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Published on 1 November 2005

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The Institute for Safe Medication Practices


Michael R Cohen
Institute for Safe Medication Practices

The Institute for Safe Medication Practices (ISMP) is the only nonprofit organisation in the USA that is entirely devoted to medication error prevention and safe medication use. In 2004, the Institute celebrated its 10th anniversary of incorporation as a nonprofit entity, but its history in medication safety reaches back decades further.

For more than 30 years, the Institute has been helping healthcare professionals keep patients safe, and it has become known and respected worldwide as the premier resource for impartial, timely and accurate medication use information. ISMP’s highly effective efforts have been built on a nonpunitive approach and systems-based solutions, and have focused primarily on strategies to improve the safety of medication use systems. ISMP participates in partnerships with other international groups focused on safe medication use, and has two affiliate organisations based in Canada and Spain.

A long history
ISMP’s error prevention efforts began in 1975 with a groundbreaking column in the journal Hospital Pharmacy. From that humble beginning, initially supported solely by volunteer efforts, the Institute has grown to an organisation of more than 20 employees and offers a wide range of important programmes and services, including:

  • Four unique medication safety newsletters for healthcare professionals and consumers that reach more than 3.5 million readers in total.
  • Influential educational conferences.
  • Onsite consulting for hospitals and other healthcare facilities.
  • Mentorship programmes for patient safety officers.
  • A wholly owned subsidiary, Med-ERRS, that assists the medical industry in improving product safety.

Over its long history, ISMP has successfully advocated for improvements in drug names, labelling and packaging, technology and medication practices that have led or could lead to medication errors. Among its many achievements (see Box), ISMP is credited with influencing the pharmaceutical industry to stop the direct administration of lidocaine concentrate prefilled syringes. In the wake of multiple deaths, ISMP convened a national meeting that led to the removal of these products from the US market. More recently, ISMP has created a list of dangerous abbreviations, symbols and dose designations, some of which have been adopted by the US Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and are mandated as National Patient Safety Goals throughout the USA.


Error analysis
One cornerstone of the Institute’s medication safety efforts is a continuous, voluntary and confidential practitioner error-reporting programme designed to learn about errors happening across the nation, understand their causes and share “lessons learned” with the entire healthcare community. The Institute provides an independent review of medication errors that have been voluntarily submitted by practitioners to a national Medication Errors Reporting Program (MERP) operated by the US Pharmacopeia (USP).

Each year, the MERP receives nearly 1,000 error reports from healthcare professionals. All information derived from the programme is shared with the US Food and Drug Administration (FDA) and pharmaceutical companies whose products are mentioned in reports. The Institute is also an FDA MEDWATCH partner, and regularly communicates with the FDA to help prevent medication errors.

Medication safety resources
ISMP has translated the knowledge gained through extensive analysis of medication errors into specific resources that healthcare practitioners and institutions can use to bring about change. For instance, the Institute has given hospitals around the world an important tool for evaluating their progress in medication safety by facilitating two landmark acute care medication safety self- assessments in 2000 and 2004. The self-assessments helped US hospitals gauge their adoption of nearly 200 characteristics and practices that most significantly influence safe medication use and compare their current systems and practices with those of other demographically similar facilities nationwide. The Institute also offers a self- assessment for community/ambulatory pharmacies in the USA, cosponsored by the American Pharmacists Association Foundation and the National Association of Chain Drug Stores, and is conducting a new self-assessment of antithrombotic therapy in hospitals that will help examine medication safety practices associated with these high-alert drugs.

ISMP also provides hospitals with more direct assistance. A pioneer in the use of failure mode and effects analysis (FMEA), the Institute offers a wide range of consulting services, providing help to hospitals, cancer centres, community pharmacies and other patient care settings around the world in the form of onsite risk assessments and objective root cause ­analyses of errors. The Institute also conducts technology assessments, where staff experts work with healthcare organisations to evaluate the error potential of pharmacy information systems, computerised order entry systems, barcoded point-of-care systems, robotics or smart pump systems, and make recommendations for safe use.

Individual practitioners can access a broad range of educational tools from ISMP, including teleconferences on specific medication safety issues, an extensive collection of educational resources (books, CD-ROMS, audio- and videotapes), a fellowship programme and knowledgeable and articulate ­speakers from varied health disciplines who are available to provide expert advice and education.

Broad-based communication
Raising awareness of the causes of medication errors is a primary goal for the Institute. The ISMP Medication Safety Alert!(™) is the nation’s only biweekly publication reaching every US hospital with information on medication errors and practical prevention strategies. ISMP also publishes three other electronic newsletters that reach more than one million nurses, community/ambulatory practitioners and ­consumers. ISMP’s website contains timely medication safety information for medical professionals and ­consumers, and a message board that allows individuals from all over the world to discuss medication use problems. Healthcare practitioners can access many of ISMP’s prevention tools online, including lists of high-alert medications, clinical trigger points that indicate that an error may have occurred and error-prone abbreviations, symbols and dose designations.

Another way that the Institute focuses attention and awareness on medication safety issues is through its annual Cheers Awards, which are now in their eighth year. The awards honour individuals, organisations and companies that have set standards of excellence in the prevention of medication errors. Nominations are accepted online (see Resources), and the awards are presented in December of each year. ISMP also partners with many national and international organisations and committees that are dedicated to preventing medication errors, including JCAHO and the National Quality Forum in the USA.

International efforts
In addition to its extensive work in the USA, ISMP has played a key role in international efforts to improve medication use. The Institute publishes columns in the European Journal of Hospital Pharmacy, FIP News Hospital Section and Australian Journal of Hospital Pharmacy. It also maintains relationships with international health organisations and holds a meeting for international pharmacists each year in December.

ISMP has provided consultation, education and assistance on medication safety issues to health professionals all over the world, including Australia, Brazil, Canada, France, Hong Kong, Ireland, Israel, Kuwait, The Netherlands, New Zealand, Nigeria, Saudi Arabia, Singapore, Spain and the UK.

ISMP Spain has been an effective leader in ­advancing safe medication use in that country, including spearheading the formation of a national, voluntary error-reporting programme. A more in-depth look at the many activities and accomplishments of ISMP Spain will be covered in a future article in Hospital Pharmacy Europe.

The Institute is always happy to hear from fellow
practitioners all over the world interested in medication
safety. For more information on ISMP or to report an error to
the USP-ISMP Medication Error Reporting Program, subscribe
to the ISMP Medication Safety Alert!(™) newsletter, or take
advantage of ISMP’s many other resources for healthcare practitioners and organisations:

ISMP Spain

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