ISMP Historical Timeline

25th anniversary

2018

ISMP launches the 2018-19 Targeted Medication Safety Best Practices for Hospitals, the purpose of which is is to identify, inspire, and mobilize widespread, national adoption of consensus-based best practices for specific medication safety issues that continue to cause fatal and harmful errors in patients, despite repeated warnings in ISMP publications.
Launch of ISMP's Gap Analysis Tool (GAT) for Safe IV Push Medication Practices, designed to heighten healthcare practitioners’ awareness of safe medication systems and practices associated with IV push medication use in adult patients, assist healthcare practitioners with identifying and prioritizing opportunities for reducing patient harm and create a baseline of national efforts to enhance safety when preparing, dispensing, and administering, IV push medications in adults.
ISMP President Michael R. Cohen receives ASHP's Zellmer Lecture Award.
Release of white paper entitled Call to Action: The Case for Medication Safety Officers (MSO)  stressing the need for MSOs to be included as an integral part of the healthcare team and providing detailed information for hospital leadership on the value of creating a dedicated position directly responsible for and empowered to lead medication safety strategy and implementation.

2017

Publication of Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults, new consensus-based practices which help healthcare practitioners prevent medication errors and improve outcomes for adult patients with diabetes.
Launch of Medication Safety Certificate program with ASHP, a self-guided, online continuing education programs for pharmacists, pharmacy technicians, and other healthcare personnel.
Launch of ISMP’s International Medication Safety Management Fellowship(s).
Revision of Antithrombotic Therapy Self-Assessment to include safety strategies for some of the newer oral anticoagulants.
Launch of High-Alert Medication Safety Self Assessment, which helps hospitals and certain outpatient settings evaluate their best practices related to specific high-alert medications, identify opportunities for improvement, and track their experiences over time.
Revision of Community/Ambulatory Pharmacy Medication Safety Self Assessment, designed to help pharmacies evaluate their current systems, proactively identify opportunities for improvement, and track their efforts over time.

2016

Celebration of ISMP Medication Safety Alert! Acute Care edition 20th anniversary.
Launch of  new Medication Safety Alert! Video series with Temple School of Pharmacy. 
Update completed of ISMP Guidelines for Safe Preparation of Compounded Sterile Preparations and called for increased use of technology/automation.
Updated ISMP's List of Look-Alike Drug Names with Recommended Tall Man Letters and released first list of High-Alert Medications in Long-Term Care (LTC) Settings.
Worked with drug companies and FDA on product safety issues, including confusion of Brintellix with Brillinta and valproate sodium and levetiracetam vials. 
ISMP participates in World Health Organization's (WHO’s) new Medication Safety Challenge
ISMP receives 2016 American Association of Colleges of Pharmacy (AACP) Award for 20 years of outstanding leadership in medication error prevention and research.

2015

Released two National Alert Network (NAN) messages, on eliminating dosage cups in fluid drams and confusion between Bloxiverz injection and Vazculep injection.
Published results of surveys that exposed potential gaps in pediatric medication safety and managing hospitalized patients with ambulatory pumps.
ISMP holds a national Summit on Optimizing Safe Subcutaneous Insulin Delivery Along the Continuum of Care, examining smart pump implementation, drug libraries, and clinical practice.
Development of the 2016-17 ISMP Targeted Medication Safety Best Practices for Hospitals.
Guidelines for Safe Practice of Adult IV Push Medications are developed to help healthcare facilities standardize the safe administration of parenteral IV push medications and prevent unsafe practices and at-risk behaviors associated with IV push administration of adult medications.
Worked with Global Enteral Device Supplier Association (GEDSA) to alert health systems to safety issues surrounding upcoming introduction of new ENFit enteral feeding tube connectors.

2014

ISMP holds the first National Summit on Safe Practices Associated with IV Push Medication Administration for Adults, funded by BD, to develop a set of best practices that will facilitate safe administration.
Published an analysis and comparison of results from the 2000 and 2011 ISMP Medication Safety Self Assessments in The Joint Commission Journal on Quality and Patient Safety that helped better define the current state of medication safety.
Published the results of the first Oncology Medication Safety Self Assessment in the Journal of Oncology Pharmacy Practice.
Co-convened the 2014 Drug Shortages Summit with AHA, the American Society of Anesthesiologists (ASA), the American Society of Clinical Oncology (ASCO), ASHP, and The Pew Charitable Trusts.
Launched new ISMP Targeted Medication Safety Best Practices to address ongoing issues and help hospitals decide where to focus their efforts; the 2014-15 best practices focus on six key areas.
Added a new section on OTC medication safety to ISMP’s consumer website.

2013

Issued National Alert Network (NAN) alert on confusion regarding the generic name of the HER2-targeted drug KADCYLA (ado-trastuzumab emtansine), spurring FDA to send out its own alert around three weeks later.
Another National Alert Network (NAN) alert is issued on severe burns and permanent scarring after glacial acetic acid (≥ 99.5%) is mistakenly applied topically and has a particularly wide reach—it is distributed internally by Boards of Pharmacy, state hospital associations, and members of the American College of Gastroenterology in addition to alert network members.
As a result of persistent, ongoing safety issues, ISMP calls on hospitals to closely reexamine their policies regarding insulin pen devices, and consider transitioning away from insulin pens for routine inpatient use.
Introduced a new monthly publication, the Long-Term Care Advise-ERR™which is the first publication dedicated to giving administrators, and all healthcare personnel (physicians, nurses, consultant pharmacists) caring with elderly residents lifesaving information on preventing medication errors.
Announced that The American Society of Medication Safety Officers (ASMSO) will become part of the Institute under the new name Medication Safety Officers Society (MSOS) to provide a framework for meeting the needs of the Medication Safety Officer community on an international scale.

2012

Released a statement and advocated for practices to help safeguard patients from errors after a national outbreak of a rare form of fungal meningitis, caused by contaminated steroid shots prepared by a compounding pharmacy in Massachusetts.
Launched its third national patient safety reporting program to capture the unique causes and consequences of vaccine-related errors. The ISMP National Vaccine Error Reporting Program (ISMP VERP) allows healthcare practitioners from all practice settings to report errors and near misses in confidence.
ISMP, along with ISMP Canada and the International Society of Oncology Pharmacy Practitioners (ISOPP), launched the 2012 ISMP International Medication Safety Self Assessment® for Oncology to identify an international baseline for safe medication practices related to oncology as well as potential opportunities for improvement.
ISMP shared the results of its survey gathering practitioner feedback on implementation of drug storage, stability, and beyond use dating requirements with the Centers for Medicare & Medicaid (CMS) and Joint Commission. 
ISMP conducted survey linking community pharmacy “guarantees” to fill prescriptions within a specified time to medication errors and continues to advocate for change on a national level.
ISMP’s survey highlighted differences in nursing, pharmacy, and risk/quality/safety manager perspectives on what constitutes a high-alert drug (one more likely to cause significant patient harm when used in error). Information gathered is used to update ISMP’s List of High-Alert Medications in the Acute Care setting.

2011

ISMP releases Guidelines for Timely Medication Administration, a guidance document respondng to the controversial CMS “30 minute rule” for medication administration in acute care to help healthcare organizations with the timely administration of medications. ISMP’s survey, guidance, and continued advocacy on this issue results in changes in the rule.
The 2011 ISMP Medication Safety Self Assessment® is launched to document the progress of U.S. hospitals in medication safety and identify the impact of new challenges that have arisen since 2004, such as drug and staffing shortages, shrinking reimbursement systems, and the application of new technology.
ISMP releases results of survey on drug shortage “Gray Market,” which continues to increase national dialogue on the issue, including the launch of an investigation by Rep. Elijah Cummings (D-Md) into several companies suspected of buying and selling on the gray market.
National Alert Network (NAN) message is issued by ASHP and ISMP, warning practitioners that potentially fatal errors may occur with dosing for the antibiotic colstimethate for injection.
ISMP issues a Statement on Use of Metric Measurements to Prevent Errors with Oral Liquids. The Institute asked prescribers, pharmacists, and other healthcare professionals, as well as pharmacy computer system and e-prescribing system vendors to only use metric measurements in prescription directions.
Along with the Vermont Oxford Network and Neonatal Intensive Care Units across the U.S., ISMP develops the List of Standard Concentrations of Neonatal Drug Infusions.

2010

ISMP applauded new packaging and labeling for morphine sulfate oral 20 mg/mL solution that included revisions long advocated by ISMP to reduce the risk of confusion between the different strengths of oral morphine solutions.
More than 17,500 nurses tell ISMP that the CMS “30 minute rule” for scheduled medications can lead to patient harm. ISMP begins drafting a guidance document to help practitioners implement the rule.
An ISMP survey showed that the U.S. economic downturn may have compromised medication safety, taking a toll on hospitals and forcing them to take steps that put patients at greater risk. The survey gained widespread news coverage.
ISMP issues Guidelines for Standard Order Sets  to ensure that computerized prescriber order entry (CPOE) order sets are carefully designed, reviewed and maintained to prevent potential errors.
ISMP publishes a case study of a well-publicized error that resulted in the death of a 16-year old patient the Joint Commission Journal on Quality and Patient Safety. The article serves as a teaching tool that supports a system-based approach to safety.
National Alert Network (NAN) message is issued by ASHP and ISMP, warning healthcare practitioners about dangerous medication errors that could be caused by a shortage of EPINEPHrine pre-filled syringes.
Began to use social media technology for medication safety advocacy, through the creation of a new weekly blog for the Philadelphia Inquirer, as well as through Facebook and Twitter.

2009

The FDA alerts healthcare providers to insulin safety issues as a direct result of ISMP notifications and newsletter coverage. A safety alert and drug safety newsletter coverage from the agency pass on ISMP’s warnings regarding sharing insulin pens between patients and removing insulin from cartons. 
Following numerous reports of potential safety problems in the hospital management of elastomeric pain relief pumps, ISMP called on healthcare organizations to review their processes and procedures for utilizing these devices to provide surgical wound analgesia and/or peripheral nerve block.
ISMP warned healthcare practitioners that IV solutions administered post-operatively can cause low sodium levels and death in healthy children. The Institute called for more education on the causes, signs, and symptoms of this condition.
ISMP opposes criminal charges for a former Ohio pharmacist involved in a 2006 fatal medication error. The Institute also helps him educate other healthcare professionals about what can be learned from his case.
ISMP, HRET, and MGMA release 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.
ISMP holds the first two-day ISMP Medication Safety Intensive Workshop to help practitioners establish aggressive, focused medication safety program and the infrastructure necessary for continued safety improvements.

2008

ISMP launches ConsumerMedSafety.org, the first website exclusively designed to alert healthcare consumers to specific drug safety issues with a focus on medication error prevention, as well as provide the first national error reporting program for consumers.
ISMP becomes one of the first federally certified Patient Safety Organizations (PSOs), providing healthcare practitioners and organizations with the highest level of legal protection and confidentiality for patient safety data and error reports they submit to the Institute.
The release of ISMP’s first QuarterWatch™ report identifies possible safety concerns with the smoking cessation drug Varenicline (Chantix) and offers recommendations for safe use. The report generates huge national media attention, and causes the Federal Aviation Administration (FAA), U.S. Federal Motor Carrier Safety Administration, and Department of Defense to essentially ban or warn against its use.
ISMP helps form the National Alert Network (NAN) along with the National Coordinating Council on Medication Error Reporting and Prevention (NCCMERP) and the American Society of Health-System Pharmacists (ASHP). The coalition begins to distribute alerts about medication errors that have caused or may cause serious harm or death—the information comes from ISMP’s voluntary reporting program.
Administration of the USP-ISMP Medication Errors Reporting Program (MERP) is transferred to ISMP, and becomes the ISMP National Medication Error Reporting Program (ISMP MERP).
An ISMP survey shows that use of automated dispensing cabinets (ADCs) has increased, but safety improvements have not been as widespread as needed to maximize their benefits. The Institute issues a set of interdisciplinary Guidelines for the Safe Use of Automated Dispensing Cabinets (ADCs)  to promote safe practices.
ISMP holds a national summit on smart pumps that brings together vendors and users to identify best practices and ways to prevent errors at point-of-care.
ISMP President Michael R. Cohen receives a 2008 John M. Eisenberg Patient Safety and Quality Award for his life-long professional commitment to promoting safe medication use and safe medication delivery systems.
ISMP moves into new office at 200 Lakeside Drive, Suite 200, in Horsham, PA

2007

Archives of Internal Medicine publishes report co-authored by ISMP that shows adverse drug events reported to FDA more than doubled between 1998 and 2005, as did the deaths associated with adverse drug events. Report is widely covered in the media.
ISMP issues alert on possible confusion between heparin and insulin, along with the New Jersey Department of Health, following multiple incidents were infants received total parenteral nutrition that contained insulin instead of heparin.
ISMP holds national Summit to Manage Drug Name Confusion; stakeholders from medicine, pharmacy, government, and industry convene to discuss risk minimization strategies.
ISMP warns that routine practices used to name, label, package, and store investigational drugs raise serious patient safety concerns, and provides recommendations for safe use.
With continued reports of fentaNYL transdermal patches being prescribed inappropriately to treat post-operative pain in opioid-naïve patients, ISMP again issues national warning about patch misuse that restates error prevention recommendations.
After analyzing medication errors by student nurses, ISMP discovers a distinct set of error-prone conditions or medications that can make mistakes involving students more likely. Institute publishes a chart giving examples and recommendations for prevention.

2006

ISMP opposes criminal charges for Wisconsin nurse involved in a fatal medication error, supporting the Wisconsin Hospital Association and Wisconsin Nurses Association stance that criminal prosecution of a healthcare professional for an unintentional error is inappropriate and unwarranted.
Medication Errors (Second Edition) book by Michael R. Cohen, ISMP President and founder is published.
As a result of the ISMP-FDA abbreviations campaign, the list of dangerous abbreviations is included in the style guide for the Journal of the American Medical Association (JAMA) and Physicians’ Desk Reference (PDR).

2005

The first ISMP Medication Safety Self Assessment for Antithrombotic Therapy in Hospitals® is conducted.
ISMP advocates changes in Tylenol blister package design with FDA and McNeil Consumer & Specialty Pharmaceuticals to reduce risk of improper dosing. McNeil recalls several Tylenol products for children as a direct result of ISMP’s alert. Due in part to ISMP’s advocacy, JCAHO announces new 2006 Patient Safety Goal requiring labeling of all medications, medication containers, or other solutions on and off the sterile field in operative and other medical procedure settings.
In the wake of several fatal error reports, ISMP calls for more action to prevent overdosing with fentanyl transdermal pain patches. Institute stresses that FDA and manufacturer advisories and labeling changes are not enough to protect patients, and makes additional safety recommendations.
ISMP and the FDA partner on a comprehensive educational campaign to eliminate potentially harmful abbreviations and a joint public meeting on labeling of large volume parenterals. In addition, ISMP presents at a public hearing on the FDA Center for Drug Evaluation and Research’s current risk management strategies for human drugs.
Michael R. Cohen, RPh, MS, ScD (hon), ISMP President, is honored with a prestigious 2005 John D. and Catherine T. MacArthur Foundation Fellowship.

2004

ISMP celebrates 10th anniversary of its incorporation as a nonprofit organization, and nearly 30 years of experience in improving the safety of medical products and professional practice.
Second version of ISMP Medication Safety Self Assessment for Hospitals® is conducted; shows hospitals have improved in virtually every category since the 2000 survey.
ISMP petitions USP for elimination of confusing ratio expressions for epinephrine dosing and labeling changes to reduce the chance of name mix-ups between epinephrine and ephedrine.
Results of ISMP survey on workplace intimidation are released, which provide proof that it is a common element of many healthcare practice settings that may cause medication errors.
ISMP begins to review and analyze medication errors submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS).

2003

ISMP Medication Safety Alert! Nurse Advise-ERR and Safe Medicine publications are launched.
ISMP's first release of Guidelines for Safe Electronic Communication of Medication Orders are drafted and posted on ISMP’s web site and American Society for Health-System Pharmacists listserve for comments.

2002

ISMP holds its first teleconference which explores use of failure mode and effects analysis (FMEA).
ISMP Medication Safety Alert! Community/Ambulatory Care Edition publication is launched.
ISMP issues a white paper on the effect of bar coding unit doses on reducing medication errors.
ISMP, AHA, and HRET release Pathways for Medication Safety; includes three tools to help hospitals with strategic planning, risk assessment, and bar code readiness.

2001

Lifetime Achievement Award, presented during ISMP's Cheers Awards Dinner, is created to honor the memory of ISMP Trustee David Vogel. The award recognizes individuals who have had a major impact on safe medication practices.
The FDA agrees to require tall man lettering for twenty name pairs after an ISMP request.
ISMP staff testify before House Committee on Ways and Means subcommittee hearing on quality issues related to the design of prescription drug benefit program for Medicare beneficiaries.
The Medication Safety Self Assessment® for Community/Ambulatory Pharmacy is conducted by ISMP, cosponsored by the American Pharmaceutical Association Foundation and National Association of Chain Drug Stores.
ISMP's international affiliate organization, ISMP-Canada, is established.

2000

First ISMP Medication Safety Self Assessment for Hospitals® is conducted—more than 1,400 hospitals respond, establishing a baseline for future change. Survey helps hospitals evaluate their medication use practices and compare them to demographically similar U.S. hospitals.
ISMP publishes warning and flies petition with United States Adopted Names Council (USAN) that leads to renaming of amrinone as inamrinone, to prevent cases of fatal sound-alike confusion with amiodarone.
ISMP receives AHA Award of Honor for dedication to the safe and improved use of medications.
ISMP publishes a white paper on electronic prescribing, calling for the elimination of handwritten prescriptions.
ISMP's international affiliate organization, ISMP-Spain, is established.

1999

ISMP partners with the American Hospital Association (AHA) in national initiative to help hospitals examine and further improve medication safety. ISMP staff meet with President Clinton and participate in White House press briefing to announce the project.
ISMP participates in national policy discussions exploring types of error reporting programs, including testifying in House and Senate hearings and participating in a Senate staff briefing.
First edition of book, Medication Errors, by ISMP President and Founder Michael R. Cohen, is published by the American Pharmaceutical Association

1998

The Cheers Awards dinner, which honors individuals and organizations that have set a standard of excellence in the prevention of medication errors and adverse events, is established.
First ISMP List of High-Alert Medications that are more likely to be involved in serious medication errors is created.
ISMP successfully helps defend three Denver nurses charged with negligent homicide in a landmark court case following an error that resulted in the death of a newborn.
Institute is chosen as one of the inaugural recipients of Health Care Quality Alliance’s Pinnacle Award, established to recognize exemplary leadership in medication use quality improvement.

1997

Medical Error Recognition and Revision Strategies (Med-ERRS), an ISMP subsidiary that works with drug companies to predict problems with names, labels, and packaging, is founded.
ISMP issues prevention recommendations to address reported incidents of magnesium sulfate overdose.
ISMP begins formal campaign that spurs the Veterans Administration to require removal, and the Joint Commission (TJC) to urge nationwide removal, of potassium chloride for injection concentrate from all patient care areas.

1996

ISMP Medication Safety Alert!® Acute Care Edition newsletter is launched to address multidisciplinary prevention of medication errors in acute care settings.
First ISMP national electronic hazard alert to healthcare practitioners issued--describes fatal events involving concentrated electrolytes.
Institute becomes founding member of the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP); influences decision to require greater specificity and clarity in prescription writing, such as eliminating doses with decimal points.
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.

1995

National forum on preventing medication errors in cancer chemotherapy is sponsored; recommendations are later published in the American Journal of Hospital Pharmacy.
ISMP’s website goes live, providing free safety information electronically.

1994

Institute officially incorporates as nonprofit organization and runs on volunteer efforts.
First article on the use of failure mode and effects analysis to examine medication errors is published by ISMP in the medical literature (Hospital Pharmacy).
First ISMP Global Conference on Medication Error Reporting Programs is held.
Administration of error reporting program is transferred to USP; becomes the ISMP National Medication Errors Reporting Program (ISMP MERP) .

1992

ISMP convenes a national meeting to discuss elimination of cardiac lidocaine in 1 and 2 g concentrate prefilled syringes, due to reports of deaths from mix-ups with 100 mg prefilled syringes. As a result of ISMP's advocacy, these products are subsequently removed from the market by their manufacturers.
ISMP President Michael R. Cohen appears on the premier segment of the program Dateline NBC, to discuss fatal medication errors, including a vincristine overdose that killed a small child.
First scholarly publication in the medical literature about the dangers of free-flow infusion pumps appears with ISMP-authored article in Hospital Pharmacy.

1991

National, confidential, voluntary medication error reporting program (MERP) is created by ISMP in coordination with the United States Pharmacopeia (USP) to provide expert analysis of the system causes of medication errors.
ISMP promotes changing vincristine labeling to reduce the likelihood of inadvertent intrathecal injection; this advocacy leads to an updated USP standard.

1987

ISMP convenes national meeting that influences the United States Pharmacopeia (USP) and U.S. Food and Drug Administration (FDA) to require that potassium chloride concentrate for injection have black caps, closures, and warning statements to prevent mix-ups with other parenteral drugs.
First ISMP list of dangerous medical abbreviations published in Nursing ’87 magazine.

1981

First printing of Medication Errors: Causes and Prevention, a comprehensive book on the causes and prevention of drug mistakes, written by Michael Cohen and Neil Davis, ISMP cofounders.

1975

ISMP’s work officially begins with a continuing column on medication safety in Hospital Pharmacy (now published by Thomas Land Publishers).

 

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