Thursday, 03 February 2011 19:34

Meet Our Staff


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, 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 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 website.
  2. Monitor ongoing use of the website to critique and suggest improvements.
  3. Suggest website topics for follow up by staff.
  4. Suggest new drug safety tools for the website to improve function for consumers.
  5. Provide feedback about as learned from family, friends, and media coverage.
  6. Communicate with others to learn where 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 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

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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