2022 Ushers in the Beginning of a New Era at ISMP

In January 2022, an era of unwavering leadership for the Institute for Safe Medication Practices (ISMP) comes to an end, as Michael R. Cohen, a persistent advocate for medication safety, has stepped down as President of ISMP. Mike will continue to support ISMP’s critical lifesaving work as President Emeritus, and Rita K. Jew, a respected and worthy successor, has been appointed as the new ISMP President (to learn more about Rita, click here). Mike will continue to be actively involved with ISMP part-time, working on newsletters and special projects close to his heart, continuing his quest for excellence in medication safety. He is an inspiration to us all, and we are delighted that he will continue to be available to ISMP. Rita will lead ISMP into a new era, as ISMP continues to provide sage guidance to influence companies, organizations, practitioners, and consumers who make, regulate, prescribe, dispense, administer, and receive medications, always focusing on the patient.

Looking Back

ISMP roots. As many know, the origin of ISMP is rooted in a monthly column entitled Medication Errors, that began in March 1975 in Hospital Pharmacy. The column grew from a conversation Mike had in 1974 with Neil Davis, both of whom were working at Temple University Hospital in Philadelphia. They were discussing a serious medication error that happened at a local hospital in which a prescriber had used an abbreviation, U for “units,” and a nurse had misread the handwritten U as a zero and administered 40 units of regular insulin to a patient instead of 4 units. The patient developed signs of severe hypoglycemia that required immediate treatment.

Dr. Davis, who was an editor of Hospital Pharmacy, suggested that the incident served as an opportunity for educating other healthcare professionals about this error-prone abbreviation. During the discussion, it became clear that much could be gained by publishing other medication errors that readers may be inclined to report in confidence to prevent patient harm and save lives. Thus, an idea was born and realized to create a national medication error reporting program that practitioners could use to confidentially report medication errors, which could then be shared anonymously with others for learning purposes. 

In 1977, Mike began a similar column for nurses in Nursing ‘77, and both the Hospital Pharmacy and Nursing ‘77 columns became leading features in the respective monthly journals. The columns prompted reports of errors from across the US, and Mike would often follow up with the practitioner to learn more about what had happened. Then Mike would share the deidentified error stories and provide error-prevention recommendations in the journal columns so others could proactively take action. Mike and Dr. Davis also began to interact with the US Food and Drug Administration (FDA), USP, The Joint Commission (TJC), and product manufacturers when important issues arose.

By 1990, Mike realized that his advocacy work for safe medication practices and products was a full-time calling that should be supported by a nonprofit organization. Shortly thereafter, ISMP was founded, and by 1994, the organization became the nation’s only 501c (3) nonprofit organization devoted entirely to preventing medication errors. Since then, ISMP has served as a vital force for progress in medication safety through its unyielding advocacy and the development of resources and learning opportunities for healthcare practitioners and consumers.

ISMP’s impact. ISMP has had a tremendously positive impact on patient safety, medication safety, and the practices of caregivers striving to provide quality and safe patient care, both across the US as well as internationally, including through ISMP sister organizations located in Brazil, Canada, and Spain, and as a founding member of the International Medication Safety Network (IMSN). Along the way, ISMP has cultivated excellent relationships with other patient safety and professional organizations, accreditors, regulators, standards-setting organizations, and the medical products industry that allow us to share our recommendations with organizations so necessary changes can be made to prevent both product- and practice-related medication errors. For example, over the years, ISMP’s frequent interactions with FDA, USP, and the medical products industry have improved the safety of thousands of products, and have had a significant impact on labeling, packaging, and nomenclature guidances and standards. Additionally, ISMP’s collaboration with TJC, the Centers for Disease Control and Prevention (CDC), the Centers for Medicare & Medicaid Services (CMS), professional organizations, and patient safety organizations has resulted in collaborative projects to advance our mutual goal of medication safety, as well as substantial changes in medication safety standards. Likewise, our recommendations to practitioners, healthcare providers, and organizations have also resulted in system- and practice-level changes. In fact, ISMP was among the first, if not the first, organization to recommend the following concepts to improve medication safety, many of which are widely implemented by healthcare providers and industry:

• Free flow protection for infusion pumps

• Removal of potassium chloride injection concentrate from patient care units

• VinCRIStine administration via a minibag instead of a syringe 

• Establishing a list of high-alert medications with layered error-reduction strategies

• Use of failure mode and effects analysis (FMEA) in healthcare

• Spotlighting Targeted Medication Safety Best Practices for Hospitals

• Employing a medication safety officer

• Maintaining a look-alike/sound-alike drug name list

• Maintaining a list of error-prone abbreviations that should never be used

• Use of tall man letters

• Calling infusion pumps with a dose error-reduction system (DERS) “smart pumps”

Throughout the years, there have been numerous times when ISMP has also brought together key stakeholders, sometimes for the first time, to discuss complex medication safety issues and create consensus-based best practices and/or action plans for organizations to implement. In some cases, ISMP has been a prickly thorn in the side, provoking important questions, challenging preexisting assumptions, exposing harmful medical products, and chipping away at the resistance to much needed system changes. At other times, ISMP has been a nurturing, healing shoulder to cry on when well-meaning and competent providers have inadvertently harmed a patient—because we are fallible human beings deeply troubled by our inability to “do no harm.”

But perhaps ISMP’s greatest contribution to healthcare has been giving a voice to health professionals who, in confidence, report errors to ISMP for altruistic reasons and/or share their ideas, observations, or questions with ISMP, without fear of even a disparaging thought. ISMP empowers others to give voice to their experiences because they trust ISMP and know their information will be used productively. Every idea, observation, question, or error report ISMP receives is carefully reviewed. Then ISMP healthcare professionals interact internally to apply their collective expertise to arrive at safety recommendations and then share compelling stories about medication errors and impactful change strategies. ISMP aims to draw national attention to medication safety problems, offers healthcare providers new ways of looking at problems, and inspires change.

Looking Forward

As we reflect on our many years of existence and the remarkable achievements that have been made in medication safety, we recognize that we have certainly not done it alone. Many of you have been on this journey with us, reporting hazards and errors, listening to the stories we share, implementing our recommendations, completing our surveys and self assessments, supporting our initiatives, and helping us learn more about how medications are used or misused. Although ISMP is a small organization, with your passionate support, we have had an enormous impact in the world of patient safety. Your participation in surveys and your detailed error reports are powerful drivers of change and will continue to serve as a major force in the patient safety movement and the foundation of our work at ISMP. We are humbled by the trust you place in ISMP and are truly indebted to you.

It has been an amazing journey thus far; however, there is still much more work to do. The role of ISMP moving forward is clear. For our entire staff, medication safety is not just a mission, it is a passion and a life’s work. We feel incredibly grateful to have been working with you to advance medication safety for more than a quarter century, and we are so proud of the shared narrative around medication safety and the accomplishments we have achieved together. Improvement is only possible within a culture that ensures all changes are well understood, embraced, and sustained—nothing sums up our mission more than this. Please continue reporting medication hazards and errors, sharing your ideas, questioning complex medication safety issues that are not well understood, and responding to our efforts to improve medication safety. You can contact ISMP at any time via email at: [email protected].