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News Release

ISMP Encourages Adoption of Medication Error Reduction Plans

20 Year CA Effort Provides Framework to Advance Prevention Strategies

The Institute for Safe Medication Practices (ISMP) is sharing its support for California’s Medication Error Reduction Plan (MERP) initiative in the hope that hospital regulators and accreditors, if not U.S. hospitals themselves, will voluntarily adopt similar programs.

ISMP has always been an advocate for learning from the experiences of others. Since 2002, the California Department of Public Health has required every licensed general, acute care hospital to establish a MERP. The CA MERP provides a framework to advance many of the error reduction strategies that ISMP has advocated for and supported, including:

  • Maintaining a robust medication error reporting system

  • Interdisciplinary teams analyzing medication risks and errors

  • Carefully planned technology implementation

  • Effective and timely use of measurable assessments to evaluate the impact of selective error-reduction strategies

  • A proactive approach to risk identification analysis

  • Use of external information to improve medication safety

  • Annual review of the strategic plan to reduce medication errors

“While ISMP realizes that resources and expertise are necessary to design and execute a robust MERP, these efforts can significantly improve safety,” says ISMP President Rita K. Jew, PharmD, MBA, BCPPS, FASHP. “We encourage hospitals and health systems working outside of CA to complete a gap analysis using the framework and develop a formal MERP that focuses on high-leverage systems and technologies to improve high-alert medication processes.”

To oversee the CA MERP, each organization must designate an interdisciplinary medication safety committee comprised of pharmacists, nurses, physicians, and administrators. Coordination of the committee’s activities by a medication safety officer (MSO) is highly recommended.

For more information on ISMP’s Medication Safety Officer Society (MSOS), which offers an open forum for information sharing and collaboration, visit: Medication Safety Officers Society- MSOS | ( To access a copy of ISMP’s white paper on MSOs, click here

For a detailed summary of the required components in each hospital’s CA MERP, sample self assessment questions, and examples of initiatives organizations could implement as part of their own programs, click here.


Renee Brehio, Medication Safety Analyst and Editor,

About the Institute for Safe Medication Practices

The Institute for Safe Medication Practices (ISMP) is the nation’s first 501c (3) nonprofit organization devoted entirely to preventing medication errors. ISMP is known and respected for its medication safety information. For more than 30 years, it also has served as a vital force for progress. ISMP’s advocacy work alone has resulted in numerous necessary changes in clinical practice, public policy, and drug labeling and packaging. Among its many initiatives, ISMP runs the only national voluntary practitioner medication error reporting program, publishes newsletters with real-time error information read and trusted throughout the global healthcare community, and offers a wide range of unique educational programs, tools, and guidelines. In 2020, ISMP formally affiliated with ECRI to create one of the largest healthcare quality and safety entities in the world, and ECRI and the ISMP PSO is a federally certified patient safety organization by the U.S. Department of Health and Human Services. As an independent watchdog organization, ISMP receives no advertising revenue and depends entirely on charitable donations, educational grants, newsletter subscriptions, and volunteer efforts to pursue its life-saving work.


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