Historical Timeline


  • ISMP’s work officially begins with a continuing column on medication safety in Hospital Pharmacy (now published by Thomas Land Publishers).


  • 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.


  • 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 medical abbreviations published in Nursing ’87 magazine.


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


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


  • 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.


  • 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 ( goes live, providing free safety information electronically.


  • 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.


  • Medical Error Recognition and Revision Strategies (Med-ERRS), 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.


  • 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 created.
  • ISMP successfully 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.


  • 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 group purchasing organization VHA. ISMP leads the effort by chairing accelerated learning workshops on adverse drug events.
  • First edition of ISMP book, Medication Errors, is published by the American Pharmaceutical Association


  • 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 (USAN) that leads to renaming of amrinone as inamrinone, to prevent cases of fatal 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.


  • Lifetime Achievement Award created to honor the memory 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.


  • First of ISMP’s teleconferences is held--explores use of failure mode 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; 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.


  • 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.


  • 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).
  • ISMP joins more than 40 other organizations in becoming a partner in Remaking American Medicine, a coalition aimed at improving the quality of health care in America through a public television series and national public outreach campaign.


  • ISMP becomes involved with the development of the Patient Safety and Quality Improvement Act of 2005, which sought to create a national database on medical errors and improve confidentiality and legal liability associated with reporting.
  • ISMP surveys show many hospital pharmacy computer systems are not doing an adequate job of detecting and correcting prescription or pharmacy order entry errors, myths and misperceptions still exist regarding hospital formularies, and healthcare providers still fear punitive action from licensing boards in wake of a medication error.
  • ISMP warns consumers and healthcare professionals that the same brand name may be used for different drugs in different countries, an overlooked issue with major safety implications. ISMP’s alert received national media coverage and generated legislative interest in light of increasing drug reimportation to help U.S. consumers save money. FDA follows up with public health advisory.
  • The first ISMP Medication Safety Self Assessment for Antithrombotic Therapy in Hospitals ® is conducted.
  • ISMP advocates changes in Tylenol blister package design with FDA and McNeil Consumer & Specialty Pharmaceuticals to reduce risk of improper dosing. McNeil recalls several Tylenol products for children as a direct result of ISMP’s alert.
  • Due in part to ISMP’s advocacy, JCAHO announces new 2006 Patient Safety Goal requiring labeling of all medications, medication containers, or other solutions on and off the sterile field in operative and other medical procedure settings.
  • In the wake of several fatal error reports, ISMP calls for more action to prevent overdosing with fentanyl transdermal pain patches. Institute stresses that FDA and manufacturer advisories and labeling changes are not enough to protect patients, and makes additional safety recommendations.
  • ISMP and the FDA partner on a comprehensive educational campaign to eliminate potentially harmful abbreviations and a joint public meeting on labeling of large volume parenterals. In addition, ISMP presents at a public hearing on the FDA Center for Drug Evaluation and Research’s current risk management strategies for human drugs.
  • The Pennsylvania Critical Access Hospitals Medication Safety Collaborative, a 15-month joint project by ISMP and Pennsylvania Office of Rural Health (PORH), is launched to help 10 hospitals throughout the state reduce system-based causes of medication errors.
  • Michael R. Cohen, RPh, MS, ScD (hon), ISMP President, is honored with a prestigious 2005 John D. and Catherine T. MacArthur Foundation Fellowship.


  • ISMP opposes criminal charges for Wisconsin nurse involved in a fatal medication error, supporting the Wisconsin Hospital Association and Wisconsin Nurses Association stance that criminal prosecution of a healthcare professional for an unintentional error is inappropriate and unwarranted.
  • ISMP serves on the committee responsible for generating the Institute of Medicine (IOM) report titled “Preventing Medication Errors: Quality Chasm Series” and responds to media and other inquiries about its recommendations following a national launch.
  • Second edition of the ISMP book Medication Errors is published.
  • The Medical Group Management Association (MGMA), the Health Research and Educational Trust (HRET), and ISMP conduct a self-assessment survey of patient safety in physician practices through a grant from the Commonwealth Fund.
  • ISMP introduces the ISMP Rural Hospital Medication Safety ConnectionTM program to provide rural hospitals with tools and collaborative learning opportunities to significantly improve medication safety. The Institute also presents for first time on medication safety at National Rural Health Association's Critical Access Hospital Conference.
  • Results of ISMP survey show that although awareness of fatal, preventable errors caused by giving IV vincristine by the intrathecal route is widespread, more healthcare facilities need to put specific strategies in place to prevent these ongoing errors.
  • CVS/Pharmacy engages ISMP to help strengthen medication safety at its stores and achieve safety goals outlined by its agreement with the Massachusetts Board of Pharmacy to resolve consumer complaints.
  • Child magazine approaches the Institute for assistance with medication safety related questions in its annual survey of children’s hospitals.
  • As a result of the ISMP-FDA abbreviations campaign, list of dangerous abbreviations is included in the style guide for the Journal of the American Medical Association (JAMA) and Physicians’ Desk Reference (PDR).
  • ISMP Medication Safety Alert!®Acute Care newsletter celebrates ten year anniversary.
  • ISMP redesigns its website so that visitors can find and print life-saving educational materials on medication errors and adverse events more quickly and easily.


  • Archives of Internal Medicine publishes report co-authored by ISMP that shows adverse drug events reported to FDA more than doubled between 1998 and 2005, as did the deaths associated with adverse drug events. Report is widely covered in the media.
  • ISMP issues alert on possible confusion between heparin and insulin, along with the New Jersey Department of Health, following multiple incidents were infants received total parenteral nutrition that contained insulin instead of heparin.
  • ISMP holds national summit to manage drug name confusion; stakeholders from medicine, pharmacy, government, and industry convene to discuss risk minimization strategies.
  • ISMP warns that routine practices used to name, label, package, and store investigational drugs raise serious patient safety concerns, and provides recommendations for safe use.
  • With continued reports of fentanyl transdermal patches being prescribed inappropriately to treat post-operative pain in opioid-naïve patients, ISMP again issues national warning about patch misuse that restates error prevention recommendations.
  • ISMP joins Task Force on Aging Research Funding, a coalition of more than 60 health-related organizations, and comments on medication safety-related aspects of the task force’s 2007 report to Congress.
  • After analyzing medication errors by student nurses, ISMP discovers a distinct set of error-prone conditions or medications that can make mistakes involving students more likely. Institute publishes a chart giving examples and recommendations for prevention.


  • ISMP launches (, the first website exclusively designed to alert healthcare consumers to specific drug safety issues with a focus on medication error prevention, as well as provide the first national error reporting program for patients.
  • ISMP becomes one of the first federally certified patient safety organizations (PSOs), providing healthcare practitioners and organizations with the highest level of legal protection and confidentiality for patient safety data and error reports they submit to the Institute.
  • The release of ISMP’s first QuarterWatch report identifies possible safety concerns with the smoking cessation drug Varenicline (Chantix) and offers recommendations for safe use. The report generates huge national media attention, and causes the Federal Aviation Administration (FAA), U.S. Federal Motor Carrier Safety Administration, and Department of Defense to essentially ban or warn against its use.
  • ISMP receives more than $700K grant from the Agency for Healthcare Quality and Research (AHRQ) to conduct a 3-year study on risk intervention development and implementation of safe practices in ambulatory and community pharmacies.
  • ISMP helps form the National Alert Network (NAN) along with the National Coordinating Council on Medication Error Reporting and Prevention (NCCMERP) and the American Society of Health-System Pharmacists (ASHP). The coalition begins to distribute alerts about medication errors that have caused or may cause serious harm or death—the information comes from ISMP’s voluntary reporting program.
  • Administration of the USP-ISMP Medication Errors Reporting Program (MERP) is transferred to ISMP, and becomes the ISMP National Medication Error Reporting Program (MERP).
  • ISMP releases a white paper on inappropriate medication use and the role of the community pharmacist in helping Americans take their medications safely.
  • Following a heparin error involving actor Dennis Quaid’s newborn twins, ISMP communicates with the Dennis Quaid Foundation regarding raising public awareness about preventing medical mistakes. Institute serves as expert commentator regarding the error for several of the nation’s largest broadcast and print media outlets.
  • Another heparin error in a Texas hospital that affects 17 infants continues to focus national attention on safety issues with the drug, and the national media again turns to ISMP for perspective.
  • An ISMP survey shows that use of automated dispensing cabinets (ADCs) has increased, but safety improvements have not been as widespread as needed to maximize their benefits. The Institute issues a set of interdisciplinary guidelines to promote safe ADC practices.
  • ISMP holds a national summit on smart pumps that brings together vendors and users to identify best practices and ways to prevent errors at point-of-care.
  • The Institute’s work with the Pharmacy Quality Alliance on mediation safety initiatives leads to new CMS requirements for high-ale drugs.
  • ISMP issues guidelines to help practitioners resolve conflicts when the safety of a medication order needs to be questioned.
  • ISMP’s advocacy on fentanyl patch overdoses gained a huge boost in national awareness when the Institute assisted CNN’s Anderson Cooper in defining the issue and appeared on camera for an interview during the broadcast coverage.
  • To collect and disseminate error prevention actions that the healthcare community is implementing, ISMP and Pharmacy OneSource launch the SPEAK Initiative. SPEAK stands for “Sharing Pharmacy Experience and Knowledge.”
  • ISMP President Michael Cohen receives a 2008 John M. Eisenberg Patient Safety and Quality Award for his life-long professional commitment to promoting safe medication use and safe medication delivery systems.
  • ISMP moves into new office at 200 Lakeside Drive, Suite 200, in Horsham, PA


  • The FDA alerts healthcare providers to insulin safety issues as a direct result of ISMP notifications and newsletter coverage. A safety alert and drug safety newsletter coverage from the agency pass on ISMP’s warnings regarding sharing insulin pens between patients and removing insulin from cartons. 
  • The Institute issued safe practice recommendations for basal opioid infusions given through patient-controlled analgesia, since they are at greater risk of pump programming errors. It also called for greater communication between industry and FDA regarding potential safety issues that may arise from opioid product withdrawals, particularly the removal of morphine concentrate oral liquid from the market. Thanks to advocacy from ISMP and others, the FDA eventually reverses its decision on oral morphine.
  • Following numerous reports of potential safety problems in the hospital management of elastomeric pain relief pumps, ISMP called on healthcare organizations to review their processes and procedures for utilizing these devices to provide surgical wound analgesia and/or peripheral nerve block.
  • ISMP warned healthcare practitioners that IV solutions administered post-operatively can cause low sodium levels and death in healthy children. The Institute called for more education on the causes, signs, and symptoms of this condition.
  • ISMP opposes criminal charges for a former Ohio pharmacist involved in a 2006 fatal medication error. The Institute also helps him educate other healthcare professionals about what can be learned from his case.
  • Second ISMP QuarterWatch report is issued, which focuses on the massive recall of the heart drug digoxin and possible psychiatric side effects of the asthma drug montelukast (Singulair).
  • ISMP, HRET, and MGMA release Pathways for Patient Safety™, a series of web-based tools aimed at increasing awareness, knowledge, and implementation of best practices to reduce the risk of patient harm in physician practices.
  • ISMP holds first two-day Medication Safety Intensive Workshop to help practitioners establish aggressive, focused medication safety program and the infrastructure necessary for continued safety improvements.


  • ISMP applauded new packaging and labeling for morphine sulfate oral 20 mg/mL solution that included revisions long advocated by ISMP to reduce the risk of confusion between the different strengths of oral morphine solutions.
  • More than 17,500 nurses tell ISMP that the CMS “30 minute rule” for scheduled medications can lead to patient harm. ISMP begins drafting a guidance document to help practitioners implement the rule.
  • Thanks to ISMP’s advocacy about hundreds of cases of Clear Care contact cleaning and disinfectant solution burning consumers’ eyes, Ciba Vision made changes in the product packaging to try to ensure that warnings as to its use are heeded.
  • ISMP releases findings of its national survey on drug shortages, revealing a serious impact on patient safety and kicking off intense national scrutiny of the issue. ISMP’s continued advocacy on drug shortages, along with several other organizations, eventually leads to the introduction of legislation on a presidential executive order.
  • An ISMP survey showed that the U.S. economic downturn may have compromised medication safety, taking a toll on hospitals and forcing them to take steps that put patients at greater risk. The survey gained widespread news coverage.
  • ISMP issues new guidelines to ensure that computerized prescriber order entry (CPOE) order sets are carefully designed, reviewed and maintained to prevent potential errors.
  • ISMP publishes a case study of a well-publicized error that resulted in the death of a 16-year old patient the Joint Commission Journal on Quality and Patient Safety. The article serves as a teaching tool that supports a system-based approach to safety.
  • A National Alert Network message is issued by ASHP and ISMP, warning healthcare practitioners about dangerous medication errors that could be caused by a shortage of EPINEPHrine pre-filled syringes.
  • Began to use social media technology for medication safety advocacy, through the creation of a new weekly blog for the Philadelphia Inquirer, as well as through Facebook and Twitter.


  • Thanks to advocacy from ISMP, FDA alerted pharmacists and other health professionals of potential injury due to confusion between FDA-approved eye medication Durezol (difluprednate ophthalmic emulsion) 0.05% and the unapproved prescription topical wart remover Durasal (salicylic acid) 26%.
  • ISMP releases a guidance document on the controversial CMS “30 minute rule” for medication administration in acute care to help healthcare organizations with the timely administration of medications. ISMP’s survey, guidance, and continued advocacy on this issue results in changes in the rule. 
  • ISMP’s advocacy leads to FDA safety alert when new concentrat​ion of liquid acetaminop​hen for infants is approved for sale, urging consumers to carefully examine the labels to avoid giving the wrong dose as a less concentrated form.
  • The 2011 ISMP Medication Safety Self Assessment® is launched to document the progress of U.S. hospitals in medication safety and identify the impact of new challenges that have arisen since 2004, such as drug and staffing shortages, shrinking reimbursement systems, and the application of new technology.
  • ISMP releases results of survey on drug shortage “Gray Market,” which continues to increase national dialogue on the issue, including the launch fo an investigation by Rep. Elijah Cummings (D-Md) into several companies suspected of buying and selling on the gray market.
  • ISMP calls for greater FDA guidance and pharmacy board oversight of sterile compounding, in the wake of reports that bacterial contamination of parenteral nutrition bags likely led to patient deaths. The Institute also holds a national sterile preparation compounding safety summit that brings together key stakeholders to discuss current methods and procedures.
  • ISMP warns that emphasizing speed in community pharmacy prescription dispensing can lead to errors, and writes to the National Association of Boards of Pharmacy (NABP) to caution against practice of advertising, promoting, and rewarding the speed at which pharmacies dispense.
  • A National Alert Network message is issued by ASHP and ISMP, warning practitioners that potentially fatal errors may occur with dosing for the antibiotic colstimethate for injection.
  • ISMP issues a statement on the use of metric measurements to prevent errors with oral liquids. The Institute asked prescribers, pharmacists, and other healthcare professionals, as well as pharmacy computer system and e-prescribing system vendors to only use metric measurements in prescription directions.
  • Along with the Vermont Oxford Network and Neonatal Intensive Care Units across the U.S., ISMP develops standard concentrations for neonatal drug infusions.


  • ISMP responds to national outbreak of a rare form of fungal meningitis, caused by contaminated steroid shots prepared by a compounding pharmacy in Massachusetts. ISMP releases a statement and advocates for better differentiation of sterile product manufacturers from compounders, regulations to provide improved enforcement, and more FDA guidance and state pharmacy board oversight to help safeguard patients from errors.  
  • ISMP releases guidelines for safe preparation of sterile compounds, developed as a result of its national sterile preparation compounding summit. The guidelines identify crucial quality control practices needed for preparing and verifying the quality and safety of the final compounded product.
  • ISMP launches its third national patient safety reporting program to capture the unique causes and consequences of vaccine-related errors. The ISMP National Vaccine Error Reporting Program (ISMP VERP) allows healthcare practitioners from all practice settings to report errors and near misses in confidence.
  • ISMP, along with ISMP Canada and the International Society of Oncology Pharmacy Practitioners (ISOPP), launched the 2012 ISMP International Medication Safety Self Assessment® for Oncology to identify an international baseline for safe medication practices related to oncology as well as potential opportunities for improvement.
  • ISMP shares the results of its survey gathering practitioner feedback on implementation of drug storage, stability, and beyond use dating requirements with the Centers for Medicare & Medicaid (CMS) and Joint Commission. 
  • In a letter to the FDA, ISMP asked for more direct disclosure of crucial emerging information about medication errors and risks to the Institute and other patient safety organizations (PSOs) to better safeguard patients. ISMP requested that FDA begin developing a process for more direct involvement of the PSOs in alerting all segments of the healthcare community to safety risks and problems.
  • ISMP conducts survey linking pharmacy “guarantees” to fill prescriptions within a specified time to medication errors and continues to advocate for change on a national level.
  • Potential safety issues for Carpuject prefilled syringes are identified by an ISMP survey of nurse practitioners; many nurses reported being unaware of a problem that could lead to overdoses with high-alert medications. Many nurses also reported using Carpuject prefilled cartridges as single- and multiple-dose vials, withdrawing all or part of the medication into an often-unlabeled syringe before administration.
  • ISMP’s survey highlights differences in nursing, pharmacy, and risk/quality/safety manager perspectives on what constitutes a high-alert drug (one more likely to cause significant patient harm when used in error). Information gathered is used to update ISMP’s high-alert drug list.
  • In response to a bill introduced in the Utah senate that would allow oncology physicians to directly provide patients with oral cancer drugs, ISMP sent a strong message warning that physician dispensing without regulatory oversight could have serious medication safety consequences.


  • ISMP issues NAN alert on confusion regarding the generic name of the HER2-targeted drug KADCYLA (ado-trastuzumab emtansine), spurring FDA to send out its own alert around three weeks later.
  • Another NAN alert is issued on severe burns and permanent scarring after glacial acetic acid (≥ 99.5%) is mistakenly applied topically and has a particularly wide reach—it is distributed internally by Boards of Pharmacy, state hospital associations, and members of the American College of Gastroenterology in addition to alert network members.
  • As a result of persistent, ongoing safety issues, ISMP calls on hospitals to closely reexamine their policies regarding insulin pen devices, and consider transitioning away from insulin pens for routine inpatient use.
  • ISMP introduces a new monthly publication, the Long-Term Care Advise-ERR™, which is the first publication dedicated to giving administrators, and all healthcare personnel (physicians, nurses, consultant pharmacists) caring with elderly residents lifesaving information on preventing medication errors.
  • An ISMP survey provides new insights into how hospitals are managing the preparation and/or purchase of compounded sterile products, following the 2012 national outbreak of fungal meningitis from contaminated steroid injections dispensed from a compounding pharmacy.
  • ISMP releases three new safety tools developed for community pharmacy that were developed from research funded by a grant from the Agency for Healthcare Research and Quality (AHRQ)—consumer information leaflets on some high-alert medications, high-alert medication modeling and error-reduction scorecards (HAMMERS), and a tool to help assess barcode verification system readiness.
  • ISMP announces that The American Society of Medication Safety Officers (ASMSO) will become part of the Institute, to provide a framework for meeting the needs of the Medication Safety Officer community on an international scale.
  • Survey results show medication safety information provided by ISMP is valued and acted upon by US hospitals; 97% of respondents indicated that the ISMP Medication Safety Alert! newsletter increases their understanding of the causative factors leading to medication errors, and 89% reported making specific changes in their own practices based on information provided in the newsletter.


  • Held the first National Summit on Safe Practices Associated with IV Push Medication Administration for Adults, funded by BD, to develop a set of best practices that will facilitate safe administration.
  • Published an analysis and comparison of results from the 2000 and 2011 ISMP self assessments in The Joint Commission Journal on Quality and Patient Safetythat helped better define the current state of medication safety.
  • Published the results of the first Oncology Medication Safety Self Assessment in the Journal of Oncology Pharmacy Practice.
  • Co-convened the 2014 Drug Shortages Summit with AHA, the American Society of Anesthesiologists (ASA), the American Society of Clinical Oncology (ASCO), ASHP, and The Pew Charitable Trusts.
  • Launched new ISMP Targeted Medication Safety Best Practices to address ongoing issues and help hospitals decide where to focus their efforts; the 2014-15 best practices focus on six key areas.
  • Issued recommendations for addressing system-based causes of vaccine errors, based on information gained from the ISMP National Vaccine Error Reporting Program (ISMP VERP).  
  • Based on two new published studies of the anticoagulant dabigatran (PRADAXA), highlighted the need for U.S. health care practitioners to gain access to a lower dose and capsule strength of dabigatran (110 mg), and a blood test capable of identifying patients at highest risk for serious injury from bleeding.
  • Added a new section on OTC medication safety to ISMP’s consumer website,
  •  Jointly filed a Citizen Petition asking FDA to clarify and strengthen the Boxed Warnings about psychiatric side effects of the smoking cessation aid Chantix (varenicline); other filing organizations were Consumer Reports, National Center for Health Research, National Physicians Alliance, and Public Citizen.
  • Began an ISMP Annual Fund in honor of our anniversary, to ensure that the Institute continues to advance medication safety for the next 20 years.


  • Mentioned in newly released CMS Conditions of Participation for Pharmaceutical Services, Interpretive Guidelines.
  • Successfully advocated for change to USP Chapter 7 to eliminate ratio expressions on single entity drug labels.
  • Identified and reported subpotent medication problem with certain plastic syringes when used for drug storage.
  • Released two National Alert Network messages, on eliminating dosage cups in fluid drams and confusion between Bloxiverz injection and Vazculep injection.
  • Published results of surveys that exposed potential gaps in pediatric medication safety and managing hospitalized patients with ambulatory pumps.
  • Held national summit on optimizing safe subcutaneous insulin delivery along the continuum of care.
  • Developed the 2016-17 ISMP Targeted Medication Safety Best Practices for Hospitals
  • Conducted MSI programs in Middle East (Qatar) and Europe (Ireland)
  • Issued safe practice guidelines on adult IV push medications. 
  • Published results of survey that exposed potential gaps in pediatric medication safety.
  •  Worked with Global Enteral Device Supplier Association to alert health systems to safety issues surrounding upcoming introduction of new ENFit enteral feeding tube connectors.
  • Held national summit on optimizing safe subcutaneous insulin delivery along the continuum of care.



  • Celebrated ISMP Medication Safety Alert! Acute Care edition 20th anniversary.
  • Launched new medication safety video series with Temple School of Pharmacy.
  • Updated ISMP guidelines on sterile compounding and called for increased use of technology/automation.
  • Updated ISMP list of drug names with tall man letters and released first list of high-alert medications used in long-term care settings.
  • Began work on high-alert medication safety self assessment for hospitals, with funding from FDA.
  • Worked with drug companies and FDA on product safety issues, including confusion of Brintellix with Brillinta and valproate sodium and levetiracetam vials.
  • Participated in World Health Organization's (WHO’s) new Medication Safety Challenge.
  • Helped lead meeting of regulators, industry, medication safety representatives at 11th Annual International Medication Safety Center meeting in Toronto, Canada.
  • Announced plans to develop medication safety certificate program with ASHP.
  • Conducted surveys on use of term ‘as directed’ in prescription directions, use of chloral hydrate in pediatric procedural sedation.
  • Credited by National Comprehensive Cancer Network (NCCN) in “Just bag it” campaign--all 27 member facilities now diluting vincristine to prevent inadvertent intrathecal administration.  
  • Received 2016 American Association of Colleges of Pharmacy (AACP) Award for 20 years of outstanding leadership in medication error prevention and research.
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