ISMP Safe medication management fellowship

Course OUtline

This outline provides an overview of the opportunities available to the ISMP Safe Medication Fellow.  The fellowship is flexible and may be adapted to take advantage of emerging opportunities that present during the course of the fellowship. Professional interests of fellows may be incorporated into planned experiences in order to accomplish individual goals.

Program Preceptor: Michael R. Cohen, RPh, MS, ScD

  • Orientation
    • Institute for Safe Medication Practices
      • Scope/purpose
      • Operations
      • Computer database, on-line access to bulletin boards, computer software, Medication Errors Reporting Program database, ISMP Medication Safety Alert! Newsletter (ISMP-MSA) database
    • Medication Errors and Adverse Drug Reactions
      • Review of relevant literature, Medication Errors book
      • Review of ISMP Medication Errors Reporting Program database and FDA Medwatch database
      • Personal instruction by Cohen and staff
      • Research and contribute articles to ISMP-MSA newsletter
      • Learn the medication use process systems through on-site consultation at healthcare facilities
    • Regulatory Standards and Accreditation Issues
      • Review of relevant federal codes
      • Review of USP and FDA labeling/packaging requirements
      • Review of past correspondence with FDA, USP, industry, etc.
      • Monitor ISMP relations and activities with Joint Commission
      • Personal instruction by Dr. Cohen
  • Error Reporting Systems
    • Mini-rotation at FDA to learn FDA Medwatch
      • Reporting Program, structure and purpose of FDA, Division of Medication Errors and Technical Support, etc., and meet with FDA staff
  • Safe Medication Management Strategies
    • Mini-rotations - Technology overview, visit healthcare sites where systems have been integrated
      • Robotics, Bar-code drug administration, physician order entry systems, pharmacy computer systems, automated dispensing equipment
    • Packaging and Labeling - Philadelphia area pharmaceutical manufacturers
  • Experiential Learning
    • Screening and triaging of reports
      • ISMP Medication Error Reports
      • FDA Medwatch reports coded as medication errors.
        • Perform follow-up with healthcare practitioners who report errors. Assure all necessary information available for ISMP evaluation of incidents
        • Communicate with manufacturers, USP and FDA to report and discuss labeling, packaging, name and device related incidents
        • Confidential medication safety reviews of hospitals. Participate in development and delivery of final report to institutions
        • Serve as primary contact for requests for assistance from outside pharmacists, nurses, risk managers, etc.
        • Prepare and conduct press interviews
    • Review adverse drug event reports sent to Medwatch
      • Follow up with reporters as necessary
      • Research ADR, determine significance and relevance to ADR preventive efforts
      • Assist in preparing reports for publication
    • Participate in Med-E.R.R.S reviews
      • Research to support trademark safety decisions
      • Participate in failure analysis of proposed trademarks
      • Participate in labeling and packaging assessment for industry
  • Research, Teaching, Publications and Presentations
    • Complete at least one major survey based research project related to safe medication management
    • Teaching
      • Present medication error and adverse drug reaction prevention seminars to senior classes at Philadelphia area nursing schools, pharmacy schools, and medical schools (at least 6 times).
      • Present seminars to hospital pharmacy departments, nursing departments, or grand rounds (at least 4)
      • Participate in and possibly lecture to Temple University’s PharmD class on preventing ADE’s (2 credit elective course)
  • Presentations
    • Lead medication error prevention roundtable discussion during a state pharmacy meeting
    • Present at least one poster or platform presentation regarding research or related topic at a professional meeting
    • Participate in radio, TV, print media interviews as opportunity presents itself
  • Publications
    • Seek publication of the major research in nationally refereed journal
    • Publish safety related articles in various professional journals
  • Other Activities
    • Attends local and national professional meetings
    • Travels with ISMP staff wherever possible
    • Learns computer and writing skills
    • Develops public speaking skills
    • Participates in proposals and grant requests
    • Interacts and networks with other healthcare disciplines, corporate executives, regulatory professionals, academics
    • Promotes initiatives of the Institute for Safe Medication Practices
    • Participates in ongoing medication error prevention projects
    • Mentors PharmD students during their rotations


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