About Us

About Us (11)


Tuesday, 24 April 2012 10:42

We value your feedback

Written by

Thank you for your submission.

Your information has been successfully processed. If your subject matter requires a response, we will be in contact with you shortly.

Monday, 02 April 2012 20:35

Frequently Asked Questions (FAQ)

Written by

Get answers to some frequently asked questions about medication errors and about reporting medication errors.


What is a medication error?

Medication errors are preventable mistakes that can happen in labeling, packaging, prescribing, dispensing, and communications when the medication is ordered. Medication errors may involve use of prescription and non-prescription medications, natural health products, imported products and/or devices used to administer medications. Causes include:

  • Incomplete patient information, with the health care professional not knowing about allergies and other medications the patient is using
  • Miscommunication between physicians, pharmacists and other health care professionals. For example, drug orders can be communicated incorrectly because of poor handwriting
  • Name confusion from drug names that look or sound alike
  • Confusing drug labeling
  • Identical or similar packaging for different doses
  • Drug abbreviations that can be misinterpreted


Back to Top

Who should report medication errors to this site?

Patients, family members, caregivers or any other individual who may be acting for, or in support of, a patient or client receiving health care, may report medication errors to this site. If you are reporting on behalf of someone you know, you should ask their permission to report the error and be sure that you know all the facts about the incident.


Back to Top


Why should I report a medication error to this site?

 When you submit an incident report to us, we will review it carefully. We look at different things, depending on the type of error you are reporting. Our goal is to prevent errors that have occurred from reoccurring. We also look for problems that can potentially cause harm. Often, we can recommend ways to prevent the same error from happening to someone else. This will make healthcare safer for other


Back to Top



I had a side effect to a drug. Should that be reported as a medication error?



Side effects (unwanted effects that happen when drugs are used under normal conditions) are also known as "adverse drug reactions" and are not considered a medication error. Adverse drug reactions should be reported to The FDA Safety Information and Adverse Event Reporting Program

  • Report an adverse drug reaction


Back to Top


Should I talk to the organization or health professional that is responsible for an error in my care?

ISMP encourages you to speak with a health professional if you think an error in your care has occurred. A health professional can take steps to find out if you have been harmed from the mistake and can help you get treatment if necessary. Also, telling a health professional about mistakes in your care will allow them to learn how and why the mistake happened and may prevent the same mistake from happening again. If your mistake happened in hospital and you are not sure who to talk to, many healthcare organizations have "patient representatives" or "patient advocates" who may be able to help with your concern.


Back to Top



Will ISMP investigate a complaint on my behalf with an organization or health professional that is responsible for an error in my care?


ISMP cannot investigate individual complaints about the healthcare organization or health professional that provided your care. ISMP will also not report the error to a professional regulatory authority (an organization responsible for disciplining health professionals). Formal complaints about a particular organization or health professional must be filed through the governing state in which the incident occurred. Contact your State Department of Health or State Licensing Board for more information.


Back to Top


Does ISMP believe a health care provider involved in an error should be punished or disciplined for making a mistake?



Medication errors are rarely the result of one person making an error. There can be many factors that can contribute to an error. Blaming the person who made the mistake without getting to the root of the problem will not prevent the same mistake from being made by someone else. Reviewing incident reports and suggesting safer ways to prescribe, package, dispense or give medication is a better way to prevent harmful errors.

When we review reports, we are looking for the problems that caused the error so that we can recommend ways to make the system safer. This is a much better way to prevent errors than punishing the person who made the mistake.


Back to Top

Friday, 25 February 2011 14:49

Make a Donation

Written by

Consumermedsafety.org is a resource offered by The Institute for Safe Medication Practices (ISMP), the only worldwide nonprofit organization devoted entirely to safe medication use and the prevention of medication errors. Through education and direct interaction, ISMP encourages the healthcare community to make changes that result in improved drug safety.

Without the generosity of hundreds of individuals and organizations, ISMP would not be able to pursue its mission. We appreciate your support.

cohen mike 4

Michael Cohen

President, ISMP

Please support our important work.

With your assistance, we will continue to build on our more than 30 years of experience helping healthcare practioners keep patients safe and lead efforts to improve the medication use process. For more information on ISMP's many activities, programs and accomplishments in the area of medication safety, please visit our main website www.ismp.org

Some of the ISMP contributions to medication safety that have been made possible by generous donors and volunteers include:
  • Launching a continuous, voluntary, confidential medication error reporting system to learn about errors happening across the nation, understand their causes, and share "lessons learned" with the healthcare community;
  • Procuring hundreds of changes in error-prone medication names, labels, and packages that have reduced the risk of potentially serious mistakes;
  • Developing free self-assessment tools for healthcare facilities that have helped them analyze the effectiveness of their medication safety programs;
  • Publishing four medication safety newsletters for medical professionals and consumers that reach more than a million readers; and
  • Providing assistance in the development of federal and state legislation and regulations related to patient safety.
Tuesday, 08 February 2011 16:34

Terms and Conditions

Written by

Click below for specific information about:

Introduction/Binding Agreement

Welcome to consumermedsafety.org, a website for consumers ("consumermedsafety", the "Site" or the "Website") provided by the Institute for Safe Medication Practices ("ISMP"). This Site contains a range of information and tools relating to health and medication. There are articles, tools, images, and other content ("Content") that have been written by ISMP, medical writers or other medical professionals and users of the Site. This Website offers you the opportunity to view Content, report medication errors, sign up for receipt of newsletters, as well as submit comments, materials, questions, ideas, suggestions, concerns, or the like to ISMP.

This Website is provided to you under the following Terms & Conditions of Use (the "Agreement") which governs your relationship with us. Your use of this Website shall be deemed to constitute your consent to be bound by this Agreement and shall be enforceable in the same way as if you had signed the Agreement. If you are not willing to accept this Agreement, we ask that you not use the Website. ISMP may make changes to the Agreement from time to time in its sole discretion, and will post any such changes on the Website. Your continued use of the Website following the posting of changes constitutes your acceptance of any such changes.

Back to Top



If you think you may have a medical emergency, call your physician or 911 immediately. ISMP does not recommend or endorse any specific medications, studies, clinical trials, tests, results, physicians, products, procedures, opinions, tips, or other information that may be mentioned on the Website. Reliance on any information provided by ISMP, its employees, or others appearing on the Website is solely at your own risk.

Back to Top

Intended Audience

This Website is intended for and directed to adults in the United States only. This Website is not intended for any children under the age of 18.

Back to Top

Personal Information and Privacy

ISMP respects your privacy. Our Privacy Policy explains our collection, use and disclosure of information that you provide to us, including, personally identifiable information.

Back to Top

Error Reporting

Through our Site, you have the ability to report medication related errors such as receiving the wrong medication, strength, or dose of medicine; confusion over look alike/sound alike drugs; taking a medication the wrong way; calculating or preparing a medicine incorrectly; misuse of medical equipment; and errors in prescribing, transcribing, dispensing, and monitoring of medications ("Error Submissions"). Our error reporting system, which is a confidential national voluntary reporting program, provides expert analysis of the causes of medication errors and disseminates recommendations for prevention. Regulatory agencies and manufacturers are notified of recommended changes in products when safety is of concern.

After we receive an Error Submission from you, we may contact you for more information so we can develop a case study with analysis for publication. Case studies are published by ISMP in various print and online resources to alert other consumers and healthcare professionals about recommendations to prevent errors.

Details regarding our use of your Error Submissions and personally identifiable information are set forth in the "Use of Information" and "Disclosure of Information" sections of our Privacy Policy. By transmitting Error Submissions using the Website, you (1) represent and warrant to ISMP that you have obtained all necessary licenses, consents, waivers, releases, authorizations and/or permissions to post or transmit Error Submissions; and (2) subject to the limitations on use of any personally identifiable information in an Error Submission, grant to ISMP an irrevocable, worldwide, nonexclusive, perpetual, fully sub-licensable, royalty-free right and license to use, reproduce, modify, adapt, publish, translate, create derivative works from, distribute, transmit, publicly perform, and publicly display such Error Submissions (in whole or part) and/or to incorporate it (in whole or in part) in other works in any form, media, or technology now known or later developed.

You acknowledge and agree that ISMP may preserve Error Submissions and may also disclose Error Submissions if required to do so by law or in the good faith belief that such preservation or disclosure is reasonably necessary to (a) comply with legal process; (b) enforce this Agreement; (c) respond to claims that any Error Submissions violate the rights of third parties; or (d) protect the rights, property, or personal safety of ISMP, its users, and the public.

You understand and agree that you shall evaluate and bear all risks associated with the use of any Error Submissions, including any reliance on the accuracy, completeness, or usefulness of such Error Submissions.

Back to Top

Received Materials

Our Website also allows you to submit comments, materials, questions, ideas, suggestions, criticisms, or the like ("Received Materials"). Details regarding our use of Received Materials and personally identifiable information that may be contained in such materials is set forth in the "Use of Information" and "Disclosure of Information" sections of our Privacy Policy.

Subject to the restrictions on use of personally identifiable information set forth in our Privacy Policy, by submitting Received Materials, you agree that ISMP will be free to reproduce, use, disclose, exhibit, publicly display, transform, edit, abridge, create derivative works from, and/or distribute Received Materials. You also acknowledge that what you post may be indexed by search engines such as Yahoo or Google. Furthermore, ISMP is free to use any ideas, concepts, know-how, or techniques contained in any Received Materials you send to ISMP, for any purpose whatsoever, including, but not limited to, developing, manufacturing, and marketing products using such information, without compensation or any other obligations to anyone, including yourself.

Back to Top

Terms and Conditions with Respect to Error Submissions and Received Materials

You acknowledge and agree to the following additional terms and conditions when sending Error Submissions and Received Materials:

  1. The Received Materials will be shared with the staff of ISMP best able to address the issues presented.
  2. Neither ISMP nor any of its affiliates are obligated to use or publish, or respond individually to your Error Submissions or Received Materials or to pay you for any Error Submissions or Received Materials.
  3. ISMP reserves the right to change due dates for Error Submissions or Received Materials, or other specifics, as it deems necessary in its sole discretion.
  4. Anything sent via US Mail or other delivery service (Tapes/Photos/Letters, etc.) will not be returned to you and may appear on consumermedsafety, or in other ISMP publications forever.

Back to Top


User Conduct Guidelines

While using the Site, you agree not to:

  • transmit any Error Submission or Received Material that is unlawful, harassing, defamatory, abusive, threatening, obscene, harmful, tortious, libelous, or invasive of another's privacy;
  • impersonate any person or entity; falsely state or otherwise misrepresent your affiliation with any person or entity; intentionally omit, delete, forge, or misrepresent transmission information, including headers, return mailing, and Internet protocol addresses; or otherwise manipulate identifiers to disguise the origin of any Error Submission or Received Material transmitted through the Website;
  • interfere with, disrupt, or harm in any way the Website or servers or networks connected to the Website;
  • engage in any activities that would infringe on or violate the personal privacy rights of others, except as permitted by applicable law.

Back to Top

Protection of Intellectual Property Rights and Licenses

This Website is owned by ISMP. All rights, title, and interest in and to the content displayed on the Website, including but not limited to the Website's look and feel, data, information, text, graphics, images, software, music, photographs, sound or video materials, designs, trademarks, service marks, trade names, and URL, are the property of ISMP or its respective partners, agents, or third party licensors and is protected by copyright law, trademark law, patent law, and/or other proprietary rights and laws. Except as expressly authorized by ISMP, you agree not to download, transmit, reproduce, copy, modify, rewrite, create derivative works, distribute, publicly display, publicly perform, license, rent, lease, loan, sell, assign, translate into any language or computer language, reverse engineer, disassemble, decompile or transfer content retrieved from the Website in any way (including, without limitation, any software) without the prior written consent of ISMP.

You are hereby granted a nonexclusive, nontransferable, revocable, limited license to view, copy, print, and distribute Content retrieved from the Website for your personal, noncommercial purposes, provided that you do not remove or obscure the copyright notice, trademark or other notices displayed on or included with the Content.

Except as expressly provided in the Agreement, nothing contained in the Agreement or on the Website shall be construed as conferring any other license or right, expressly, by implication, by estoppel, or otherwise under any of ISMP's Intellectual Property Rights or under any third party's intellectual property rights. Any rights not expressly granted herein are reserved.

Except as otherwise noted, all Content posted on this Website is:


For further information regarding permission to use Content, Error Submissions or Received Materials, please Contact Us.

Back to Top

Trademarks/Service Marks

"CONSUMERMEDSAFETY.ORG", "PREVENT-ERR", "SAFE MEDICINE", and "ISMP" logo and design, are registered trademarks of ISMP.

All other trademarks, logos, and service marks are the property of their respective owners.

The trademarks, logos and service marks (collectively the "Marks"), including those listed above, displayed on the Website identify ISMP's products and services, and inform the public that ISMP is the source of those products and services. Nothing contained on the Website should be construed as granting any right or license to use any Mark displayed on the Website except if used in connection with Content, Error Submissions or Received Materials. Your misuse of any Mark is strictly prohibited, including without limitation, your use of the Marks in any of the following ways:

  • To identify materials or services that are not ISMP materials or services;
  • In, as, or part of your own trademarks or services marks;
  • In any manner likely to cause confusion;
  • In a manner that implies inaccurately that ISMP sponsors, endorses or is otherwise connected with your products, services or other activities; or
  • In a manner that disparages ISMP or dilutes the Marks.

You are also advised that ISMP will enforce its intellectual property rights in the Marks to the fullest extent of the law. You agree not to display or otherwise inappropriately use the Marks without prior written permission from ISMP, which may be withheld by ISMP in its sole discretion. Please make such requests through our online form. We will evaluate your request and respond as soon as commercially practical.

Back to Top

Notice and Procedure for Making Claims of Copyright Infringement

ISMP asks our users to respect the intellectual property of others. Pursuant to the Digital Millennium Copyright Act, 17 U.S.C. Sec. 512, ISMP has designated an agent to receive notices of claimed copyright infringement. If you believe in good faith that your work has been copied in a way that constitutes copyright infringement, please provide ISMP's Copyright Agent the following information:

  1. An electronic or physical signature of the person authorized to act on behalf of the owner of the copyright interest;
  2. A description of the copyrighted work that you claim has been infringed;
  3. A description of where the material that you claim is infringing is located on the Website;
  4. Your name, address, telephone number, and email address;
  5. A statement by you that you have a good faith belief that the disputed use is not authorized by the copyright owner, its agent, or the law; andA statement by you, made under penalty of perjury, that the above information in your notice is accurate and that you are the copyright owner or authorized to act on the copyright owner's behalf.

ISMP's Copyright Agent for Notice of claims of copyright infringement on its Website can be reached through our online form, by phone: 1-877-MED-SAFE (633-7233) or by mail at:

Institute for Safe Medication Practices
Attn: Copyright Agent
200 Lakeside Drive, Suite 200 
Horsham, PA 19044

Upon receipt of the written notification containing the information as outlined in 1 through 6 above, ISMP's Copyright Agent will investigate the claim and if the claim is valid shall:

  • remove or disable access to the material that is alleged to be infringing;
  • forward the written notification to such alleged infringer ("Subscriber"); and
  • take reasonable steps to promptly notify the Subscriber that it has removed or disabled access to the material.You may want to seek the advice of independent legal counsel before filing a notification.

Back to Top



If Subscriber believes that a notice of copyright infringement has been wrongfully filed against it and it would like to submit a Counter-Notification, Subscriber may file a Counter-Notification in Response to Claim of Copyright Infringement with ISMP's Copyright Agent.

To be effective, a Counter-Notification must be a written communication provided to ISMP's Copyright Agent for Notice that includes the following information:

  1. A physical or electronic signature of the Subscriber;
  2. Identification of the material that has been removed or to which access has been disabled and the location at which the material appeared before it was removed or access to it was disabled;
  3. A statement under penalty of perjury that the Subscriber has a good faith belief that the material was removed or disabled as a result of a mistake or misidentification of the material to be removed or disabled; and
  4. The Subscriber's name, address, and telephone number, and a statement that the Subscriber consents to the jurisdiction of Federal District Court for the judicial district in which the address is located, or if the Subscriber's address is outside of the United States, for any judicial district in which ISMP may be found, and that the Subscriber will accept service of process from the person who provided notification or an agent of such person.

Upon receipt of a Counter-Notification containing the information as outlined in 1 through 4 above, ISMP's Copyright Agent shall investigate such Counter-Notification and if the Counter-Notification claim is valid shall:

  • promptly provide you with a copy of the Counter-Notification;
  • inform you that it will replace the removed material or cease disabling access to it within ten (10) business days; and
  • replace the removed material or cease disabling access to the material within ten (10) to fourteen (14) business days following receipt of the Counter-Notification, provided ISMP's Copyright Agent for Notice has not received notice from you that an action has been filed seeking a court order to restrain Subscriber from engaging in infringing activity relating to the material on ISMP's network or system


Back to Top

Linking to ISMP

You are granted a limited, revocable, and nonexclusive right to create a hyperlink to the home page of consumermedsafety so long as the link does not portray consumermedsafety, ISMP, its affiliates, or their items or services in a false, misleading, or offensive manner. You may not use any consumermedsafety or ISMP logo or graphic or trademark as part of the link without the prior express written permission of ISMP.

Back to Top

Your Contact with Third Parties

These terms and conditions apply only to consumermedsafety, and not to the websites of any other companies or organizations, including those to which this Website links. We do not endorse or take responsibility for the content, advertising, products or other materials made available through any other site. Please see our Sponsorship and Advertising Policy for more information.

Your dealings with third parties found on or through the Website are solely between you and the third party. These dealings include, but are not limited to, your participation in promotions, the payment for and delivery of items if any, and any terms, conditions, warranties, or representations associated with such dealings. We do not monitor any transaction between you and third party providers of products or services. ISMP does not make any representations or warranties with respect to any items or services that may be obtained from such third parties, and you agree that ISMP will have no liability with respect to any loss or damage of any kind incurred as a result of any dealings between you and any third party, or as a result of the presence of such third parties on the Website.

Back to Top


You agree to indemnify and hold harmless ISMP, its directors, officers, employees, agents, sponsors, subsidiaries, parents, and affiliates, from and against any and all liabilities, losses, claims, demands, disputes, damages, and costs of any kind, including, without limitation, reasonable attorneys' fees and costs of litigation resulting from or in any way connected with your use of the Website; Content, or your breach of the Agreement.

Back to Top

No Warranties


Back to Top

Limitations of Liability


Back to Top

Modification or Suspension of the Website

You agree that ISMP may, in its sole discretion, and at any time, modify, discontinue, or suspend its operation of this Website, or any portion of the Website, temporarily or permanently, without notice to you, and you agree that ISMP will not be liable for any consequences of doing so.

Back to Top


You agree that ISMP may, in its sole discretion, and at any time, terminate your use of the Website, and may remove or delete any or all of your information, Error Submissions, or Received Materials within the Website, without prior notice to you for any reason that ISMP, in its sole discretion, deems appropriate. You further agree that ISMP will not be liable to you or to any third party for the consequences of any termination of your use of or access to the Website. In the event of any termination of your use of or access to the Website, you agree that the provisions of the Agreement regarding Received Materials, Protection of Intellectual Property Rights and Licenses, Trademarks/Service Marks, Indemnification, No Warranties, Limitations of Liability, and Applicable Law shall survive any such termination.

Back to Top

Compliance with Laws

You agree to comply with all applicable laws and regulations regarding your use of the Website, including, without limitation, intellectual property laws, privacy laws and laws regarding import/export of technical data by virtue of your online transmission.

Back to Top

Electronic Communications

The information communicated on the Website constitutes electronic communication. When you communicate with us through the Website or via other forms of electronic media, such as email, you are communicating with us electronically. You agree that we may communicate electronically and that such communications, as well as notices, disclosures, agreements, and other communications that we provide to you electronically, are equivalent to communications in writing and shall have the same force and effect as if they were in writing and signed by the party sending the communication.

Back to Top

Entire Agreement

This Agreement and any other terms, policies, rules, guidelines, or instructions posted on the Site constitute the entire agreement between you and consumermedsafety and ISMP and supersede all previous written or oral agreements. If any part of these terms and conditions is held invalid or unenforceable, that portion shall be construed in a manner consistent with applicable law to reflect, as nearly as possible, the original intentions of the parties, and the remaining portions shall remain in full force and effect.

Back to Top

Applicable Law

The Agreement and the resolution of any dispute related to the Agreement or the Website shall be governed by and construed in accordance with the laws of the United States, including without limitation federal copyright and trademark laws, and with the laws of the Commonwealth of Pennsylvania applicable to contracts entered into and to be wholly performed therein, without giving effect to any principles of conflicts of law or choice of law. Any legal action or proceeding between ISMP and you related to the Agreement shall be brought exclusively in a federal or state court of competent jurisdiction sitting in Pennsylvania, and you agree to submit to the personal and exclusive jurisdiction of such courts and waive any right or claim that this is an inconvenient forum.

Back to Top

Contact Information

If you have any questions or concerns with respect to the Agreement or the Website you may contact a representative of ISMP using our online form, by phone: 215-947-7797

or by mail at:

Institute for Safe Medication Practices
Attn: consumermedsafety.org IT
200 Lakeside Drive, Suite 200 
Horsham, PA 19044

These Terms & Conditions of Use were last updated on 4/20/12.

Back to Top


Tuesday, 08 February 2011 16:11

Become a Sponsor

Written by

To further ISMP's mission to advance patient safety worldwide by empowering the healthcare community, including consumers, to prevent medication errors, ISMP gladly accepts donations from sponsoring companies for its programs and consumer education activities, including the development and maintenance of the consumermedsafety.org website. ISMP shall recognize such sponsorship payments on a designated portion of the website under strict guidelines.

For more information on sponsorship, please contact Jennifer Gold at 267-725-0055

Sponsor Guidelines

ISMP maintains a distinct separation between publicity content and editorial content on consumermedsafety.org. All content on consumermedsafety.org has been independently developed by ISMP with the following exceptions:

  • Drug library
  • Drug database
  • Drug interaction database
  • Any page where the source of the information is clearly listed
  • Links to another site. These links are clearly defined with an intermediary screen stating your departure from consumermedsafety.org.

ISMP does not endorse any companies or any program, product, service, or facility. Advertisements for or links to specific programs, products and/or services of sponsors are not accepted. The presence of a company's logo or name on our site does not imply endorsement of the company or any of its products. Contributions from sponsors are considered charitable donations to ISMP, a 501c (3) nonprofit organization whose mission is devoted entirely to medication error prevention and safe medication use.

ISMP reserves the right to decline any sponsorship payment or other donation from any organizations, industries or individuals that, in ISMP's judgment, may be incompatible with its mission. ISMP maintains its objectivity and independence with respect to any activities that are developed, sponsored, or supported with corporate funds. ISMP does not permit influence by corporate sponsors beyond the usual input ISMP seeks from stakeholders. ISMP retains independence and control over all programs, projects, or products bearing the ISMP name, logo, or trademarks, and over the use of ISMP intellectual property. Sponsors may not use ISMP's name or logo, or the name of consumermedsafety.org without the prior written approval of ISMP.

ISMP may consider the results of research studies, test results, or other information from corporate sponsors as well as other external experts that may help to inform ISMP staff on issues to be addressed on consumermedsafety.org or in other ISMP program and product development process. ISMP may accept a corporate sponsor's provision of in-kind expertise to assist with specific tasks such as market research, data analysis, or testing provided that all such in-kind expertise complies with ISMP policies on disclosure and conflicts of interest.

The following language shall appear on the webpage listing all of consumermedsafety.org sponsors:

"ISMP accepts sponsorship payments and donations to help develop and maintain its programs, including this website. The presence of a sponsor's or donor's name or logo does not constitute an endorsement or recommendation by ISMP of a particular company, organization, or individual, or its programs, products, services or facilities.

There are certain categories of industries and companies that ISMP will not permit on consumermedsafety.org at any time. These categories include but are not limited to the following:

  • Alcohol, tobacco products, firearms/weapons
  • Fireworks
  • Law firms
  • Pornography
  • Sweepstakes, gambling/lottery
  • Political, social cause, religious affiliations or ads
  • Advertising, including any message that promotes or markets any program, product, service or facility
  • Illegal or objectionable products
  • Fraudulent, deceptive, illicit, misleading or offensive material, including material that misrepresents, ridicules, discriminates (real or implied) or attacks an individual or group on the basis of age, national origin, race, religion, gender, sexual orientation, marital status, disability or any other status deemed inappropriate for consumermedsafety.org
  • The simulation of news or an emergency
  • Material that is directly intended to attract children

ISMP retains final approval of all sponsor logos/text/banners that are directly linked or adjacent to the content. This includes verification of text and content and placement before it is produced on the site. Company logos will be displayed in such a way that it is clear that they are not part of the consumermedsafety.org site content. No unsolicited commercial messages are allowed.

ISMP reserves the right to reject, cancel or remove at any time any sponsor from consumermedsafety.org for any reason. In such a case, ISMP will provide prompt notice to the sponsor, together with an explanation. ISMP also reserves the right to determine the appropriate placement of the logos/text/banners on consumermedsafety.org. Sponsors cannot collect any personally identifiable information from consumermedsafety.org visitors or place any cookies, applets or other such files — if those files transmit any personally identifiable information to the sponsors — on computers of consumermedsafety.org visitors who do not visit sponsors' sites by clicking on their logos/banners.

ISMP retains the exclusive right to determine how any and all search results for specific information by keyword or topic are displayed on consumermedsafety.org. ISMP search results are not influenced based on monetary or other donations provided by Sponsors.

Sponsors must comply with all applicable domestic and foreign laws, including applicable laws and regulations of regulatory bodies. This includes pharmaceutical advertising to physicians and consumers that must comply with FDA guidelines for Direct to Physician (DTP) and Direct to Consumer (DTC) advertising. ISMP does not monitor compliance with applicable laws and regulations. However, ISMP reserves the right to review all logos/text/banners for compliance with applicable laws and regulations and, if ISMP becomes aware of any breach or potential breach of any applicable law or regulation or of these guidelines, ISMP may remove the logos/text/banners. No logos/text/banners will be allowed on consumermedsafety.org that, in ISMP's judgment, could injure the good name or reputation of ISMP or consumermedsafety.org.

Tuesday, 08 February 2011 15:48

Privacy Policy

Written by

Welcome to consumermedsafety.org, a Website for consumers ("consumermedsafety", the "Site" or the "Website") provided by the Institute for Safe Medication Practices ("ISMP").

ISMP is committed to protecting your online privacy. This Privacy Policy is designed to tell you about our practices regarding collection, use and disclosure of information that you may provide to us via this Site. In general, you can visit consumermedsafety and use some of the functionality of the Site without revealing any personally identifiable information. However, you may choose to provide personally identifiable information if you report medication errors and to gain access to some of our content and services, as explained below.

Please be sure to read this entire Privacy Policy before using or submitting information to this Site.

Click below for specific information about:



Your Consent

By using this Website, you agree to the terms of this Privacy Policy and our Terms & Conditions of Use (the "Agreement"). Whenever you submit information via this Website, you consent to the collection, use, and disclosure of that information in accordance with this Privacy Policy and the Agreement.

Back to Top

U.S. Residents

This Site is intended for use by residents of the United States only.

Back to Top

About Children

ISMP conforms to the Children's Online Privacy Protection Act (COPPA). This Website is not intended for any children under the age of 18.

Back to Top

Personally Identifiable Information

Some areas of this Website may provide you with an opportunity to submit personally identifiable information such as your full name, email address, and other information that can be uniquely identified with you in order for you to benefit from the specified features (such as newsletter subscriptions, reporting of medication errors and sending a question to the safety experts) or to participate in a particular activity (such as a survey or other promotion).

Back to Top

Non-Personal Information Collection

As you navigate through this Website, certain anonymous information can be collected (that is, gathered without you actively providing the information) using various technologies, such as cookies, Internet tags or web beacons, and navigational data collection (log files, server logs, clickstream). These technologies allow your Internet browser to automatically transmit information, such as pages you have visited, and paths taken through the Website, the URL of the Website you just came from and the Internet Protocol (IP) address and the browser version currently being used by your computer. You may set your browser to notify you when a cookie is sent or to refuse cookies altogether, but certain features of this Website might not work without cookies.

Back to Top

Use of Information

Non-Personal Information: ISMP uses the non-personal passive information that has been collected from you to improve the content of the Website, provide better service to visitors of the Website, compile and analyze statistics and trends, and market and promote various features.
Personally Identifiable Information: ISMP uses the personally identifiable information that has been collected from you to communicate information to you (if you have requested it), customize the Website based on your preferences, develop case studies, and to alert healthcare professionals, manufacturers and others about pharmaceutical labeling, packaging and nomenclature issues that may foster medication errors by their design.

Back to Top

Disclosure of Information

Except as provided below, personally identifiable information including your name and email address will not be disclosed to anyone other than the staff at ISMP unless:
you provide prior consent; orISMP enters into an agreement with an analytics company to measure: (i) how visitors use our Website, (ii) determine which offers visitors find of interest, and (iii) other visitor activities. While the analytics company logs information coming from our Website, ISMP retains full ownership of data stored by the analytics company, and controls how that data is used; orISMP and a third party are involved with the sale, assignment, or other transfer of the business of this Website to which the information relates, in which case we will require any such buyer to agree to treat such information in accordance with this Privacy Policy and use it for the same purposes; orISMP is required to disclose such information by applicable laws, court orders, or government regulations.ISMP may disclose Error Submissions and Received Materials to third parties including, but not limited to, the Food and Drug Administration (FDA) MedWatch program, the manufacturer or labeler of a particular medication, or the manufacturer of a medical device. All personally identifiable information will be redacted or removed, unless permission is granted by you to disclose such information, from any Error Submissions or Received Materials and may be disclosed, reported or published without your consent or approval at the sole discretion of ISMP.
The collection, use, and disclosure of information contemplated in this Privacy Policy may involve a transfer of the information to jurisdictions located outside your country of residence that may not have equivalent laws and rules regarding personally identifiable information. In these cases, if required by such laws, you will be asked to consent to such transfers and disclosures in accordance with this Privacy Policy.

Back to Top

Opt-Out Procedures

Participation on consumermedsafety is voluntary and you may opt-out at any time from receiving communications from us and/or from our receiving your personally identifiable information (such as your name, address, and/or other contact information) by notifying us using our online form with the word "remove" in the subject or message section. Upon receipt of your request to opt-out we will remove you from all future mailings and not contact you.

Back to Top


ISMP takes reasonable steps to protect the security of personally identifiable information that is transmitted to our Website and to protect such information from loss, misuse, unauthorized access, disclosure, alteration or destruction. Information transmitted over the Internet is not ever completely secure or error-free. Please be aware that email sent to or from this Website may not be secure.

Back to Top

Links to Other Websites

This Website may contain links to third parties over which ISMP has no control. These links are provided solely as a convenience to users and should not be construed as an affiliation with or endorsement by ISMP of content, items, or services on those third-party Websites. Sponsors or advertisers may use their own cookies, web beacons or other online tracking technologies in the advertisements served on consumermedsafety and in emails, special promotions or newsletters that are sent to you. ISMP does not control the use of the information collected by these third parties nor how they use the non-personal information they gather.
Your access to and use of such other Websites, including the content, items, or services on those Websites, is solely at your own risk. These linked Websites may collect personal information from you when you enter their Website. To ensure protection of your privacy, always review the privacy policies of the Websites you visit when linking from this Website.

Back to Top

Access, Correction, and Deletion of Personally Identifiable Information

You may contact us by telephone at 1-877-MED-SAFE (633-7233) or via our online form to learn if we are storing your personally identifiable information. If so, we will provide you with a readable copy of such personally identifiable information at no charge. To keep personally identifiable information that you provide via this Website accurate, current, and complete, please contact us as specified below and we will take appropriate steps to update or correct such information in our possession, or to delete your information from our contact list.

Back to Top

Contact Us

If you have any questions, comments, requests, or concerns related to this Privacy Policy or the information practices of this Website, do not hesitate to contact us:
By email: using our online form.
By mail:Institute for Safe Medication PracticesAttn: consumermedsafety.org IT200 Lakeside Drive, Suite 200 Horsham, PA 19044B

Back to Top

Changes to this Privacy Policy

Occasionally, this Privacy Policy will be updated. Changes to this Privacy Policy will be posted on this Website. Your continued use of the Website after changes to the Privacy Policy have been posted will constitute automatic consent to the changes.

Back to Top

Thursday, 03 February 2011 20:28

About ISMP

Written by
Institute for Safe Medication Practices
200 Lakeside Drive; Suite 200
Horsham, PA 19044-2321
Phone: 215-947-7797
Fax: 215-914-1492

ISMP Website for Healthcare Professionals

The Institute for Safe Medication Practices (ISMP), based in suburban Philadelphia, is the nation’s only 501c (3) nonprofit organization devoted entirely to medication error prevention and safe medication use. ISMP represents over 30 years of experience in helping healthcare practitioners keep patients safe, and continues to lead efforts to improve the medication use process. The organization is known and respected worldwide as the premier resource for impartial, timely, and accurate medication safety information.

The Institute has a long history of achievements. Its medication error prevention efforts began in 1975 with a groundbreaking and continuing column in Hospital Pharmacy that increases understanding and educates healthcare professionals and others about medication error prevention. In 2004, the Institute celebrated the 10th anniversary of its official incorporation as a nonprofit organization.

Today, a continuously expanding core of knowledge in medication safety fuels the Institute’s highly effective initiatives to improve the medication use process. These initiatives, which are built upon a non-punitive approach and system-based solutions, fall into five key areas: knowledge, analysis, education, cooperation, and communication.

More than 30 years ago, ISMP started a cornerstone of its medication error prevention efforts - a voluntary practitioner error-reporting program to learn about errors happening across the nation, understand their causes, and share “lessons learned” with the healthcare community. ISMP is also responsible for reviewing all medication error reports submitted by healthcare facilities to the Commonwealth of Pennsylvania Patient Safety Authority. Each year, ISMP's national Medication Errors Reporting Program (MERP), receives hundreds of error reports from healthcare professionals. Detailed information about the impact of the MERP can be found here. In addition, ISMP’s wholly owned corporate subsidiary, Med-E.R.R.S. (Medical Error Recognition and Revision Strategies), works directly and confidentially with the pharmaceutical industry to prevent errors that stem from confusing or misleading naming, labeling, packaging, and device design.

In addition, ISMP now is certified as a Patient Safety Organization (PSO) by the Agency for Healthcare Research and Quality. Because reporting to a PSO confers both privilege and confidentiality to the information reported, ISMP’s PSO status will afford an even higher level of protection when clinicians and organizations report errors or engage in other types of consulting services with the Institute. In addition, ISMP can work with other PSOs to provide expert analysis of error data--click here for more information.

The Institute’s other initiatives include publishing four "ISMP Medication Safety Alert!®" newsletters for healthcare professionals and consumers that reach nearly a million total readers; presenting frequent educational programs, including teleconferences on current medication use issues; offering posters, videos, patient brochures, books and other resources; developing valuable medication safety tools such as lists of high alert drugs and potentially dangerous abbreviations; and providing confidential consulting services to healthcare systems to proactively evaluate medication systems or analyze medication-related sentinel events. ISMP collaborates on a continuing basis with a wide variety of partners--healthcare practitioners, legislative and regulatory bodies, healthcare institutions, consumers, healthcare professional organizations, regulatory and accrediting agencies, employer and insurer groups, and the pharmaceutical industry.

As an independent watchdog organization, ISMP receives no advertising revenue and depends entirely on charitable donations, educational grants, newsletter subscriptions, and volunteer efforts to pursue its lifesaving work.

Thursday, 03 February 2011 19:34

Meet Our Staff

Written by


Executive Staff

Michael R. Cohen, RPh, MS, ScD (hon.), DPS (hon.), FASHP
Michael R. Cohen, RPh, MS, ScD (hon.), DPS (hon.), FASHP, is president of The Institute for Safe Medication Practices, a non-profit healthcare organization that specializes in understanding the causes of medication errors and providing error-reduction strategies to the healthcare community, policy makers, and the public. He is editor of the textbook, Medication Errors (American Pharmaceutical Association) and serves as co-editor of the ISMP Medication Safety Alert! publications that reach over 2 million health  professionals and consumers in the US, as well as regulatory authorities and others in over 30 foreign countries. He is editor for the ISMP consumer website, and writes a guest column called Check-Up that appears weekly on the Philadelphia Inquirer website and occasionally in the Inquirer’s Sunday Health section. Dr. Cohen previously served as Vice Chair of the Patient Safety Advisory Group for the Joint Commission (creates the National Patient Safety Goals) and currently serves as a consultant to FDA and a member of the Non-prescription Drug Advisory Committee (NDAC). In 2005 he was recognized as a MacArthur Fellow by the John D. and Catherine T. MacArthur Foundation. In 2008, The Joint Commission and National Quality Forum awarded Dr. Cohen the prestigious John M. Eisenberg Patient Safety and Quality Award in recognition of his life-long professional commitment to promoting safe medication use and a safe medication delivery system. In 2014 he was made an honorary member of the American Society of Health-System Pharmacists (ASHP).
Allen J. Vaida, PharmD, FASHP
Executive Vice President
Allen Vaida previously served as director of pharmacy, assistant vice president and director of pharmacy, vice president of clinical operations, and chief operating officer at Mercy Suburban Hospital in Norristown, PA. He has served on the boards of several healthcare organizations, including as a trustee for ISMP from its incorporation as a nonprofit organization in 1994 until his employment at ISMP in 2000. Dr. Vaida served on the United States Pharmacopeia's Safe Medication Use Expert Committee from 2000 through 2005, was a member of the FDA’s Drug Safety and Risk Management Advisory Committee, and still serves as special government employee. He is a clinical assistant professor at the University of the Sciences in Philadelphia, adjunct assistant professor at Temple University School of Pharmacy, and adjunct associate professor for the Centers for Health Policy and Primary Care and Outcomes Research at Stanford University and Stanford University School of Medicine. He has published numerous articles and given professional presentations on hospital and pharmacy systems and management, error prevention strategies, healthcare outcomes, integrated systems and interdisciplinary collaboration. Dr. Vaida received a BS in Biology from the University of Scranton, a BS in Pharmacy from the Philadelphia College of Pharmacy and Science, and a Doctor of Pharmacy from the University of Minnesota.
Judy Smetzer, RN, BSN
Vice President
Prior to joining ISMP, Judy Smetzer served as associate vice president at St. Luke's Quakertown Hospital in Quakertown, PA. During her 30-year career, Ms. Smetzer has advanced from a staff nurse to various management positions, increasingly focusing on quality improvement and risk management. She has served as a risk management consultant for a long-term and community-based healthcare organizations, published many articles on medication error prevention in peer-reviewed journals, and is a contributing author of the handbook Mosby’s Nursing PDQ for Medication Safety. Ms. Smetzer serves as an author and editor of ISMP’s four newsletters for acute care providersnursesambulatory/community care providers, and consumers. She also is an adjunct assistant professor at Temple University School of Pharmacy, teaching a course on medication error surveillance and control planning. Ms. Smetzer received a BSN from Cedar Crest College.
Susan F. Paparella, RN, MSN
Vice President
Before joining ISMP, Susan spent over 20 years in the acute care setting, as the Director for Critical Care and Emergency Services then as the Director for Hospital-wide Quality Improvement, Risk Management, and Education. Since 2000, Susan has directed and performed onsite medication safety risk assessments and root cause analyses for hospitals and healthcare facilities throughout the US and Canada. She frequently participates in the investigation of medication safety issues specific to adult populations; specifically around oncology and critical care/emergency care practice. Susan serves as part-time faculty in the Temple University School of Pharmacy, and at Virginia Commonwealth University in their Executive Patient Safety Fellowship Program. She is the immediate past chairperson of the Emergency Nurses Association’s (ENA’s) Patient Safety Committee, and their LUNAR III research group. She also is the author and section editor of Danger Zone, which is a regular column on medication safety in the Journal of Emergency Nursing. Susan graduated with honors from Villanova University, is a member of the American Association of Hospital Risk Managers (ASHRM), Sigma Theta Tau International, and the American College of Healthcare Executives.
Ronald S. Litman, D.O. 
Medical Director
Dr. Ron Litman is a pediatric anesthesiologist at The Children’s Hospital of Philadelphia (CHOP) and Professor of Anesthesiology and Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. He is the Chair of the hospital’s Sedation Committee, the Vice-Chair of the Conflict of Interest Committee, and a member of the Therapeutics & Standards Committee. He became a crusader for safer medication practices after investigating a fatal medication error in a child during anesthesia. Dr. Litman attended medical school at the NY College of Osteopathic Medicine, completed a residency in pediatrics at Rainbow Babies and Children’s Hospital in Cleveland, OH, anesthesiology residency at Mount Sinai Medical Center in New York, and fellowship in pediatric anesthesia and critical care at CHOP. From 1991 to 2001 he was Director of Pediatric Anesthesia at Strong Memorial Hospital in Rochester, NY, and returned to Philadelphia in 2001.
Russell H. Jenkins, MD
Medical Director Emeritus
Russ Jenkins was previously director of respiratory therapy at St. Luke's Quakertown Hospital in Quakertown, PA, where he also served as chairman of the pharmacy and therapeutics committee. In addition, he was affiliated with Grand View Hospital in Sellersville, PA, and the University of Pennsylvania Medical Center in Philadelphia, PA. In the past, Dr. Jenkins has served as clinical professor of medicine at Hahnemann Hospital and Temple University School of Medicine, clinical associate professor of medicine at the University of Pennsylvania, and clinical associate professor at St. Francis de Sales University. He was president and a founding member of Quaker Pointe PHO. Dr. Jenkins received a MD from Temple University and is certified by the American Board of Internal Medicine.

Healthcare Professional Staff

Matthew P. Fricker, Jr, MS, RPh, FASHP 
Program Director
Prior to joining ISMP, Matt was employed in the acute care setting for over 27 years, most recently as director of pharmacy and materials management and Institutional Review Board chairman. In addition to performing onsite medication safety risk assessments and speaking about medication safety in hospitals throughout the United States, he has managed several medication safety collaboratives designed to improve safety with high alert drugs, including anticoagulants and opioids. Matt created program tools and content for the Regional Medication Safety Program for Hospitals, a collaborative program with the Health Care Improvement Foundation of the Delaware Valley Healthcare Council and ECRI Institute. He has also co-developed medication safety programs for critical access hospitals in Pennsylvania and throughout the US.   Matt received his BS in Pharmacy and MS in Hospital Pharmacy Administration from Temple University and has published numerous articles in the pharmacy and medical literature.
Michael J. Gaunt, PharmD
Medication Safety Analyst

Editor, ISMP Medication Safety Alert! Community/Ambulatory Care Edition
Michael Gaunt coordinates ISMP's role in the ISMP Medication Errors Reporting Program (MERP), a confidential national voluntary medication error reporting program. He also serves as the editor of the monthly ISMP Medication Safety Alert! Community/Ambulatory Care Edition newsletter. Dr. Gaunt is a Clinical Analyst for the Pennsylvania Patient Safety Reporting System (PA-PSRS), a statewide adverse event and near miss reporting system. He has authored and reviewed articles for the Pennsylvania Patient Safety Advisory and has published articles in the pharmacy literature, including regular columns in Pharmacy Times and America's Pharmacist. Dr. Gaunt represents ISMP on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). He is a preceptor for Doctor of Pharmacy candidates from Temple University School of Pharmacy. Dr. Gaunt has worked in patient care positions in outpatient and inpatient settings at Madison Center and Hospital, a community mental health center in South Bend, IN. His past pharmacy experience primarily consists of work in retail community pharmacy. Dr. Gaunt received a BA in History from the University of Notre Dame and a Doctor of Pharmacy with a Certificate in Drug Safety from Temple University.
Jennifer Lynn Gold, RN MSN
Medication Safety Analyst 
Before coming to ISMP, Jennifer L. Gold practiced oncology nursing for 14 years at the Hospital of University of Pennsylvania, a 671 bed teaching hospital in Philadelphia. Her area of specialization has been adult oncology with a primary focus on the care of patients requiring bone marrow transplantation. Ms. Gold is also an experienced educator, having served for three years as a clinical instructor at La Salle University School of Nursing in Philadelphia. Ms. Gold received her BSN from West Chester University in West Chester, PA and her MSN from La Salle University in Philadelphia, PA. She is a member of the Oncology Nursing Society (ONS) and maintains her Oncology Nurse Certification through the Oncology Nursing Certification Corporation (ONCC). At ISMP Ms. Gold is responsible for development and operation of the ISMP website for consumers, Consumermedsafety.org. She also oversees review of all consumer-generated medication error reports and analyzes all MedWatch reports received from the US Food and Drug Administration via a standing Freedom of Information Act request, under a cooperative agreement between ISMP and FDA.
Matthew Grissinger, RPh, FISMP, FASCP
Director of Error Reporting Programs
Matthew Grissinger is the Director of Error Reporting Programs at ISMP as well as the Manager of Medication Safety Analysis for the Pennsylvania Patient Safety Authority (Pa-PSA). He is a frequent speaker on pharmacy topics and current issues in medication safety. He has published numerous articles in the pharmacy literature, including regular columns in P&T and the PSA Patient Safety Advisory and is a journal reviewer for Joint Commission Journal on Quality and Patient Safety, Pharmacoepidemiology and Drug Safety, and Annals of Internal Medicine. Mr. Grissinger serves on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), the National Quality Form (NQF) Common Formats Expert Panel, the Editorial Board for P&T, the Faculty Advisory Board for the Pharmacy Learning Network (PLN) and the Publications Advisory Board for Davis’s Drug Guide for Nurses. He also served on the United States Pharmacopeia’s (USP) Safe Medication Use Expert Committee from 2005-2010, the FDA Proprietary Name Review Concept Paper workshop panel in 2008 and the Naming, Labeling, and Packaging Practices to Minimize Medication Errors workshop panel in 2010. Mr. Grissinger received a BS in Pharmacy from the Philadelphia College of Pharmacy and Science and is a fellow of the Institute for Safe Medication Practices as well as the American Society of Consultant Pharmacists. Prior to joining ISMP, he served as a home care and long-term care pharmacy surveyor for the Joint Commission.
Donna Horn, RPh, DPh 
Director, Patient Safety - Community Pharmacy
Donna Horn directs ISMP’s patient safety activities in community/ambulatory practice. She has more than 25 years of experience in the retail/chain community pharmacy practice setting, most recently serving as the Privacy Officer and Manager of Regulatory Affairs for Brooks/ Eckerd Pharmacy where she wrote numerous policies and procedures to govern pharmacists working in chain pharmacy. Prior to joining ISMP, she served as President and Chairman of the National Association of Boards of Pharmacy where her focus was in patient safety, primarily on reducing medication errors in community pharmacy. Ms. Horn also served 11 years on the Massachusetts Board of Registration in Pharmacy as both a member and as President. During her tenure on the Massachusetts Board of Pharmacy Ms. Horn was instrumental in authoring regulations, policies and best practices to help pharmacists in Massachusetts interpret, explain and supplement the pharmacy laws. Her work has focused on Continuous Quality Improvement, policies on promoting ease of access to appropriate reference materials, monitoring prescription usage in chronic disease state patients, drug recall procedures, proper staffing guidelines and incorporating strategies to optimize therapeutic outcomes. Ms. Horn received a BS in Pharmacy from the Massachusetts College of Pharmacy and Allied Health Sciences.
Arounsavanh Khemdy
Pharmacy Technician Analyst and Research Assistant
Aroun Khemdy is the Pharmacy Technician Analyst and Research Assistant for ISMP. Ms. Khemdy works in the medication error reporting department and supports the ISMP Medication Errors Reporting Program (MERP), a confidential national voluntary medication error reporting program. She is also an analyst for the Pennsylvania Patient Safety Reporting System (PA-PSRS), a statewide adverse event and near miss reporting system. Prior to joining ISMP, Ms. Khemdy worked for PharMerica in Plymouth Meeting, PA, and has over eleven years of experience as a pharmacy technician and a coder in medical records in the long-term care and correctional pharmacy settings.
Rebecca L. Lamis, PharmD
Medication Safety Analyst
Becky came to ISMP from Wesley Medical Center, a 760-bed, acute-care, teaching hospital, located in Wichita, Kansas.  Becky completed a pharmacy practice residency at Wesley Medical Center where she gained clinical experience in adult medicine, both adult and pediatric critical care, research/grantsmanship, and medication safety.  Becky received a BA in Biology and Spanish from Simpson College in Indianola, Iowa, and her PharmD from the University of Iowa in May of 2008.  She completed an ISMP Safe Medication Management Fellowship in 2010.
Michelle Mandrack, RN, MSN
Director of Consulting Services
Michelle Mandrack is the Director of Consulting Services at the Institute for Safe Medication Practices. Prior to joining ISMP in 2001, Michelle spent over 20 years as a nurse in acute care settings in a variety of clinical and managerial roles. She was the Director of Maternal Child Health and subsequently, the Director of Nursing at Mercy Suburban Hospital in Norristown, PA. In her present position, Michelle manages ISMP’s consulting services as well as performs onsite medication risk-assessments and root-cause analyses for hospitals and healthcare facilities throughout the US. She has frequently participated in the analysis of medication safety issues specific to the pediatric and neonatal populations. Michelle also performs medication-related technology assessments including CPOE, pharmacy, and bar-code point-of-care systems. She has participated in several state-wide medication safety collaboratives, and co-created the Rural Hospital Medication Safety Connections Program. She regularly provides educational programming to healthcare professionals related to medication safety risk assessment and development of error reduction strategies. Michelle serves as part-time faculty at Temple University School of Pharmacy, and at Virginia Commonwealth University in their Executive Patient Safety Fellowship Program. She received her BSN from Thomas Jefferson University and her MSN from Drexel University and is a member of Sigma Theta Tau International Honor Society of Nursing.
Christina Michalek, BSc Pharm, RPh, FASHP
Medication Safety Specialist
Christina Michalek has more than 20 years of acute care hospital pharmacy experience involving clinical practice and management.  Most recently she served as Director of Pharmacy at Lehigh Valley Health Network in Allentown and Bethlehem, PA, where she advanced pharmaceutical care in a well-seasoned environment of computerized physician order entry, bar code medication verification, and robotic automation. During this period she served as a Consultant with the Institute for Safe Medication Practices. Prior to that time she was Pharmacy Operations Manager and then Director of Pharmacy at Doylestown Hospital, Doylestown, PA. Chris has served on the Board of Directors of the Pennsylvania Society of Health-System Pharmacists, as a presidential officer of the Bucks-Montgomery County chapter in PA, and volunteered on several advisory boards and educated a variety of community groups as a medication safety representative.  She has presented at national, local, and state meetings, as well as local radio on advancing hospital pharmacy practice and the use of technology for safe medication use. She is a graduate of the University of the Sciences’ Philadelphia College of Pharmacy, completed an ASHP accredited residency program at Suburban General Hospital in Norristown, PA, and is designated as a fellow of the American Society of Health-System Pharmacists.
Darryl S. Rich, PharmD, MBA, FASHP
Medication Safety Specialist
Prior to joining ISMP, Darryl Rich was a surveyor for The Joint Commission in the hospital, home care, and ambulatory accreditation programs. In addition, he worked for the Standards Interpretation Group serving as an internal resource for The Joint Commission related to pharmacy and medication management . Dr. Rich  served as Field Director for Surveyor Management and Development at The Joint Commission prior to becoming a surveyor.  Before starting at The Joint Commission in 1993, Dr. Rich was National Director of Pharmacy Services for Critical Care America, Inc., a national home infusion company. He previously served as Director of Pharmacy Services at Boston University Medical Center and Clinical Assistant Professor of Pharmacy at Northeastern University.  Dr. Rich is an active member and Fellow in the American Society of Health System Pharmacists and a past President of the New England Council of Health-System Pharmacists. He has received numerous awards, given over 640 invited presentations and has authored 76 publications in refereed journals, including eight books and four video series.  Dr. Rich received his Bachelor of Science from The University of California at Davis, his Doctor of Pharmacy degree from the University of California at San Francisco and a Master’s in Business Administration in Health Care Management from Bryant University in Rhode Island.
Ann D. Shastay, RN, MSN, AOCN
Managing Editor
Ann Shastay joined the staff of ISMP in July 2008, bringing with her 20 years of oncology nursing experience in both the acute care and outpatient office/clinic settings.  Prior to joining ISMP, Ann worked for 10 years at Holy Redeemer Hospital in Meadowbrook, PA where she was the Director of the Bott Cancer Center and also managed their inpatient oncology unit.  Prior to attaining that position, she worked as an inpatient Clinical Nurse Specialist educating nurses, developing competency programs, writing and reviewing policies and procedures, serving on various committees, presenting community outreach programs and developing numerous patient education materials.  Through the Oncology Nursing Society, Ann is trained to present the two-day ONS Chemotherapy and Biotherapy Course which educates nurses on safe chemotherapy administration practices.  Ann received both her BSN and Masters of Science in Nursing from Widener University, Chester, PA.  Ann also maintains her Advanced Oncology Certification (AOCN) through the Oncology Nursing Certification Corporation (ONCC).
Hedy G. Cohen RN, MS 
Clinical Consulting Nurse
Hedy Cohen has more than 18 years clinical nursing background in critical care and nursing management. She is a frequent speaker on current issues in medication safety and has authored numerous articles on improving the medication use process. She also has co-authored a handbook on high-alert drugs; and is on the national advisory boards for Nursing Advance and Davis's Drug Guide for Nurses. She is a part-time instructor at Jefferson University School of Pharmacy. Ms. Cohen received a BSN from LaSalle University, a MS in Health Systems Administration from the Rochester Institute for Technology, and has done doctoral work in health policy at the University of the Sciences in Philadelphia.

ISMP Safe Medication Management Fellow

Ivyruth Andreica, BSN, PharmD
2014-2015 ISMP Safe Medication Management Fellow
Supported by Express Scripts Foundation
Ivyruth joins ISMP from Massachusetts General Hospital a 1057 – bed, academic medical center  located in Boston, Massachusetts. Dr. Andreica practiced as an emergency department clinical pharmacist at the hospital’s Level- 1 Trauma emergency department as well as the emergency department’s short stay units. She graduated cum laudewith her Bachelors of Science in Nursing degree from Texas Woman’s University in 2006. While working as a critical nurse, she decided to pursue pharmacy to better understand medications and their impact on critically ill patients. She proceeded to attend and  graduate  with her Doctor of Pharmacy degree from Massachusetts College of Pharmacy and Health Sciences  in 2011.  Dr. Andreica has a unique healthcare background due to years as a critical care nurse in the medical intensive care unit, concurrent pharmacist experience at a small community hospital with an ambulatory oncology and infusion clinic, and ultimate transition to a large academic medical center.  Her interests include critical care, toxicology, health policy, medication safety and overall patient safety.
Ariane Conrad, PharmD, BCACP, CDE 
2014-2015 FDA/ISMP Safe Medication Management Fellow
Ariane comes to the program from New Orleans, LA, where she worked as a clinical assistant professor at Xavier University of Louisiana and as an ambulatory care pharmacist with the Interim Louisiana State University Public Hospital since 2008.  Her primary areas of clinical practice include diabetes, obesity, and hypertension.  Prior to her position at Xavier University, she worked as an internal medicine clinical pharmacist at Ochsner Medical Center in New Orleans. Ariane earned her Doctor of Pharmacy degree from Xavier University in 2003 and completed a pharmacy practice residency (PGY-1) with the Central Arkansas Veterans Healthcare System in Little Rock, Arkansas in 2004.  In 2012 and 2014 respectively, she earned the designations of Board Certified Ambulatory Care Pharmacist (BCACP) and Certified Diabetes Educator (CDE).  Her interests include diabetes and obesity management and overall patient safety.


Renee Brehio, MA
Public and Media Relations
Renee Brehio manages ISMP’s public relations, media and marketing activities, including the Institute’s online press room. Ms. Brehio has more than 12 years of experience in healthcare communications, including planning and implementing large-scale public education campaigns. She has worked for the U.S. Department of Health and Human Services, several healthcare nonprofit associations, and one of the world’s largest public relations agencies. Medical issues and conditions that she has helped promote better awareness of include AIDS/HIV, breast and cervical cancer, and medication errors. Ms. Brehio earned her BA and MA degrees in English and Communications from Georgetown University.
Rachel Cohen, MS, RD
Business Manager and Project Coordinator
Rachel Cohen oversees the financial and human resources operations at ISMP. She also plans, coordinates and manages various projects and educational programs such as teleconferences, educational symposia, and meetings, and works with the Institute’s Board of Trustees. Prior to joining ISMP, Ms. Cohen served as a Clinical Dietitian in the Albert Einstein Healthcare Network in Philadelphia, PA. Her specialty was solid organ transplantation. Ms. Cohen has also served as a consultant dietitian for several home care agencies. Ms. Cohen received a BS in Liberal Studies from West Chester University and completed a coordinated undergraduate program in dietetics at Immaculata College. She received a MS in Health Education from Saint Joseph University.
Thomas J. Moore
Senior Scientist, Drug Safety and Policy
Thomas J. Moore is senior scientist, drug safety and policy, at ISMP. He has spent more than a decade as a researcher, writer and lecturer on the risks and benefits of prescription drugs. He is the author of four books about medical care, including two examining the nation's system for minimizing the dangers of prescription drugs.Deadly Medicine (Simon & Schuster, 1995) was an investigation of the nation's worst drug disaster in which tens of thousands of heart patients died from the inappropriate use of drugs for irregular heartbeats. Prescription for Disaster (Simon & Schuster, 1998) sounded the alarm about the nation's failure to take adequate measures to minimize the risks of prescription drugs. He is also author of numerous articles about medication error and drug safety for peer reviewed scientific journals as well as the magazine articles for the general public. . Prior to focusing on drug policy issues, he was a prize-winning investigative reporter in Washington, and worked on the U.S. Senate staff.
Thursday, 03 February 2011 19:32

Meet our Advisory Board

Written by

Consumermedsafety.org relies on the advice of an advisory board. Functions performed by members, who have agreed to make a voluntary commitment to this work, include:

  1. Review and provide comments on consumermedsafety.org website.
  2. Monitor ongoing use of the website to critique and suggest improvements.
  3. Suggest website topics for follow up by consumermedsafety.org staff.
  4. Suggest new drug safety tools for the website to improve function for consumers.
  5. Provide feedback about consumermedsafety.org as learned from family, friends, and media coverage.
  6. Communicate with others to learn where consumermedsafety.org has been helpful personally and/or professionally.
  7. Be willing to be called upon for occasional media interviews about the website.
  8. Be available for ad-hoc discussions with consumermedsafety.org professional staff.

Our advisory board members share in our excitement about this website and its potential to reach millions of consumers with important medication safety information. We sincerely appreciate their willingness to serve.

Tabitha Carreon, PharmD
Community Pharmacist
El Paso, Texas
Ilene Corina
Patient Safety Consultant
Pulse of New York
Wantagh , New York
Alan Y. Medvin, JD
Medvin & Elberg, Newark, NJ
Barbara L. Olson, MS, RNC, FISMP
Nursing Consultant
Grayson, Georgia
Jennifer Reddan, PharmD, FASHP
Clinical Pharmacy Manager
Aurora St. Luke's Medical Center
Milwaukee, WI
Debora Simmons, RN MSN CCRN CCNS
Patient Safety Consultant
Pearland, Texas
Lorri Zipperer
Zipperer Project Management
Evanston, Illinois
Robert A. Zorowitz, MD, MBA, CMD
Medical Director
Village Nursing Home and Village Care PACE
New York, New York
Thursday, 03 February 2011 19:13

Meet Our Safety Partners

Written by

American Hospital Association
ISMP and the American Hospital Association (AHA) have a strategic partnership to help identify improvements in medication safety for all US hospitals.

Food and Drug Administration
ISMP is a Food and Drug Administration (FDA) MedWatch Partner. ISMP reviews all FDA MedWatch reports which contain information about medication errors. As a MedWatch partner, ISMP also promotes FDA’s initiatives to reduce adverse drug reactions.

Joint Commission
ISMP is a member of the Joint Commission of Healthcare Organizations (JC) sentinel event... And National patient safety goals...

National Coordinating Council for Medication Error Reporting and Prevention
ISMP's is a member of the National Coordinating Council on Medication Error Reporting and Prevention (NCC MERP). Membership on the council is held by major national professional and lay organizations as well as state and federal regulatory authorities and the USP.

U.S. Pharmacopeia
ISMP Medication Errors Reporting Program (MERP) was formerly operated by the United States Pharmacopeia in cooperation with the Institute for Safe Medication Practices (ISMP). The program is now fully opearated by ISMP, but safety issues continue to be shared with USP in order to improve medication safety through USP's expert committees and standards development.