Thursday, 03 February 2011 19:34

Meet Our Staff

Executive Staff

Michael R. Cohen RPh, MS, ScD (hon.), DPS (hon.), FASHP

President, Institute for Safe Medication Practices


Ronald S. Litman D.O.

Medical Director


Susan Paparella RN, MSN

Vice President


Judy Smetzer RN, BSN

Vice President


Allen J. Vaida PharmD, FASHP

Executive Vice President



Renee Brehio

Public and Media Relations


Rachel Cohen MS, RD

Business Manager


Michael J. Gaunt PharmD

​Medication Safety Analyst and Editor


Jennifer L. Gold BSN, MSN

Medication Safety Analyst


Matthew Grissinger RPh, FISMP, FASCP

​Director of Error Reporting Programs

Arounsavanh Khemdy

​Pharmacy Technician Analyst and Research Assistant


​Rebecca L. Lamis PharmD, FISMP

Medication Safety Analyst


Michelle Mandrack RN, MSN

Director of Consulting Services


Christina Michalek BSc Pharm, RPh, FASHP

​Medication Safety Specialist


Thomas J. Moore

​Senior Scientist, Drug Safety and Policy


Ann D. Shastay RN, MSN, AOCN

Managing Editor


ISMP Safe Medication Management Fellows

Vivek Brahmbhatt PharmD

​2017-2018 FDA/ISMP Safe Medication Management Fellow


Kayla Cierniak PharmD, MS

2017-2018 FDA/ISMP Safe Medication Management Fellow


Viktoriya Ingram PharmD

2017-2018 ISMP Safe Medication Management Fellow Sponsored by Baxter International Inc.


Barbrakaryne N. Nchinda Fobi PharmD, MPH

2017-2019 ​ISMP International Medication Safety Management Fellow Sponsored by Baxter International Inc.


David Valentine PharmD

​2017-2018 ISMP Safe Medication Management Fellow

Institute for Safe Medication Practices
200 Lakeside Drive, Suite 200
Horsham, PA 19044

(215) 947-7797

Thursday, 03 February 2011 19:32

Meet our Advisory Board

ISMP gratefully acknowledges the dedication of its Board of Trustees (BOT).  The Trustees are a group of highly respected professionals who provide strategic direction to ISMP.

Board of Trustees

Michael R. Cohen RPh, MS, ScD (hon.), DPS (hon.), FASHP

President, Institute for Safe Medication Practices

Gregory J. Baldwin

Healthcare Investor and Consultant

David W. Bates MD, MSc

Chief Division of General Internal Medicine Brigham & Women's Hospital

Mark Cziraky PharmD

Vice President of Research at HealthCore, Inc., an Anthem Company

Janice Dunsavage RPh, MAS

Corporate Director, Pharmacy, UPMC Pinnacle

Rebecca S. Finley PharmD, MA, FASHP

Dean, Thomas Jefferson University, Jefferson School of Pharmacy

Ronda G. Hughes PhD, MHS, RN, CLNC, FAAN

Associate Professor/Director, Center for Nursing Leadership; College of Nursing, University of South Carolina

Russell H. Jenkins MD

Medical Director Emeritus, Institute for Safe Medication Practices

Ronald S. Litman D.O.

Medical Director, ISMP; Pediatric Anesthesiologist, The Children’s Hospital of Philadelphia

Margaret M. McGoldrick MBA

President, Abington Jefferson Health

Marty Minniti RN

Senior Vice President Product Development Chief, Care Partners Plus-Wellby

Donald J.M. Phillips BS, PharmD, FCPP

Business Adviser

David U RPh, BScPhm, MScPhm

President and Chief Executive Officer, ISMP Canada

L. Albert Villarin Jr. MD, FACEP

Chief Medical Information Officer, Staten Island University Hospital

Zane Wolf PhD, RN, CNE, FAAN

Dean Emerita and Professor, School of Nursing and Health Sciences, Department of Nursing, LaSalle University

Thursday, 03 February 2011 19:13

Meet Our Safety Partners

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.

Thursday, 03 February 2011 17:48


A unique website for consumers is provided to you by the Institute for Safe Medication Practices (ISMP). This unique website is designed to help you, the consumer, avoid mistakes when taking medicines. Preventing medication errors is a huge responsibility that doctors, pharmacists, and nurses take seriously. But you, too, can play a vital role in preventing dangerous errors, and is exactly what you need to protect yourself and your loved ones! 

The majority of the material provided on our website, is original, written by the ISMP staff. Content is developed from

  • Reports submitted to the Medication Error Reporting Program (MERP) by practitioners and consumers with research by our editorial staff to confirm and validate.
  • Shared work from our newsletter publications, including the ISMP Medication Safety Alert! For acute care hospitals, a consumer newsletter, a community pharmacy/medicine newsletter and a nursing newsletter. Together the readership exceeds 2 million. More information about our publication can be seen at: 
  • Independent articles developed, produced and edited entirely for consumermedsafety by ISMP staff.
  • Some information, as noted on the website, is shared with us by the US Food and Drug Administration.
  • Occasionally, consumermedsafety will make mention of an article from which the topic is derived. In all cases we include the source material. does not host any forms of advertisements. This website is funded by our organization, the Institute for Safe Medication Practices. Occasionally, we will accept funding in the form of sponsorship. There is no conflict of interest between our organization and a sponsor. At all times the content is solely the responsibility of the authors and does not represent the official views of the sponsor. When funding is received from a sponsor the opening page will identify the funding source. The content receiving funding on are as follows: and

The information on this website should only support and not replace the advice of your healthcare professional.


It was double trouble for a patient when she and her doctor both made errors and it led to a 4-fold overdose of an antidepressant medication, CELEXA (citalopram Hydrobromide). The patient was starting this medication for the first time and after three days she began to experience severe anxiety, agitation, nausea, and severe fatigue. She called her doctor about her symptoms. The error was identified when they reviewed the medication together and realized what was causing the problem – a medication error.

Wednesday, 26 January 2011 21:06

Know where to look for OTC label ingredients

There is evidence that some patients (and perhaps even health professionals) may not recognize that FDA-required facts about over-the-counter (OTC) medications, including dosing information, are often on a peel-back label that is stuck to the bottle.

Consumers must use caution when purchasing prescription drugs over the telephone or the Internet.  In addition to the increased risk of purchasing unsafe and ineffective drugs from the thousands of Web sites operating outside the law, there is the danger that personal data can be compromised

Wednesday, 26 January 2011 21:01

Keep camphor away from children

The New York City Department of Health and Mental Hygiene issued an alert a few years ago about the use of camphor products around children. The alert mentioned children who were hospitalized with seizures after ingestion and contact with over-the-counter (OTC) camphor products.

Wednesday, 05 January 2011 17:05

Other Ways to Report Errors

If you can't report your incident using our internet reporting form, you may report an incident by telephone by calling ISMP at 267-725-0055.

Wednesday, 05 January 2011 17:04

How We Maintain Your Privacy

Welcome to, a website for consumers provided by the Institute for Safe Medication Practices (ISMP).

ISMP is committed to protecting your privacy while using our website. In general, you can visit and use most of its functionality and tools without revealing any personal, identifiable information. However, you may choose to provide personal, identifiable information if you report medication errors and to gain access to some of our services. Any personal information you choose to provide, including your name, email address, and medications you take, will not be disclosed to anyone other than the staff at ISMP unless:

  • You provide prior consent
  • ISMP enters into an agreement with an analytics company to measure how visitors use our website (ISMP retains ownership of the data and controls how the data are used)
  • ISMP and a third party are involved with the sale, assignment, or other transfer of the business of this website, in which case we will require any such buyer to agree to treat such information in accordance with this Privacy Policy
  • ISMP is required to disclose such information by applicable laws, court orders, or government regulations.

ISMP may disclose the errors reported on its website 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. However, all personally identifiable information, including your name and email address, will be redacted or removed, unless permission is granted by you to disclose such information.

For additional information, please read our Privacy Policy, which provides additional information about our practices regarding collection, use, and disclosure of information that you may provide to us via this website.


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