Historical Timeline

1975

ISMP’s work officially begins with a continuing column on medication safety in Hospital Pharmacy (now published by Facts and Comparisons).

1981

First printing of Medication Errors: Causes and Prevention, a comprehensive book on the causes and prevention of drug mistakes, written by Michael Cohen and Neil Davis, ISMP cofounders.

1987

ISMP convenes national meeting that influences the United States Pharmacopeia (USP) and U.S. Food and Drug Administration (FDA) to require that potassium chloride concentrate for injection have black caps, closures, and warning statements to prevent mix-ups with other parenteral drugs.
First ISMP list of dangerous drug abbreviations published in Nursing ’87 magazine.

1991

National, confidential, voluntary medication error reporting program (MERP) created by ISMP to provide expert analysis of the system causes of medication errors.
ISMP promotes changing vincristine labeling to reduce the likelihood of inadvertent intrathecal injection; this advocacy leads to an updated USP standard.

1992

ISMP convenes national meeting to discuss elimination of cardiac lidocaine in 1 and 2 g concentrate prefilled syringes, due to reports of deaths from mixups with 100 mg prefilled syringes. Products are subsequently pulled off the market by their manufacturers.
ISMP staffer appears on the first segment of the first Dateline show on ABC, which discussed fatal medication errors, including a vincristine overdose that killed a small child.
First mention in the medical literature of the dangers of free-flow infusion pumps appears with ISMP-authored article in Hospital Pharmacy.

1994

Institute officially incorporates as nonprofit organization and runs on volunteer efforts.
First article on the use of failure mode and effects analysis to examine medication errors is published by ISMP in the medical literature (Hospital Pharmacy).
First ISMP Global Conference on Medication Error Reporting Programs held.
Administration of error reporting program is transferred to USP; becomes the ISMP MERP.

1995

National forum on preventing medication errors in cancer chemotherapy is sponsored; recommendations are later published in the American Journal of Hospital Pharmacy.
ISMP’s website (www.ismp.org) goes live, providing free safety information electronically.

1996

ISMP Medication Safety Alert!^® ® newsletter launched to address multidisciplinary prevention of medication errors in acute care settings.
First ISMP national electronic hazard alert to healthcare practitioners issued--describes fatal events involving concentrated electrolytes.
Institute becomes founding member of the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP); influences decision to require greater specificity and clarity in prescription writing, such as eliminating doses with decimal points.
ISMP successfully promotes inclusion of a maximum dose statement on cisplatin vial caps and seals to increase recognition of dose limits for this cancer agent.

1997

Medical Error Recognition and Revision Strategies (Med-E.R.R.S), an ISMP subsidiary that works with drug companies to predict problems with names, labels, and packaging, is founded.
Prevention recommendations issued to address reported incidents of magnesium sulfate overdose.
ISMP begins formal campaign that spurs the Veterans Administration to require removal, and Joint Commission (JC) to urge nationwide removal, of potassium chloride for injection concentrate from all patient care areas.
New ISMP column in three publications alerts more than 200,000 physicians to potential errors.

1998

The Cheers Awards dinner, which honors individuals and organizations that have set a standard of excellence in the prevention of medication errors and adverse events, is established.
ISMP issues repeated warnings about errors from dangerously confusing dose labeling on Cerebyx (fosphenytoin), which influences manufacturer’s decision to re-label the product.
First ISMP list of high alert medications that are more likely to be involved in serious medication errors is published in the Journal of Healthcare Risk Management.
ISMP helps defend three Denver nurses charged with negligent homicide in a landmark court case following an error that resulted in the death of a newborn.
Institute is chosen as one of the inaugural recipients of Health Care Quality Alliance’s Pinnacle Award, established to recognize exemplary leadership in medication use quality improvement.

1999

ISMP partners with the American Hospital Association (AHA) in national initiative to help hospitals examine and further improve medication safety. ISMP staff meet with President Clinton and participate in White House press briefing to announce the project.
ISMP participates in national policy discussions exploring types of error reporting programs, including testifying in House and Senate hearings and participating in a Senate staff briefing.
Three-year patient safety project begun with the Veterans Health Administration (VHA); ISMP leads the effort by chairing accelerated learning workshops on adverse drug events.

2000

First ISMP Medication Safety Self Assessment for Hospitals ® is conducted—more than 1,400 hospitals respond, establishing a baseline for future change. Survey helps hospitals evaluate their medication use practices and compare them to demographically similar U.S. hospitals.
Warnings published and petition filed with United States Adopted Names Council that lead to renaming of amrinone as inamrinone, to prevent sound-alike confusion with amiodarone.
ISMP receives AHA Award of Honor for dedication to the safe and improved use of medications.
Discussion paper on adverse event and error reporting in healthcare published that serves as a conceptual model for error reporting position statements by leading healthcare organizations.
Institute white paper on electronic prescribing calls for elimination of handwritten prescriptions.
ISMP affiliate organization in Spain established.

2001

Lifetime Achievement Award created in honor of ISMP Trustee David Vogel. The award recognizes individuals who have had a major impact on safe medication practices.
ISMP requests that FDA require tall man lettering, which involves upper and lower casing portions of drug names to distinguish them from other similarly named drugs. The FDA agrees for twenty name pairs.
Institute joins National Quality Forum’s Safe Practices Advisory Committee, helps prepare national consensus document on safe medication use.
ISMP staff testify before House Committee on Ways and Means subcommittee hearing on quality issues related to the design of prescription drug benefit program for Medicare beneficiaries.
Regional Medication Safety Program for Hospitals implemented by ISMP, ECRI, and the Delaware Valley Health Council to improve safety at hospitals in the greater Philadelphia area.
ISMP conducts Medication Safety Self Assessment ® for Community/Ambulatory Pharmacy, cosponsored by the American Pharmaceutical Association Foundation and National Association of Chain Drug Stores.
ISMP affiliate organization in Canada is established.

2002

First of ISMP’s teleconferences is held--explores use of failure modes and effects analysis.
New monthly ISMP medication safety newsletter for community and ambulatory care practitioners is launched.
Second white paper issued, on the effect of bar coding unit doses on reducing medication errors.
ISMP, AHA, and HRET release Pathways for Medication Safety Ò ; includes three tools to help hospitals with strategic planning, risk assessment, and bar code readiness.
JC adopts some items from ISMP’s list of error-prone medication abbreviations, symbols, and dose designations for use in its National Patient Safety Goals.
ISMP and the Pediatric Pharmacy Advocacy Group issue pediatric pharmacy medication safety guidelines designed to reduce the incidence of medication errors among children.

2003

New ISMP medication safety newsletters for nurses and consumers are launched.
Review of medication errors associated with patient-controlled analgesia published in ISMP Medication Safety Alert!^®, along with recommendations for its safe use.
Guidelines for safe electronic communication of medication orders are drafted and posted on ISMP’s web site and American Society for Health-System Pharmacists listserve for comments.
The Commonwealth of Pennsylvania’s Patient Safety Authority contracts with ECRI to create the Pennsylvania Patient Safety Reporting System (PA-PSRS); ECRI subcontracts with ISMP for analysis of all medication error reports from acute care hospitals, birthing centers, and surgicenters.

2004

ISMP celebrates 10th anniversary of its incorporation as a nonprofit organization, and nearly 30 years of experience in improving the safety of medical products and professional practice.
Second ISMP Medication Safety Self Assessment for Hospitals conducted; shows hospitals have improved in virtually every category since the 2000 survey.
ISMP petitions USP for elimination of confusing ratio expressions for epinephrine dosing and labeling changes to reduce the chance of name mix-ups between epinephrine and ephedrine.
ISMP calls for immediate replacement of Brethine ampuls with available vials, to reduce risk of errors resulting from look-alike ampul packaging for Brethine and Methergine, which are both frequently used in labor and delivery settings but have opposite effects.
Results of ISMP survey on workplace intimidation are released, which provide proof that it is a common element of many healthcare practice settings that may cause medication errors.
ISMP holds one day educational meeting devoted to safety issues associated with patient-controlled analgesia; attracts more than 170 risk managers and other healthcare professionals.
ISMP begins to review and analyze medication errors submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS).