Pharmacy News

ISMP Turns 20 as Nonprofit Safety Organization

[January 15, 2014, AJHP News]

Cheryl A. Thompson

BETHESDA, MD 02 Jan 2014—The medication-error prevention group synonymous with the phrase high-alert medications this month celebrates its 20th anniversary as a nonprofit organization.

Incorporation of the Institute for Safe Medication Practices (ISMP) actually occurred in 1989, said President Michael R. Cohen, who cofounded the group with Neil M. Davis.

Michael Coehn

The longstanding monthly journal column on medication safety by Cohen and widespread media coverage of his and Davis’s 1981 book, Medication Errors: Causes and Prevention, had resulted in invitations from hospitals to give talks to the staff or evaluate medication-use systems after a serious error. The hospitals offered honorariums for the talks and evaluations.

"We started to see that this was becoming more of a business than just a journal column," Cohen said.

By about 1992, he said, the business of giving talks consumed much of his time.

"I’m starting to realize I could leave my director of pharmacy job because we’re giving so many talks," Cohen said of his work with ISMP. "But I knew it had to be a nonprofit, and I wanted to work more closely with FDA and USP [the United States Pharmacopeial Convention] and the professional organizations like ASHP, et cetera. And so I decided to form a nonprofit."

In the 20 years since Cohen turned ISMP into a nonprofit organization, the group has

  • Sponsored a national forum on preventing medication errors in cancer chemotherapy,
  • Launched newsletters to address the multidisciplinary prevention of medication errors and the nation’s first website exclusively designed to alert health care consumers to specific drug safety issues,
  • Campaigned to require removal of potassium chloride injection concentrate from all patient care areas,
  • Created and updated a list of high-alert medications that are more likely to be involved in serious medication errors,
  • Successfully helped defend three Denver nurses charged with negligent homicide after an error that resulted in the death of a newborn and opposed criminal charges for a Wisconsin nurse and a former Ohio pharmacist involved in fatal medication errors,
  • Periodically conducted the ISMP Medication Safety Self Assessment for Hospitals to help facilities evaluate their medication-use practices relative to those at demographically similar U.S. hospitals,
  • Issued white papers that encourage electronic prescribing over handwritten prescriptions, placement of bar codes on unit doses of medications, and the role of the community pharmacist in helping Americans take their medications safely,
  • Filed petitions with the United States Adopted Names Council to rename amrinone in order to prevent cases of fatal sound-alike confusion with amiodarone and with USP to eliminate ratio expressions for epinephrine doses,
  • Asked FDA to require tall-man lettering on drug labels to distinguish certain drug names from those of similarly named drugs,
  • Released medication safety guidelines (in conjunction with the Pediatric Pharmacy Advocacy Group) designed to reduce the occurrence of medication errors among children, a guidance document on the Centers for Medicare and Medicaid Services’ so-called 30-minute rule for medication administration in the acute care setting to help health care organizations with the timely administration of medications, and guidelines for the safe preparation of compounded sterile products,
  • Called for more action to prevent overdoses with fentanyl patches and more education on the causes, signs, and symptoms of hyponatremia in children who receive postoperative i.v. solutions,
  • Provided rural hospitals with tools and collaborative learning opportunities to improve medication safety,
  • Held national summits to manage drug-name confusion and identify best practices for smart infusion pumps and ways to prevent errors at the point of care,
  • Earned federal certification as a patient safety organization that provides health care practitioners and organizations with legal protection and confidentiality for the patient safety data and error reports they submit to the organization, and
  • Identified possible safety concerns with varenicline, prompting the Federal Aviation Administration, Federal Motor Carrier Safety Administration, and Department of Defense to discourage or warn against the drug’s use.

The above accomplishments are part of the organization’s "historical timeline" at

And the work continues. In December 2013, ISMP launched the 2014–15 Targeted Medication Safety Best Practices for Hospitals, at The organization identified six consensus-based best practices that it believes warrant hospitals’ focus over the next two years.


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