Institute for Safe Medication Practices

Last updated
Institute for Safe Medication Practices
Type 501(c)(3) nonprofit organization
Founded1975  OOjs UI icon edit-ltr-progressive.svg
FounderMichael R. Cohen
Headquarters
United States  OOjs UI icon edit-ltr-progressive.svg
Website www.ismp.org   OOjs UI icon edit-ltr-progressive.svg

The Institute for Safe Medication Practices (ISMP) is an American 501(c)(3) organization focusing on the prevention of medication errors and promoting safe medication practices. [1] It is affiliated with ECRI. [2]

Activities

Among others, ISMP maintains and disseminates a list of "do not crush" medications, [3] as well as clinical best practices. [4] The ISMP's Medication Safety Self-Assessment tool has been used in surveys of medication safety in hospitals in the United States and elsewhere. [5] [6] [7] [8]

The ISMP frequently investigates and reports on medication errors that have occurred in practice. These investigations are often published in the peer-reviewed journal Hospital Pharmacy. [9] [10] [11]

Related Research Articles

<span class="mw-page-title-main">Pharmacist</span> Healthcare professional

A pharmacist is a healthcare professional who specializes in the preparation, dispensing, and management of medications and who provides pharmaceutical advice and guidance. Pharmacists often serve as primary care providers in the community, and may offer other services such as health screenings and immunizations.

<span class="mw-page-title-main">Pharmacy</span> Clinical health science

Pharmacy is the science and practice of discovering, producing, preparing, dispensing, reviewing and monitoring medications, aiming to ensure the safe, effective, and affordable use of medicines. It is a miscellaneous science as it links health sciences with pharmaceutical sciences and natural sciences. The professional practice is becoming more clinically oriented as most of the drugs are now manufactured by pharmaceutical industries. Based on the setting, pharmacy practice is either classified as community or institutional pharmacy. Providing direct patient care in the community of institutional pharmacies is considered clinical pharmacy.

<span class="mw-page-title-main">Subcutaneous administration</span> Insertion of medication under the skin

Subcutaneous administration is the insertion of medications beneath the skin either by injection or infusion.

A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.

<span class="mw-page-title-main">Polypharmacy</span> Use of five or more medications daily

Polypharmacy (polypragmasia) is an umbrella term to describe the simultaneous use of multiple medicines by a patient for their conditions. The term polypharmacy is often defined as regularly taking five or more medicines but there is no standard definition and the term has also been used in the context of when a person is prescribed 2 or more medications at the same time. Polypharmacy may be the consequence of having multiple long-term conditions, also known as multimorbidity and is more common in people who are older. In some cases, an excessive number of medications at the same time is worrisome, especially for people who are older with many chronic health conditions, because this increases the risk of an adverse event in that population. In many cases, polypharmacy cannot be avoided, but 'appropriate polypharmacy' practices are encouraged to decrease the risk of adverse effects. Appropriate polypharmacy is defined as the practice of prescribing for a person who has multiple conditions or complex health needs by ensuring that medications prescribed are optimized and follow 'best evidence' practices.

<span class="mw-page-title-main">Self-induced abortion</span> Abortion performed by a pregnant person themselves outside the recognized medical system

A self-induced abortion is an abortion performed by the pregnant woman herself, or with the help of other, non-medical assistance. Although the term includes abortions induced outside of a clinical setting with legal, sometimes over-the-counter medication, it also refers to efforts to terminate a pregnancy through alternative, potentially more dangerous methods. Such practices may present a threat to the health of women.

Cardiotoxicity is the occurrence of heart dysfunction as electric or muscle damage, resulting in heart toxicity. The heart becomes weaker and is not as efficient in pumping blood. Cardiotoxicity may be caused by chemotherapy treatment and/or radiotherapy; complications from anorexia nervosa; adverse effects of heavy metals intake; the long-term abuse of or ingestion at high doses of certain strong stimulants such as cocaine; or an incorrectly administered drug such as bupivacaine.

<span class="mw-page-title-main">Levobupivacaine</span> Chemical compound

Levobupivacaine (rINN) is a local anaesthetic drug indicated for minor and major surgical anaesthesia and pain management. It is a long-acting amide-type local anaesthetic that blocks nerve impulses by inhibiting sodium ion influx into the nerve cells. Levobupivacaine is the S-enantiomer of racemic bupivacaine and therefore similar in pharmacological effects. The drug typically starts taking effect within 15 minutes and can last up to 16 hours depending on factors such as site of administration and dosage.

Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.

A Patient Safety Organization (PSO) is a group, institution, or association that improves medical care by reducing medical errors. Common functions of patient safety organizations are data collection, analysis, reporting, education, funding, and advocacy. A PSO differs from a Federally designed Patient Safety Organization (PSO), which provides health care providers in the U.S. privilege and confidentiality protections for efforts to improve patient safety and the quality of patient care delivery

<span class="mw-page-title-main">Compounding</span> Preparation of a custom medication

In the field of pharmacy, compounding is preparation of custom medications to fit unique needs of patients that cannot be met with mass-produced products. This may be done, for example, to provide medication in a form easier for a given patient to ingest, or to avoid a non-active ingredient a patient is allergic to, or to provide an exact dose that isn't otherwise available. This kind of patient-specific compounding, according to a prescriber's specifications, is referred to as "traditional" compounding. The nature of patient need for such customization can range from absolute necessity to individual optimality to even preference.

<span class="mw-page-title-main">Clinical pharmacy</span> Branch of pharmacy for direct provision

Clinical pharmacy is the branch of pharmacy in which clinical pharmacists provide direct patient care that optimizes the use of medication and promotes health, wellness, and disease prevention. Clinical pharmacists care for patients in all health care settings but the clinical pharmacy movement initially began inside hospitals and clinics. Clinical pharmacists often work in collaboration with physicians, physician assistants, nurse practitioners, and other healthcare professionals. Clinical pharmacists can enter into a formal collaborative practice agreement with another healthcare provider, generally one or more physicians, that allows pharmacists to prescribe medications and order laboratory tests.

<span class="mw-page-title-main">Chemotherapy-induced acral erythema</span> Medical condition

Chemotherapy-induced acral erythema, also known as palmar-plantar erythrodysesthesia or hand-foot syndrome is reddening, swelling, numbness and desquamation on palms of the hands and soles of the feet that can occur after chemotherapy in patients with cancer. Hand-foot syndrome is also rarely seen in sickle-cell disease. These skin changes usually are well demarcated. Acral erythema typically disappears within a few weeks after discontinuation of the offending drug.

<span class="mw-page-title-main">Tall Man lettering</span> Practice of writing part of a drugs name in upper case letters

Tall man lettering is the practice of writing part of a drug's name in upper case letters to help distinguish sound-alike, look-alike drugs from one another in order to avoid medication errors. For example, in tall man lettering, "prednisone" and "prednisolone" should be written "predniSONE" and "predniSOLONE", respectively. The Office of Generic Drugs of the US Food and Drug Administration (FDA) encourages manufacturers to use tall man lettering labels to visually differentiate their drugs' names, and a number of hospitals, clinics, and health care systems use tall man lettering in their computerized order entry, automated dispensing machines, medication admission records, prescription labels, and drug product labels.

<span class="mw-page-title-main">Bar code medication administration</span>

Bar code medication administration (BCMA) is a bar code system designed by Glenna Sue Kinnick to prevent medication errors in healthcare settings and to improve the quality and safety of medication administration. The overall goals of BCMA are to improve accuracy, prevent errors, and generate online records of medication administration.

Drug therapy problems (DTPs) represent the categorization and definition of clinical problems related to the use of medications or "drugs" in the field of pharmaceutical care. In the course of clinical practice, DTPs are often identified, prevented, and/or resolved by pharmacists in the course of medication therapy management, as experts on the safety and efficacy of medications, but other healthcare professionals may also manage DTPs.

Medicines reconciliation or medication reconciliation is the process of ensuring that a hospital patient's medication list is as up-to-date as possible. It is usually undertaken by a pharmacist and may include consulting several sources such as the patient, their relatives or caregivers, or their primary care physician.

Travel health nursing is a nursing specialty which promotes the health and safety of national and international travelers. Similar to travel medicine, it is an interdisciplinary practice which draws from the knowledge bases of vaccines, epidemiology, tropical medicine, public health, and health education. Travel nursing has experienced an increase in global demand due to the evolution of travel medicine. Travel health nursing was recognized during the 1980s as an emerging occupation to meet the needs of the traveling public, and additional education and training was established. Travel health nurses typically work in "private practice, hospital outpatient units, universities, the government, and the military", and have more opportunities and leadership roles as travel has become more common. However, they also experience organizational and support-related conflicts with general practitioners and patients in healthcare settings.

John W. Senders was an American professor of industrial engineering and psychology who did research on safety and human error. He founded Canada's Institute for Safe Medication Practices (ISMP), introduced the visual occlusion paradigm, and organized the first conference on human error, which came to be known as Clambake I.

References

  1. Guidestar. "Institute for Safe Medication Practices". Guidestar by Candid. Retrieved 2021-06-30.
  2. ECRI. "ECRI and the Institute for Safe Medication Practices (ISMP) Launch New Patient Safety Organization". www.prnewswire.com (Press release). Retrieved 2021-06-30.
  3. Cohen, Michael R. (July 2007). ""Do Not Crush" list". Nursing2021. 37 (7): 12. doi:10.1097/01.NURSE.0000279404.54880.3a. ISSN   0360-4039.
  4. "ISMP Publishes 2020-2021 Consensus-Based Medication Safety Best Practices for Hospitals". Institute For Safe Medication Practices. 27 February 2020. Retrieved 2021-06-30.
  5. Lesar, Timothy; Mattis, Arnold; Anderson, Ernest; Avery, Jean; Fields, John; Gregoire, Jill; Vaida, Allen; VHA New England Medication Error Prevention Initiative Collaborative (2003-05-01). "Using the ISMP Medication Safety Self-Assessment™ to Improve Medication Use Processes". The Joint Commission Journal on Quality and Safety. 29 (5): 211–226. doi:10.1016/S1549-3741(03)29026-2. ISSN   1549-3741. PMID   12751302 via Elsevier Science Direct.
  6. Vaida, Allen J.; Lamis, Rebecca L.; Smetzer, Judy L.; Kenward, Kevin; Cohen, Michael R. (2014-02-01). "Assessing the State of Safe Medication Practices Using the ISMP Medication Safety Self Assessment® for Hospitals: 2000 and 2011". The Joint Commission Journal on Quality and Patient Safety. 40 (2): 51–AP3. doi:10.1016/S1553-7250(14)40007-2. ISSN   1553-7250. PMID   24716328.
  7. Greenall, Julie; Shastay, Ann; Vaida, Allen J; U, David; Johnson, Philip E; O’Leary, Joe; Chambers, Carole (2015-02-01). "Establishing an international baseline for medication safety in oncology: Findings from the 2012 ISMP International Medication Safety Self Assessment® for Oncology". Journal of Oncology Pharmacy Practice . 21 (1): 26–35. doi:10.1177/1078155214556522. ISSN   1078-1552. PMID   25361598. S2CID   36967892.
  8. McCarthy, Kaitlyn R.; Christakos, Eugenia; Kurzatkowski, Amy; Gernant, Stephanie A. (2021-07-01). "Characterizing perceptions of an abbreviated ISMP Medication Safety Self Assessment for community pharmacies". Journal of the American Pharmacists Association . 61 (4): S105–S117. doi: 10.1016/j.japh.2021.02.013 . ISSN   1544-3191. PMID   33812781. S2CID   233029198.
  9. Mancano, Michael A.; Esordi, Morgan V.; Patel, Darshil D.; Milenki, Kristen J. (2019-04-01). "ISMP Adverse Drug Reactions: Longitudinal Thumbnail Fissures Due to Erlotinib Priapism Associated With the Use of ExtenZe Blindness From a Nevirapine-Based HAART Regimen Hyperprolactinemia and Galactorrhea Due to Aripiprazole Trypophobia Associated With Gabapentin Coadministered Linezolid and Methadone Cause Serotonin Syndrome". Hospital Pharmacy. 54 (2): 88–92. doi:10.1177/0018578718824449. ISSN   0018-5787. PMC   6431722 . PMID   30923400.
  10. Mancano, Michael A. (2018-02-01). "ISMP Adverse Drug Reactions: Influenza Vaccine–Induced Stevens-Johnson Syndrome; Vilazodone-Induced Nightmares; Dabigatran-Induced Pustular Eruptions; Neurotoxic and Cardiotoxic Symptoms After Cannabis Concentrate Exposure; Rosuvastatin-Induced Skin Eruption". Hospital Pharmacy. 53 (1): 15–17. doi:10.1177/0018578717739727. ISSN   0018-5787. PMC   5805017 . PMID   29434381.
  11. Mancano, Michael A.; Lapin, Jonathan; Paik, Andrew (2019-08-01). "ISMP Adverse Drug Reactions: Pheochromocytoma Crisis Induced by Metoclopramide Baclofen Dependence Following High-Dose Therapy Fatal Cardiotoxicity Following High-Dose Cyclophosphamide Acute Anterograde Amnestic Syndrome Induced by Fentanyl Ivermectin-Induced Toxic Epidermal Necrolysis Pembrolizumab-Induced Type 1 Diabetes". Hospital Pharmacy. 54 (4): 241–245. doi:10.1177/0018578719828860. ISSN   0018-5787. PMC   6628555 . PMID   31320773.