ISMP Celebrates Your Contribution to Our Success During Our 25th Anniversary

Since 1994, when ISMP first became the nation’s only nonprofit organization devoted entirely to preventing medication errors, we have served as a vital force for progress in medication safety through our unyielding advocacy and the development of resources and learning opportunities for healthcare providers and consumers. As we reflect on our 25 years of existence (1994-2019) and the remarkable achievements that have been made in medication safety along the way, we recognize that we have certainly not done it alone. Only with your help has ISMP been able to pursue its unique mission to advance patient safety worldwide by empowering the healthcare community, including consumers, to prevent medication errors.

In some cases, we have been a prickly thorn in the side, provoking important questions, challenging preexisting assumptions, and steadily chipping away at the resistance to much needed system change born out of the hazards and errors reported by you. At other times, we have been a nurturing, healing shoulder to cry on when well-meaning and competent providers have inadvertently harmed a patient because we are fallible human beings deeply troubled by our inability to “do no harm.” While conducting national summits and self assessments, we have brought key stakeholders together at the table, sometimes for the first time, to discuss complex medication safety issues and create consensus best practices and/or action plans to implement them.

We have also empowered others to give voice to their experiences through surveys and by creating confidential, national medication error-reporting programs for both healthcare providers and consumers. We review every survey response and error report we receive. We then use this information to share compelling stories about medication errors and impactful change strategies to draw national attention to medication safety problems, offer healthcare providers new ways of thinking, and inspire change. Your participation in surveys and your reports of hazards, close calls, and errors are powerful drivers of change, both in the US and abroad, and they will continue to be a major force in the patient safety movement and the foundation of our work at ISMP.

Many of you have been on this incredible journey with us throughout our 25 years, reporting hazards and errors, listening to the stories we share, implementing our recommendations in practice, participating in surveys and self assessments, supporting our work, and helping us learn more about how medications are used or misused. Although ISMP is a relatively small organization, with your support we have had an enormous impact in the world of patient safety. In honor of our 25-year anniversary, we would like to share some of the progress we have made together and what ISMP has to offer the healthcare community today to promote safer medication use.

Medication Safety Progress

ISMP’s advocacy work has resulted in needed changes in clinical practice and public policy to prevent harmful and fatal errors, along with thousands of medication labeling and packaging changes, working cooperatively with the US Food and Drug Administration (FDA) Division of Medication Error Prevention and Analysis (DMEPA). Medication safety will always be an ongoing issue given the influx of new drugs, frequent changes in system design and technology, and human fallibility. However, many of the serious medication errors that ISMP has drawn attention to have been corrected or prevented with high-leverage strategies, and our patients are safer for it. 

One of our earliest successes was with potassium chloride (KCl) for injection concentrate. Multiple patients had died after receiving undiluted concentrated KCl instead of intravenous (IV) furosemide, or when it was used instead of 0.9% sodium chloride to dilute other medications or flush IV lines. We worked tirelessly with other organizations to remove concentrated potassium vials from nursing units, replacing them with diluted, premixed KCl large- and small-volume solutions. Thanks to those efforts, we have seen a significant reduction in deaths related to concentrated KCl vials and are aware of only one tragic fatality in the last 20 years in the US.

One of our most recent examples involves IV vinca alkaloids. For years, ISMP has called upon organizations to prevent fatal errors with these medications by preparing and administering them in minibags instead of syringes, to avoid inadvertent intrathecal administration. Today, most US hospitals and cancer centers comply with this practice, and many professional groups, including the National Comprehensive Cancer Network (NCCN), the Oncology Nursing Society (ONS), the American Society of Clinical Oncology (ASCO), and the World Health Organization (WHO), endorse the practice. Based on error reports and at least 135 worldwide cases of intrathecal administration of vinca alkaloids in which none were prepared in minibags, the US prescribing information now includes directions to dilute these drugs in a flexible plastic container to reduce the risk of wrong route errors; however, the labeling also provides explicit directions for preparation and administration of vinca alkaloids via a syringe. ISMP is now calling upon FDA to require the removal of administration by syringe from the prescribing information for all vinca alkaloids (see the SAFETY brief about additional support for this important action).

These are just two examples from among many serious medication errors that have been addressed since ISMP featured them in our newsletters and advocated for needed changes on behalf of healthcare practitioners who reported them. For additional examples, see the Sidebar, and visit the list of ISMP achievements and historical timeline on our website. Many of the changes have been accomplished through collaborative efforts with professional, accrediting, and regulatory agencies; corporate funders; and within individual organizations or larger health systems to increase the power and reach of our efforts.

ISMP Resources

In addition to direct advocacy work, ISMP has provided healthcare practitioners with practical guidelines, tools, and resources to improve medication safety and encouraged the widespread use of best practices such as barcode scanning and use of premixed IV solutions. Many have been developed with input from voluntary, expert advisory groups and, thus, represent consensus best practices. In the past year alone, ISMP has provided healthcare practitioners with the following new guidelines, resources, and tools:  

• Created an ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices to help practitioners prevent harm when preparing, dispensing, and administering IV push medications for adults

• Published a white paper emphasizing the need for medication safety officers and the value of creating a dedicated position

• Issued the 2018-2019 Targeted Medication Safety Best Practices for Hospitals

• Released revised Guidelines for the Safe Use of Automated Dispensing Cabinets

• Published revised Guidelines for Safe Electronic Communication of Medication Information

• Conducted the second national summit on smart infusion pumps focused on optimizing the use of the technology, preparing for interoperability with the electronic health record, and library analytics, which resulted in a draft set of updated guidelines currently posted on the ISMP website for public comment

• Conducted the ISMP Medication Safety Self Assessment^® for High-Alert Medications and created 6 consumer learning guides to help educate patients

• Provided more than 100 educational programs via webinars, online learning, and face-to-face presentations or multi-day workshops about medication error prevention and Just Culture 

• Launched an updated website with enhanced navigation capabilities and features making it easier for practitioners to stay up-to-date

ISMP has made many other free resources available to practitioners as well (see the Sidebar for examples).

And did you know that ISMP publishes more than just this acute care newsletter? We offer four additional digital newsletter publications - for acute care nurses (Nurse AdviseERR, published monthly), community pharmacy/ambulatory care providers (ISMP Medication Safety Alert! Community/Ambulatory Care, published monthly), long-term care providers (Long-Term Care AdviseERR, published every other month), and consumers (Safe Medicine, published every other month). Healthcare organizations can provide Safe Medicine to their patients via the Intranet, hard copy, or republished content; or consumers can purchase the newsletter separately.

If a healthcare organization wants more hands-on assistance in reducing and preventing medication errors, ISMP consulting services can provide an unbiased analysis of practice, technology, and system vulnerabilities associated with all aspects of the medication use process in a wide range of practice settings. ISMP can also offer a unique perspective when assisting with medication-related sentinel event investigation, root cause analysis, and development of an action plan; evaluating health information technology to facilitate safe implementation; and assessing specialty services or areas (e.g., pediatrics, oncology, ambulatory surgery, compounding pharmacies).

ISMP also offers individually tailored mentorship programs for practitioners with oversight of medication safety lasting 1 to 2 weeks, and year-long fellowships for practitioners to learn directly from ISMP experts onsite in our Horsham, PA, office, preparing them for leadership roles in medication safety. For at-home learners, ISMP also provides an online medication safety certificate course in partnership with the American Society of Health System Pharmacists (ASHP).

We hope that you will take advantage of the information, educational opportunities, and recommendations ISMP has to offer by visiting our website. You can receive alerts about upcoming programs, opportunities to provide input, and new web features by joining our email contact list - just choose the “Join Mailing List” option under Make a Selection.

International Error Prevention Efforts

In addition to extensive advocacy work in the US, ISMP has played a key role in international efforts to improve safe medication use, and has established affiliate organizations in Canada, Spain, and Brazil. ISMP is also one of the founding organizations of the International Medication Safety Network (IMSN) and provides consultation and assistance on medication safety issues to healthcare professionals all over the world, including Europe, Australia, New Zealand, the Middle East, and Asia. Some examples of recent global efforts include working with IMSN and FDA to hold a global summit on drug packaging and labeling, and drafting the first set of Global Targeted Medication Safety Best Practices. Additionally, ISMP offers international fellowships to practitioners desiring an opportunity to be involved in global medication safety efforts.

How You Can Help Us Continue Our Efforts

It has been an amazing journey so far; however, there is still much more work to do—both in the US and globally. The role of ISMP moving forward is clear. For our entire staff, medication safety is not just a mission, it is a passion and a life’s work. We feel incredibly grateful to have been working with you to advance medication safety for a quarter century, and we are so proud of the shared narrative around medication safety and the accomplishments we have achieved together. We are humbled by your passionate response to our advocacy work, educational programs, recommendations, and requests for information to enhance learning. Improvement is only possible within a culture that ensures any changes are well understood, embraced, and sustained—nothing sums up our mission more than this. Please continue reporting hazards and errors, questioning complex medication safety issues that are not well understood ([email protected]), and responding to our efforts to improve medication safety. You can also help ensure a safer future for patients by donating to ISMP to honor this year’s milestone anniversary. For more information or to make a charitable contribution, visit our 25^th anniversary webpage.

Sidebar:

ISMP Impact on the Healthcare Community

Firsts

ISMP helped introduce the following concepts in healthcare (created or were first to publish):

• High-alert medications (for acute care, long-term care, community/ambulatory setting)

• Tall man lettering for look-alike drug name pairs

• Error-prone abbreviations and dose expressions to avoid 

• Action Agendas (actionable summaries of medication safety problems)

• QuarterWatch (quarterly analysis of FDA MedWatch reports)

• Use of failure mode and effects analysis (FMEA) in medication safety

• Need for free-flow protection with infusion pumps

• Use of an independent double check when a single pathway can result in a harmful error

Landmark Nomenclature, Labeling, and Packaging Changes

Some important changes that have happened because of ISMP involvement:

• VinCRIStine 5 mg multi-dose vials taken off the market to avoid confusion with vinBLAStine 5 mg vials

• Cardiac lidocaine in 1 and 2 g concentrate prefilled syringes taken off the market to avoid direct IV administration

• Neuromuscular blocker warning statements about the need for ventilation included on labeling and packaging

• Dosing volume by “mL” rather than household measures more widely adopted

• Movement from apothecary to metric measurements on labels and dosing devices

• Elimination of ratio expressions on single entity drug labels

• Vaccine labeling changes initiated to prevent errors

• Elimination of the “Rule of Six”

• Guidance from FDA regarding safe labeling practices

• Promoted pre-market trademark safety testing of new brand names to avoid name confusion prior to approval

Safety Foundations

ISMP has created essential medication safety programs and tools, including:

• The only national voluntary medication errors reporting program for healthcare providers and consumers

• Newsletters with trusted, real-time safety information distributed to nearly every US hospital and many other settings

• National Alert Network (NAN Alerts), in cooperation with the National Coordinating Council for Medication Error Reporting and Prevention and ASHP

• Groundbreaking Medication Safety Self Assessments® for healthcare organizations

• Free medication safety resources, including lists of high-alert medications, often-confused drug names, and error-prone abbreviations and symbols

• Guidelines with consensus-based best practices to address safety issues with technology (e.g., smart infusion pumps, automated dispensing cabinets, electronic communication of medication information), high-alert medications, and error-prone processes (e.g., adult IV push medications, compounded sterile preparations, timely administration of drugs)

• Hosting the Medication Safety Officers Society (MSOS), with nearly 2,000 members, to facilitate information sharing and collaboration