Voluntary reporting of medication errors through ISMP has an impact

The Institute for Safe Medication Practices (ISMP), a nonprofit organization devoted to medication error prevention and safe medication use, has a voluntary practitioner error-reporting program that has helped to identify a variety of medication errors and their causes. Since its inception in the mid-1970s, ISMP has been sharing this information with healthcare professionals through its Medication Safety Alert newsletters, including its monthly edition for pharmacists, “ISMP Medication Safety Alert Community/Ambulatory Edition.”

ISMP receives about 1,000 medication error reports annually and follows up on every report to determine what went wrong, according to Matthew C. Grissinger, RPh, FISMP, FASCP, director of Error Reporting Programs at ISMP, Horsham, Pa. He spoke at the annual PPSI (Pharmacists Planning Service) breakfast during the American Pharmacists Association meeting that took place this week.

“If there are medication errors, it is not an individual pharmacist but the medication-use process that is responsible,” Grissinger said. The breakdowns in the medication-use process usually occurs in the prescribing, order entry, storage, or dispensing of the drug, he said.

ISMP also is responsible for reviewing all medication error reports that are submitted to the Commonwealth of Pennsylvania Patient Safety Authority. Since June 2004, ISMP has received approximately 260,000 reports from over 400 organizations required to report all potential medication errors and harmful events. The organization offers its consulting services to hospitals to identify and prevent medication errors, using a team of doctors, nurses, and pharmacists to determine the causes of these errors.

Examples of medication errors that have occurred in hospitals include confusion with look-alike vials of medication, the use of devices for medication delivery, similar drug names and similar brand-name extensions for over-the-counter drugs, dosing mixups, and ambiguous orders written by prescribers, Grissinger noted. He showed examples of how the medication process breakdown occurred and steps to help avoid these errors in the future.

ISMP’s subsidiary, Med-E.R.R.S. (Medication Error Recognition and Revision Strategies) works directly and confidentially with pharmaceutical industry to prevent such errors as confusing or misleading names, labeling, packaging, and device design.

ISMP encourages pharmacists to report any medication errors, so that they can be included in its newsletter and shared with other healthcare practitioners. “One person can make a difference by reporting an error,” Grissinger said.

To report a medication error, contact ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044-2321. Phone: 215-947-7797; Fax: 215-914-1492. The Web site for error reporting is https://www.ismp.org/orderforms/reporterrortoismp.