health Research and Educational Trust (HRET) and the Medical Group Management Association (MGMA), the Pathways for Patient Safety™, a series of Web-based tools aimed at increasing awareness, knowledge and implementation of best practices to reduce the risk of patient harm in physician practices (2009)
  • Introduced the first Medication Safety Self Assessment® for Automated Dispensing Cabinets based on guidelines developed by a national forum of practitioners and vendors with expertise in the safe use of ADCs, which was convened by ISMP (2009)
  • Issued guidance on the safe use of intravenous infusion devices following a 2007 ISMP-led forum which included key stakeholders (2009)
  • Launched PracticeRx, in cooperation with Brandofino Communications, a safety alert system and error reporting tool for the iPhone that allows users to access crucial and timely information from the Institute, as well as make a real difference to medication safety by reporting errors (2010)
  • Began collaboration with ISMP Canada, and the International Society of Oncology Pharmacy Practitioners (ISOPP) to develop a new self-assessment tool to help hospitals and ambulatory cancer centers throughout the world evaluate oncology medication safety (2010)
  • Participated in a collaborative project with American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) to educate clinicians about nutrition support therapy error reporting (2010) Developed guidelines for Standard Order Sets to help ensure that such order sets are carefully designed, reviewed, and maintained in order to prevent errors (2010)
  • Developed software for a community pharmacy medication error-reporting program with ISMP Canada (2010)
  • Published an updated version of ISMP’s List of Drugs with Tall Man Lettering based on a practitioner survey and review by ISMP and other medication safety experts (2010)
  • Xactdose revised their labeling for levETIRAcetam, phenytoin, and nystatin unit dose suspensions to express the total concentration (2010)

III. Change

Drug and device packaging, labeling, and nomenclature changes
In direct response to errors or hazards submitted to the MERP that involved unclear or look-alike packaging and labeling, or look- and/or sound-alike drug names:

  • ISMP convenes a national meeting that influences the U.S. Pharmacopeia (USP) and US Food and Drug Administration (FDA) to establish a federal requirement that potassium chloride concentrate for injection have black caps, closures, and warning statements to prevent confusion with other parenteral drugs (1987)
  • ISMP promotes changing vincristine labeling to reduce the likelihood of inadvertent intrathecal injection; this advocacy leads to an updated USP standard requiring special warning labels (1991)
  • ISMP convenes a national meeting to discuss elimination of cardiac lidocaine in 1 and 2 g concentrate prefilled syringes, due to reports of error-related deaths from mix-ups with 100 mg prefilled syringes; their manufacturers subsequently pull products off the market (1992)
  • ISMP successfully promotes inclusion of a maximum dose statement on cisplatin vial caps and seals to increase recognition of dose limits for this cancer agent (1997)
  • ISMP published nationwide warnings and filed a petition with the United States Adopted Names Council that led to renaming of amrinone as inamrinone, to prevent sound-alike confusion with amiodarone (2000)
  • Abbott redesigned the label on Carpuject boxes of metoclopramide injection 10 mg/2 mL to reduce similarity with another Carpuject product, metoprolol 5 mg/5 mL (2000)
  • Abbott discontinue packaging nonnutritional medications, and dopamine and potassium chloride injections, in the Universal Additive Syringes (UAS) to prevent the risk of fatal direct IV injections of the concentrated products (2000)
  • Genentech revised the label on Herceptin (trastuzumab) vials and its accompanying diluent to prevent further errors when reconstituting the product (2002)
  • Bedford Laboratories changed the color of the flip-off cap on ephedrine vials to prevent further errors related to similar appearance with its ketorolac injection vials (2003)
  • Bedford Laboratories redesigned its acetazolamide injection 500 mg labels based on reports that they looked dangerously close to the company’s acyclovir 500 mg vials, using color differences and tall man letters (2003)
  • Lilly revised its labels on Zyprexa (olanzapine) containers using tall man letters to help prevent further mix-ups with Zyrtec (cetirizine) containers (2003)
  • Abbott Laboratories revised the background colors on the label for its labetalol injection vials and cartons to help prevent further mix-ups with Dopram vials from ESI Lederle (2003)
  • Abbott Laboratories Hospital Products Division revised the labels of its premixed product, lidocaine, to give it a unique appearance and to print important information on both sides of the overwrap (2003)
  • BD Medical Systems re-engineers its hypodermic syringes to remove tip caps to eliminate the risk of accidental choking if, although contraindicated by BD, used for oral medications (2003)
  • ISMP petitioned USP for elimination of ratio expressions for epinephrine; ISMP also calls for labeling changes to reduce the chance of name mix-ups between epinephrine and ephedrine (2004)
  • KV Pharmaceuticals, and its subsidiary, Ther-Rx, revised the unit dose labels for Niferex and Chromagen (multivitamins with iron) products to specify the total iron content on each individual blister for all strengths of these products (2004)
  • Janssen revised the labels on its unit dose packages of Risperdal (risperidone) M-Tab to make the product name and strength more prominent, and removed the numbered directions for opening the package, which had been confused as the dose (2005)
  • Mayne Pharma added the warning statement “Not for intrathecal or epidural use” to the front of applicable vial and carton labels, and moved the statement “No bacteriostat added” to the side and back of the carton to reduce initial misunderstanding that the product contains no preservatives (2005)
  • Mayne Pharma revised its label on hydromorphone vials so it is clear that only 1 mL (2 mg) is available in the 2 mL vials (2005)
  • Johnson & Johnson’s McNeil Consumer & Specialty Pharmaceuticals recalled several Tylenol (acetaminophen) products after due to confusing labels that made it unclear if one or two tablets were needed for an 80 mg dose (2005)
  • Janssen changed the brand name of its Alzheimer’s drug Reminyl (galantamine hydrobromide) to Razadyne to prevent further mix-ups with the antidiabetic agent Amaryl (glimepiride) (2005)
  • Lexi-Comp revised their monograph for fluorouracil 5-day infusion for head and neck cancer (2005) FDA released an alert about falsely elevated glucose readings in patients who have received parenteral products containing certain substances (2005)
  • Reliant Pharmaceuticals released a warning to healthcare professional about the potential for confusing Omacor (omega- 3-acid ethyl esters) prescriptions with Amicar (aminocaproic acid) (2005)
  • FDA published a Public Health Advisory to warn US citizens traveling abroad or buying prescription drugs via the Internet about risks when obtaining medications from foreign sources (2006)
  • McNeil Consumer and Specialty Pharmaceuticals returned the 500 mg Extra Strength Tylenol (acetaminophen) pouch from its current white color to the familiar yellow color to help distinguish it from the white 325 mg Tylenol pouch (2006)
  • Bayer added a boxed warning to the Nimotop (nimodipine) labeling to caution about medication administration errors with this product (2006)
  • FDA published a Public Health Advisory about methemoglobinemia associated with the use of topical benzocaine sprays marketed under different names, including Hurricane, Topex, and Cetacaine (2006)
  • American Pharmaceutical Partners (APP) agreed to revise the labeling of adenosine injection, 12 mg/4 mL, to reflect that the vial contains 4 mL. The vial contained 12 mg in 4 mL but was packaged in a vial with a capacity of 5 mL. The vial was also labeled as a “5 mL single dose vial,” giving the impression that the vial actually contains 5 mL of drug (2006)
  • PharMEDium introduced a new cap for use with all pain management admixtures compounded in the Baxter APII containers (2007)
  • Sanofi pasteur changed the carton and vial labels for Daptacel (diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed) and Adacel (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine adsorbed) to avoid look-alike packaging confusion between the two products (2007)
  • PharMEDium introduced a new cap for use with all pain management admixtures compounded in the Baxter APII containers (2007)
  • Astra Zeneca received approval for an update to the “patient’s instructions for use” section of the product label for Pulmicort Flexhaler (budesonide inhalation powder) due to confusion with interpreting the dose counter (2008)
  • Zymogenetics eliminated the IU abbreviation on their Recothrom thrombin (recombinant) topical packaging and vial labels (2008)
  • Sanofi-aventis notified health professionals to exercise all necessary precautions to avoid the potential for risks to patients caused by using the same insulin pen for multiple patients, even if needles are changed before each use (2009)
  • Brookstone Pharmaceuticals initiated a nationwide voluntary recall of all lots of Concentrated Acetaminophen Drops in 16 ounce (473 mL) bulk containers after a June 2008 ISMP Hazard Alert warned that this 100 mg/mL product (similar to TYLENOL Infant Drops, but available in a pint bottle) might be confused with the lower concentration liquids (160 mg/5 mL, also available in pint bottles) (2009)
  • Ciba Vision, the company that makes Clear Care Cleaning and Disinfecting Solution  for contact lenses initiated communication with FDA regarding updates to the container warning system for their product (2010)
  • Roxane pharmaceuticals revised their oral morphine sulfate solution packaging and labeling (2010)

    Organization system changes
    In direct response to ISMP publication of errors or hazards submitted to the MERP, individual organizations reported the following examples of system changes that had been made (based on surveys):   

    • Established protocols for electrolyte replacement, Cerebyx, TPA, heparin, methadone, and conscious sedation (2000)
    • Separated products with look-alike names or packaging, and/or purchased them from different manufacturers (2000, 2004, 2005)
    • Programmed computer alerts and applied auxillary labels for neuromuscular blocking agents, concentrated oral morphine products, lipid-based products, and drugs with look-alike names (2000)
    • Monitored compliance with prohibited abbreviations (2000, 2004)
    • Programmed computer alerts for cross allergies (e.g., Atrovent and peanut allergies) (2000, 2004)
    • Removed concentrated electrolytes, ketamine, concentrated esmolol, and Cerebyx from patient care units (2000, 2004)
    • Removed nifedipine capsules from crash carts and prohibited its sublingual use (2000)
    • Improved control of drug samples (2000)
    • Removed from service infusion pumps without free-flow protection (2000)
    • Limited morphine PCA to a single concentration (2000)
    • Instituted full unit-dose dispensing of all neonatal intensive care unit drugs (2000)
    • Abandoned tabulating error rates based upon voluntary practitioner reporting (2000)
    • Removed TB syringes with orange color-coded 25 gauge needles from patient care units (2003)
    • Sequestered neuromuscular blocking agents that are stored on units (2003)
    • Changed the concentrations of drugs stored in pediatric code carts to match those listed on the Broselow tape (2003)
    • Included newsletter information in new staff orientation and other education programs (2003, 2005)
    • Used the information to support implementation of computerized prescriber order entry (CPOE) systems (2003)
    • Placed markers at the bedside for IV line labeling (2005)
    • Stocked oral syringes in all patient care areas for use with liquid medications (2005)
    • Removed outdated drug reference books (2005)
    • Created new processes for reporting near misses and hazardous situations (2005)
    • Made format changes to computer-generated medication administration records to reduce the risk of errors (2005)

    Individual practice changes
    In direct response to ISMP publication of errors or hazards submitted to the MERP, individual practitioners reported the following examples of practice changes that had been made (based on surveys):   

    • Established nurse/pharmacist double checks for medication cart exchanges (2000)
    • Dispense insulin or oral hypoglycemic drugs only after confirmation of a diagnosis of diabetes, intolerance of glucose load with TPN, or some other therapeutic reason for the medication (2002)
    • Increased reporting of drugs with similar names and labels (2003)
    • Decreased personal use of dangerous abbreviations (2003, 2005)
    • Eliminated the numbering of orders and the use of checkmarks during transcription to avoid misinterpretation of orders and medication administration entries (2003)
    • Always ask prescribers to read their orders to staff before leaving the unit (2003)
    • Improved systematic and consistent read back of telephone orders (2005)
    • Overcame embarrassment when asking for a double check (2005)


    IV.     Standards

    National safety guidelines, standards, and goals
    In direct response to analysis of reports submitted to the MERP and trended findings:

    • USP responds to repeated reports of accidental intrathecal injection of vincristine submitted to the MERP and requires manufacturer labeling to state: FATAL IF GIVEN INTRATHECALLY. FOR IV USE ONLY. DO NOT REMOVE COVERING UNTIL MOMENT OF INJECTION. Individually prepared doses must also be placed by the dispenser in an overwrap labeled with a similar warning7 (1991)
    • USP responds to errors stemming from confusion caused by the apothecary system of measurement by eliminating a conversion table in its national formulary publication, ceasing to officially recognize the apothecary system, and requiring drug strengths to be expressed only in metric units on the container label8 (1994)
    • Fatal chemotherapy errors reported to the MERP became the impetus for a national forum organized by ISMP on preventing chemotherapy errors; recommendations were later published in the American Journal of Hospital Pharmacy9 (1995, 1996)
    • ISMP and USP worked with the National Coordinating Council on Medication Error Reporting and Prevention to recommend greater clarity in prescription writing to prevent the types of errors reported to MERP (e.g., eliminating trailing zeros for whole number doses) (1996)
    • ISMP began a formal campaign that spurred the Veterans Administration to require removal, and Joint Commission (JC) to urge nationwide removal, of potassium chloride concentrate for injection from all patient care areas (1997)
    • ISMP prepared test cases of medication safety alerts for computerized physician order entry, based upon the types of prescribing errors reported to the MERP, used by First Consulting Group and the Leapfrog Group, which brings together more than 100 organizations that provide healthcare benefits to seek improvement in medical quality, safety, and outcomes (1999)
    • Upon ISMP’s request, FDA asks pharmaceutical companies to use tall man lettering for labeling of products with look-alike drug names, particularly for twenty generic drug name pairs prone to confusion (2001)
    • Joint Commission adopts recommendations from ISMP’s list of error-prone medication abbreviations, symbols, and dose designations for use in its National Patient Safety Goals (2002)
    • ISMP and the Pediatric Pharmacy Advocacy Group issue pediatric pharmacy medication safety guidelines designed to reduce the incidence of medication errors among children (2002)
    • Guidelines for safe electronic communication of medication orders are drafted and posted on ISMP’s website and American Society for Health-System Pharmacists (ASHP) listserve for comments (2003)
    • JC adopts recommendations from ISMP’s list of look- and sound-alike drug names gathered from the MERP along with related error reduction strategies for use in its National Patient Safety Goals (2004)
    • JC adopts ISMP’s recommendations to prohibit use of infusion pumps without protection for accidental free-flow for use in its National Patient Safety Goals (2003); the goal is later retired with full compliance nationwide among accredited organizations (2006)
    • JC responds to repeated descriptions of errors related to unlabeled products on the sterile field and issues a National Patient Safety Goal to help improve labeling practices (2006) 


V.      Public policy advocacy

Advocacy activities
In direct response to trended findings from errors and hazards submitted to the MERP, ISMP led the following public policy advocacy activities:  

    • ISMP staff member appeared on the first segment of the first Dateline show on ABC, which discussed fatal medication errors reported to the MERP involving lidocaine concentrate syringes, unlabeled medications, and a vincristine overdose that killed a small child; this brought national attention to medication errors and their prevention (1992)
    • Held the first Global Conference on Medication Error Reporting Programs with U.S. and international experts and approximately 100 pharmacists from around the world (1994)
    • ISMP partnered with the American Hospital Association (AHA) in a national initiative to help hospitals examine and further improve medication safety; ISMP staff met with President Clinton and participated in White House press briefing to announce the national initiative, which was based in part upon findings from the MERP (1999)
    • Participated in national policy discussions exploring types of error reporting programs; Institute experts met with Senate and House staff, testified in Senate committee hearings, and presented a Senate staff briefing with AHA and the American Pharmaceutical Association (APhA); this, along with ongoing USP and ISMP advocacy, contribute to the subsequent passage of legislation in 2005 offering evidentiary protection of patient safety data and error reports submitted to agencies such as ISMP and USP (1999)
    • Published a discussion paper on adverse event and error reporting in healthcare; paper is highly acclaimed, and serves as a conceptual model for error reporting position statements by leading healthcare organizations10 (2000)
    • ISMP staff member testified at an FDA public meeting on bar code labeling regulations; findings from the MERP are used to support the need for bar codes on unit dose packages of medications; ISMP also issued a white paper on bar coding11 (2002)
    • ISMP supported the signing of the Patient Safety and Quality Improvement Act of 2005 which offers protection for patient safety information, including errors reports and root cause analyses, if it is shared with certified independent patient safety organizations (2005)
    • ISMP launched, in association with the Pennsylvania Office of Rural Health (PORH), a 15-month program, called the Pennsylvania Critical Access Hospitals Medication Safety Collaborative, to help small Pennsylvania rural hospitals meet the challenges faced in implementing comprehensive medication safety programs (2006)
    • ISMP supported the stance taken by the Wisconsin Hospital Association and Wisconsin Nurses Association that criminal prosecution of a healthcare professional for an unintentional error is inappropriate and unwarranted (2006)
    • With ISMP Canada, established International Medication Safety Network (
    • ISMP convened a national forum of stakeholders to address the use of Automated Dispensing Cabinets (2007)
    • ISMP partnered with, a free, drug safety monitoring service, in an effort to increase consumers’ knowledge about their medications and empower them to better safeguard their health (2008)
    • ISMP urged the greater examination and improvement of drug recall policing process following fines and citations for “unprofessional conduct” levied against some individual pharmacists and hospitals by the California Board of Pharmacy (CBOP) and California Department of Public Health (CDPH) (2008)
    • ISMP became one of the first ten Patient Safety Organizations (PSOs) designated by the Secretary of the Department of Health and Human Services (HHS) (2008)
    • ISMP opposed criminal charges filed against an Ohio pharmacist who was charged with involuntary manslaughter for his role in a 2006 fatal medication error that occurred while preparing the final dose of chemotherapy for a two-year-old child (2009)
    • ISMP signed an agreement with the Medication Safety Officer Association to provide them with logistical support (2009)
    • Surveyed nurses about the often-questioned “30-minute rule”. A landslide of more than 17,500 frontline nurses responded, providing more than 8,000 optional additional comments (2010)
    • Conducted a national survey of more than 1,800 healthcare practitioners uncovering high levels of frustration as well as low levels of patient safety caused by recent drug shortages (2010)
    • Launched a National Alert System with the American Society of Health-System Pharmacists (ASHP) to provide time-critical safety information to healthcare professionals (2010)
    • Established an International Medication Safety Mentorship program (2010)
    • Established contracts with healthcare organizations to serve as a Patient Safety Organization (2010)
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