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ISMP Achievements

For decades, ISMP has been a vital force for change, education, and advocacy about medication safety. ISMP’s work has resulted in thousands of changes in clinical practice, public policy, and drug labeling and packaging that have impacted millions of patients and healthcare professionals. ISMP also has kept the entire healthcare community alerted to emerging issues and provided valuable tools, guidelines, and recommendations for error prevention.

ISMP was chosen as one of the inaugural recipients of Health Care Quality Alliance’s Pinnacle Award recognizing exemplary leadership in medication use quality improvement, and has received the American Association of Colleges of Pharmacy Award for outstanding leadership in medication error prevention and research and the American Hospital Association (AHA) Award of Honor for dedication to the safe and improved use of medications.

Following are just a few of ISMP’s many accomplishments over the years.

Safe Medication Standards

  • Warned about errors due to confusion about the apothecary system of measurement; in response, USP ceased to officially recognize the apothecary system and required drug strengths to be expressed only in metric units on the container label (1994)
  • Began a formal campaign that spurred the Veterans Administration, and Joint Commission to urge nationwide removal of potassium chloride concentrate for injection from all patient care areas (1997)
  • Published multiple recommendations that were adopted by the Joint Commission for its National Patient Safety Goals, including from ISMP’s list of look- and sound-alike drug names (2004)
  • Influenced manufacturer recall of several acetaminophen products due to confusing labels (2005), the removal of concentrated acetaminophen 100mg/ml in pint bottles from the market (2008), and the Food and Drug Administration’s (FDA’s) issuance of a safety alert related to infant liquid acetaminophen concentration (2011)
  • Worked with the Pharmacy Quality Alliance on mediation safety initiatives that led to new Centers for Medicare & Medicaid Services (CMS) requirements for high-alert drugs (2008)
  • Developed standard concentrations for neonatal drug infusions, along with the Vermont Oxford Network and Neonatal Intensive Care Units across the U.S. (2011)
  • Successfully advocated for changes to USP Chapter 7 to eliminate ratio expressions on single entity drug labels (2015)

 Drug Packaging and Labeling

  • Influenced USP and FDA to require that potassium chloride concentrate for injection have black caps, closures, and warning statements to prevent mix-ups with other parenteral drugs (1987)
  • Promoted changing vincristine labeling to reduce chance of inadvertent intrathecal injection; led to an updated USP standard requiring special warning labels (1991)
  • Requested and FDA agreed to ask pharmaceutical companies to use tall man lettering for labeling of products with look-alike drug names, particularly for twenty generic drug name pairs prone to confusion (2001). Manufacturer revised labels on Zyprexa (olanzapine) containers using tall man letters, as advocated by ISMP, to help prevent mix-ups with Zyrtec (cetirizine) containers (2003)
  • Promoted the inclusion of special warning statements on the packaging of several products, including maximum dose on cisplatin vial caps, paralyzing agent on neuromuscular blocking agents
  • Influenced several packaging and labeling changes to prevent errors related to vaccines, such as color differentiation of Daptacel (DTaP) and Adacel (Tdap) carton and vial labels
  • Brought about hundreds of packaging and labeling changes to prevent errors related to medications

Tools and Resources for the Healthcare Community

  • Published the first of many medication safety tools and resources, such as a list of dangerous drug abbreviations (1987), scholarly article on application of failure mode and effects analysis in healthcare settings (1994), list of high-alert medications that are more likely to be involved in serious medication errors (1998), and the first scholarly article about the dangers of free-flow infusion pumps (1992)
  • Launched the first certificate program in medication safety for Temple University School of Pharmacy (2000)
  • Became one of the first federally certified patient safety organizations (PSOs) (2008)
  • Established the ISMP National Medication Errors Reporting Program (ISMP MERP) in 1991, which is the first and only confidential, voluntary practitioner-based medication error reporting program. In 2008, launched the first national error reporting program for patients, and in 2012 launched the National Vaccine Error Reporting Program (ISMP VERP).
  • Launched the ISMP Cheers Awards dinner to highlight extraordinary contributions to medication safety (1998)
  • Conducted the ISMP Medication Safety Self Assessment® for Hospitals, in partnership with the AHA and the Healthcare Research and Education Trust (HRET), in 2000, 2004, and 2011.
  • Conducted focused self assessments on community/ambulatory pharmacy, antithrombotic therapy, physician practices, automated dispensing cabinets, international oncology practices and high-alert medications
  • Issued white papers on electronic prescribing (2000), role of the community pharmacist in medication safety (2008), and value medication safety officers can provide (2018)
  • Created several publications for healthcare practitioners— QuarterWatch™ Reports and the ISMP Medication Safety Alert! ® Acute Care, Community/Ambulatory Care, Nurse Advise-ERR, Consumer Safe Medicine, Long-Term Care AdviseERR newsletters
  • Published guidelines on automated dispensing cabinets (ADCs), smart pumps, standard order sets, timely administration of scheduled medications, adult IV push medications, safe preparation of sterile compounds, optimizing safe subcutaneous insulin use in adults, and communication of electronic medication information
  • Participated in national policy discussions exploring types of error reporting programs, including testifying in Senate committee hearings and presenting a Senate staff briefing with AHA and the American Pharmaceutical Association (APhA); contributed to the passage of legislation in 2005 offering evidentiary protections for patient safety data and error reports submitted to agencies such as ISMP
  • Established a National Alert System with the American Society of Health-System Pharmacists (ASHP) and National Coordinating Council on Medication Error Reporting and Prevention (NCC MERP) to provide time-critical safety information to healthcare professionals (2009)
  • Released safety tools for community pharmacy—consumer information leaflets on high-alert medications, high-alert medication modeling and error-reduction scorecards, and an assessment tool for barcode verification system readiness
  • Founded the Medication Safety Officers Society (MSOS) to continue the mission of the now dissolved American Society of Medication Safety Officers (ASMSO)
  • Launched the Targeted Medication Safety Best Practices to address ongoing issues and help hospitals decide where to focus their efforts (updated every two years since 2014)
  • Introduced new medication safety video series with Temple University School of Pharmacy (2016)

Public Policy Efforts

  • Appeared on the first segment of the premiere edition of Dateline NBC show to discuss fatal errors involving lidocaine concentrate syringes, unlabeled medications, and a vincristine overdose; raised national awareness of need for medication error prevention (1992)
  • Held the first Global Conference on Medication Error Reporting Programs with U.S. and international experts (1994), which led to the establishment of the International Medication Safety Network (IMSN) (2005)
  • Participated in White House press briefing and met with President Clinton to announce a national initiative helping hospitals examine and further improve medication safety following the publication of “To Err is Human” (1999)
  • Testified at an FDA public meeting on barcode labeling regulations and used findings from ISMP’s error reporting program to support the need for barcodes on unit dose packages of medications (2002)
  • Co-convened a drug shortages summit with AHA, the American Society of Anesthesiologists, the American Society of Clinical Oncology, ASHP, and The Pew Charitable Trusts (2014, 2018)
  • Published results of survey on the drug shortage “Gray Market” (2011) that helped inform an FDA summit on the issue leading to the introduction of legislation and a presidential executive order from President Obama
  • Continue to advocate for safer medication practices, including use of the metric system for measuring liquid medication doses as well as for weighing patients

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About ISMP

Click to learn about the Institute for Safe Medication Practices.