ISMP Safe Medication Management Fellowship Outline

This outline provides an overview of some of the learning opportunities and experiences available to the ISMP Safe Medication Management Fellow. The fellowship is flexible and may be adapted to take advantage of emerging opportunities. Professional interests of Fellows also may be incorporated into planned experiences in order to accomplish individual goals.

Orientation and Medication Safety Instruction

  • Institute for Safe Medication Practices (ISMP) and ISMP's affiliate, ECRI
    • Learn about ISMP's and ECRI's history, achievements and role in advancing in safety
    • Become familiar with ISMP's and ECRI's initiatives, products and service lines, ongoing collaborations, advocacy work, and role as a joint Patient Safety Organization (PSO)
    • Participate in the services offered by ISMP's for-profit subsidiary, Med Safety Board.
  • Medication safety-related professional, regulatory, and standard-setting organizations
    • Learn about the role of collaborating with professional organizations also involved in patient safety work
    • Understand how they influence safety and become familiar with their recommendations, standards, and/or requirements
  • Foundational medication safety concepts, issues, and errors
    • Receive one-on-one and group instruction from leading medication safety experts at ISMP, as well as participation in educational programming through webinars, podcasts, symposia and personal presentations
    • Review relevant literature and publications, including published journal articles, the ISMP Medication Safety Alert! newsletters, and the book, Medication Errors
    • Learn key concepts including but are not limited to:
      • Systems thinking approach and ISMP’s Key Elements of the Medication Use System™
      • Culture of safety and the Just Culture model
      • Human factors
      • Error reporting and analysis
      • Risk identification and use of metrics
      • Application of root cause analysis (RCA) and failure mode and effects analysis (FMEA)
      • High-alert medications and application of associated risk-reduction strategies
      • Integration of technology throughout the medication-use process
      • Regulatory requirements and standards for industry and healthcare organizations

Learning Experiences and Involvement

  • Communication and networking with healthcare practitioners, consumers, and the public
    • Serve as the primary contact for medication safety-related inquiries. As such, research and respond to incoming questions and concerns from healthcare practitioners and consumers. Participate in and/or lead group discussions, as needed, to formulate facility-specific recommendations or devise new ISMP recommendations
    • Participate with ISMP staff on confidential consultation visits to healthcare facilities with ISMP staff and contribute findings for inclusion in the final report
    • Interact with current medication safety officers/other professionals in medication safety to learn about their day-to-day activities, role and impact on safety, and how they address and prioritize medication safety issues
    • Participate in media interviews related to medication safety topics as opportunities present
  • Communication and networking with professional organizations, regulatory agencies, and drug information vendors
    • Participate in regular calls with drug information vendors and regulatory agencies
    • Attend meetings with pharmaceutical or device companies and regulatory agencies
    • Participate in regular medication safety calls with professional organizations and health systems
    • Attend local, national and possibly international professional meetings related to medication safety
  • Review of medication error reports
    • Analyze reports of hazardous conditions and medication and vaccine errors, including close calls, submitted to ISMP’s national error reporting programs by healthcare practitioners and consumers. Learn from events and aggregate causal analysis reported to the ECRI and ISMP Patient Safety Organization (PSO)
    • Contribute to internal discussion around submitted reports and perform follow-up with individuals who reported to ISMP MERP to ensure that all necessary information is available for ISMP evaluation of incidents
    • Communicate with manufacturers, USP, and the US Food and Drug Administration (FDA) to report/discuss submitted concerns or incidents related to labeling, packaging, naming, or medication devices
  • Publication and development of medication safety resources
    • Review ISMP’s medication safety newsletters and contribute content as needed
    • Prepare the content for the ISMP Medication Safety Alert! Action Agendas
    • Research medication-safety related topics and use evidence to support conclusions
    • Write and/or review information for continuing columns in journals as needed
    • Participate in ongoing medication error prevention projects and collaborate with ISMP staff on the development of educational events, proposals and grant applications, and medication safety tools and resources, including self assessments, guidelines, and the Best Practices
    • Provide support for dedicated research projects
  • Participate in Med Safety Board safety reviews
    • Review medication packaging and labeling designs for safety concerns
    • Contribute to other medication safety consulting work for industry as needed
  • Travel Opportunities
    • Travel with ISMP staff wherever possible
    • Visit healthcare sites where certain technology systems have been integrated to observe their functionality and learn about the benefits and any potential risks with their implementation in the medication-use process
    • Visit medication safety-related professional organizations, pharmaceutical companies, and regulatory agencies to understand their structure and role and to interact/network with staff
  • Teaching and presentation opportunities
    • Participate in and possibly lecture to Temple University’s PharmD class on medication errors
    • Mentor PharmD students during their rotations with ISMP
    • Prepare and present webinars or presentations to internal and outside healthcare practitioners as needed on various medication safety topics, journal articles, or medication error analysis
    • Present a poster presentation regarding a research or related topic at a professional meeting