Download Community/Ambulatory Care Edition December 2008 Vol.7, Issue 12

ISMP
Educating the Healthcare Community
About Safe Medication Practices
Medication Safety Alert!
Community/Ambulatory Care Edition
Voice mail: What's that you said?
In our October 2006 issue, we described a mix-up between
CLINDESSE (clindamycin vaginal gel) used for bacterial
vaginosis and CLINDETS (clindamycin pledgets) used for
acne. A prescriber left a prescription on a pharmacy’s voice
mail (or interactive voice response system [IVR]) for
Clindesse, with instructions “use as directed.” Upon playback, the order sounded like Clindets and was processed and
dispensed as such. Later that day, the patient realized the
error, called the pharmacy, and the correct medication was
dispensed without delay in treatment. Another pharmacist
reported a similar event that occurred when a prescriber left a
voice mail prescription for the alpha1 agonist midodrine, used
to treat symptomatic orthostatic hypotension. The prescription
was misinterpreted and transcribed as the analgesic MIDRIN
(acetaminophen, isometheptene, dichloralphenazone). The
mix-up was discovered upon prospective drug utilization
review (DUR) when the pharmacist realized the patient had
been taking midodrine. The error was corrected before reaching the patient.
We also have received medication error reports describing
misinterpretation of the directions for use when retrieving
prescriptions from voice mail. For example, a nurse called in
a prescription for “Six mercaptopurine 50 mg daily for
30 days, a one month supply” for ulcerative colitis. The pharmacy technician who retrieved the prescription from the voice
mail system transcribed it as “mercaptopurine 50 mg, 6 QD,
# 150.” As a result, the instructions on the dispensed prescription directed the patient to take 6 tablets per day instead of 1 a
day as the prescriber intended. The patient took 6 tablets a
day for 5 days and developed extreme nausea and vomiting,
which resolved once the patient stopped the medicine. The
pharmacist who reported this error surveyed a few colleagues
about this event. Each one of them interpreted the voice mail
as the pharmacy technician did and would have directed the
patient to take 6 tablets per day.
SAFE PRACTICE RECOMMENDATIONS: As there are no
opportunities for direct interaction with the pharmacist or the
ability to read back the prescription, prescribers should avoid
leaving prescriptions on voice mail systems whenever possible. This is especially true for any high-alert medication such
cont’d on page 2
®
E-mail: [email protected]
Hotline: 1 800 FAIL SAF(E)
Volume 7, Issue 12
December 2008
Safety Briefs
ISMP to continue MERP. In a decision to focus
full attention and resources on its core standards
setting activities, the United States Pharmacopeia
(USP) is transferring the Medication Errors Reporting
Program (MERP) to the Institute for Safe Medication
Practices (ISMP). The program was previously
operated by USP in cooperation with ISMP. We are
pleased to accept total responsibility for the MERP.
As always, we remain fully committed to work
closely with FDA, USP, the medical product industry,
healthcare providers, and consumers to affect changes
in products and practices both nationally and internationally. We appreciate your continuing support and
look forward to working with you, our colleagues, in
the many years ahead. To report an error, near-error,
or hazardous condition, please access the ISMP
MERP on our website at: www.ismp.org.
Warfarin by generic name. In our September
2008 issue, we mentioned the potential for confusion
between the branded warfarin product JANTOVEN
and the branded diabetic medications JANUVIA
(sitaGLIPtin) and JANUMET (sitaGLIPtin and
metFORMIN). Just as dangerous, if not more so, is
that some health professionals and patients may not
recognize that Jantoven is a brand of warfarin, and
patients could easily end up taking two warfarin
products together. A case was reported to us in which
the patient took warfarin prescribed and dispensed
under both names, which resulted in an INR of 9.7!
On a discharge medication reconciliation form,
warfarin was identified as a medication the patient
had been receiving at home and continued while the
patient was hospitalized. The physician checked
“continue home warfarin” and wrote a new prescription based on the inpatient warfarin order. The
community pharmacy dispensed Jantoven, but didn’t
discuss the nature of the drug with the patient and
didn’t ask any questions that might have determined if
the patient already had warfarin at home. It’s unfortunate that manufacturers feel they must brand longestablished products such as warfarin, a designated
cont’d on page 2
ISMP Medication Safety Alert!®
as chemotherapeutic agents, even if used for non-oncologic
indications. If voice mail must be used:
December 2008
page 2
Voice mail (cont’d from page 1)
Prescribers, or those speaking on the prescriber’s behalf,
must speak clearly when communicating orders.
Clear and specific instructions should be provided on each
prescription. Avoid “use as directed.”
Include the medication’s indication as well as route of
administration with the order.
Spell out drug names that have been confused and sound
out digits for dosages (e.g., one – five instead of fifteen).
Have a second person listen to the order. This should be a
requirement if the recipient is inexperienced.
Pharmacies should record information on their outgoing
voice mail messages that prompt prescribers to provide:
1) prescriber’s full name, with spelling, and phone number;
2) patient’s full name with spelling; 3) patient’s date of
birth; 4) patient’s allergy history; 5) drug name (both brand
and generic if applicable) with spelling; 6) drug strength;
7) purpose of the drug; 8) specific directions for use;
9) specific quantity to dispense; and 10) number of authorized refills. These prompts should also be used when
accepting direct phone calls.
Never use a number prefix for mercaptopurine. The prefix
does not appear in either the proper name or on the product
label. Use of the prefix increases the risk of an overdose.
Prevent-ERR™: Disulfiram-like
reaction involving metronidazole
An 87-year-old female was admitted to the
hospital with a flare-up of diverticulitis. She was
previously treated with levofloxacin
(LEVAQUIN) and metronidazole (FLAGYL). Upon admission, she was again started on these two antibiotics:
levofloxacin 500 mg IV every 24 hours and metronidazole
500 mg PO every 8 hours. The patient complained of facial
flushing and reported that her “face felt like it was on fire”
after two doses of metronidazole. The reaction was listed as
an allergy and metronidazole was discontinued. Upon interviewing the patient, it was discovered that she kept an
alcohol-containing mouthwash in her room and admitted to
using “a lot of it…more than twice daily.”
Metronidazole, an antibiotic used to treat a variety of infections caused by anaerobic bacteria, is a fairly well-tolerated
antibiotic. However, when taken with alcohol, the combination can produce a disulfiram-like reaction. While the exact
cont’d on page 3
high-alert medication, since it only adds to the potential
for dangerous confusion. When branded generics are
dispensed to patients, it is important that the generic
name be listed on the prescription container label,
along with the brand name, as necessary, whether
Jantoven or Coumadin. Presently, many community
pharmacies simply list the brand name for branded
products, but that might not help the patient identify
duplicate medications, especially if the pharmacy does
not have the complete patient profile. This error may
also have been avoided with counseling, at acute care
discharge and outpatient pharmacy dispensing. This
should be an integral component of both discharge
reconciliation and outpatient pharmacy dispensing, no
matter which health professional provides the service.
Safety Briefs (cont’d from page 1)
Benazepril confused with Benadryl. A pharmacist
reported a mix-up between benazepril (LOTENSIN)
and BENADRYL (diphenhydramine). A patient faxed
a request to the pharmacy to ask for her “benazapryl.”
The pharmacist who received the fax interpreted it as
Benadryl and placed a bottle of diphenhydramine in the
bag for pick-up. Around this same time, the pharmacy
went through a change in wholesaler and many
manufacturers of generic products were changed. A few
days later, a co-worker of the patient picked up the
medication (along with several others). The technician
at the point-of-sale told the co-worker that many of the
manufacturers had changed recently and that some of
the pills may look different. The patient received the
diphenhydramine, filled her medication box with the
capsules, and took diphenhydramine daily for 3 weeks
before noticing she was unusually tired. When she
brought the bottle back to the pharmacy, the error was
recognized.
Digitek Class I recall. During ISMP’s review of
reports in the FDA’s Adverse Event Reporting
Program, we noticed a signal linking reported deaths
and serious injuries to recalled DIGITEK (digoxin)
tablets. Thus, we are reminding all healthcare practitioners about this consumer-level Class I recall. In
April, all lots of Digitek were recalled because tablets
could have a thickness approximately double that
required and hence contain more active ingredient. A
digoxin overdose can cause serious injury or death.
Two strengths were involved: 0.125 mg (round yellow
cont’d on page 3
ISMP Medication Safety Alert!®
mechanism is unknown, the symptoms of a disulfiram-like
reaction are similar to those produced when ethanol and
disulfiram (ANTABUSE), a drug used to treat chronic
alcoholism, are taken together. When ethanol is ingested, it is
converted to acetaldehyde. Normally, the acetaldehyde is
immediately metabolized through an enzyme called aldehyde
dehydrogenase into acetic acid, a harmless compound.
Disulfiram inhibits the aldehyde dehydrogenase enzyme,
leading to a build up of acetaldehyde–the compound responsible for the symptoms of a typical “hangover” (e.g., nausea,
vomiting, headache, tachycardia, and facial flushing).
December 2008
page 3
Prevent-ERR (cont’d from page 2)
Whenever prescribing or dispensing metronidazole, healthcare professionals should employ the following strategies to
reduce the risk of disulfiram-like reactions:
Counsel patients to avoid any beverages or other products
that contain alcohol. Alcoholic beverages should not be
consumed during metronidazole therapy and for at least
one day afterward.1
Ensure this warning is verbally relayed to the patient and
appears in any drug information provided to the patient.
Identify prescription and over-the-counter (OTC) medications that contain alcohol. For example, KALETRA
(lopinavir/ritonavir) oral solution used for HIV, contains
42.4% alcohol (v/v).2 Also, medications that are available
in ‘elixir’ form as well as many OTC products (e.g., cough
and cold products, mouthwashes) contain alcohol.
Program reminders into pharmacy computer systems and
electronic prescribing software to alert pharmacists and
prescribers to the disulfiram-like reaction when an alcoholcontaining product and metronidazole are ordered for the
same patient.
Differentiate between a disulfiram-like reaction (an adverse
effect) and a true drug allergy when obtaining allergy
histories from patients. The disulfiram-like reaction is mild
compared to a true drug allergy which can be life threatening. The preventable disulfiram-like reaction with
metronidazole is not a reason to rule out its future use.
References: 1) Flagyl [package insert] New York, NY: Pfizer Inc; Aug 2006.
Available on Internet at: http://www.pfizer.com/files/products/uspi_flagyl.pdf.
Viewed 22 Dec 2008. 2) Kaletra [package insert] North Chicago, IL: Abbott
Laboratories; Oct 2008. Available on Internet at: http://www.rxabbott.com/pdf/
kaletratabpi.pdf. Viewed 22 Dec 2008.
Editor’s note: Prevent-ERR™ is offered by Temple University
School of Pharmacy and ISMP to bring information to healthcare providers who are in a position to reduce patient harm
from adverse drug reactions and errors.
tablets imprinted with a “B” and “145”) and 0.25 mg
(round white tablets imprinted with a “B” and “146”).
The tablets were manufactured by the Actavis Group
and distributed by Mylan Pharmaceuticals under the
Bertek and UDL Laboratories names. To return the
recalled product, call 888-277-6166. ISMP will report
additional findings related to this signal on Digitek in
our next QuarterWatch report in January 2009.
Safety Briefs (cont’d from page 2)
HealthAlerts
FDA has become aware of reports of acute phosphate
nephropathy, a type of acute kidney injury, associated
with the use of oral sodium phosphate products (OSP) for
bowel cleansing prior to colonoscopy or other procedures.
These products include the prescription products, VISICOL and
OsmoPrep, and OSPs available over-the-counter (OTC) without
a prescription as laxatives (e.g., FLEET PHOSPHO-SODA). In
some cases when used for bowel cleansing, these serious
adverse events have occurred in patients without identifiable
factors that would put them at risk for developing acute kidney
injury.
FDA is requiring the manufacturer of Visicol and OsmoPrep to
add a Boxed Warning to the labeling for these products. FDA is
also requiring that the manufacturer develop and implement a
risk evaluation and mitigation strategy (REMS), which will
include a Medication Guide, and to conduct a post-marketing
clinical trial to further assess the risk of acute kidney injury
with use of these products. FDA recommends, in light of the
risk of acute phosphate nephropathy, over-the-counter laxative
OSP products should not be used for bowel cleansing.
Consumers should only use OSPs for bowel cleansing pursuant
to a prescription from a healthcare professional. Please refer to
the FDA’s Drug Information Page (www.fda.gov/cder/drug/
infopage/OSP_solution/default.htm) for more information.
Note: C.B. Fleet Company has announced a voluntary recall of
all their OTC Fleet Phospho-Soda products to address the
FDA's decision. For more information about the recall, visit the
manufacturer’s website at: www.phosphosoda.com.
Subscription Information
Individual subscription rates are $52 per year for 12 monthly
issues. Discounts are available for organizations with multiple
sites or multiple users. For more information, contact ISMP at
215-947-7797 or e-mail to [email protected].
ISMP Medication Safety Alert!®
December 2008
page 4
ConsumerMedSafety.org
An ISMP website that alerts consumers to drug safety issues
“Preventing medication errors is no longer just a responsibility for health professionals—consumers like you can also
play a vital role.” That’s what the homepage banner says on
our new consumer website, ConsumerMedSafety.org
(www.consumermedsafety.org). ConsumerMedSafety.org
is the first and only website on the Internet exclusively
designed to bring the message of adverse drug event prevention directly to consumers. There are relatively few websites
that offer consumers quality information about medication
safety; and to the best of our knowledge, there are no other
websites dedicated entirely to consumers and hosted by a
charitable organization with a
singular mission to understand the
causes of medication errors and
provide time-critical error-reduction strategies to the healthcare
community and consumers.
This unique, interactive website
provides reliable, expert advice
that will clearly impact medication
safety. The site offers consumers
various methods of learning about
drug safety, including but not
limited to the following:
Blinded, memorable stories about actual errors that have
happened and how to prevent them
Peer-reviewed advice from safety experts, including you,
our healthcare professional readers
A consumer error-reporting program that communicates
issues to ISMP, FDA, and medical product manufacturers
to foster large-scale changes in healthcare
Safety tools and resources, such as how to administer
medications by various routes and which medications
cannot be crushed
Emailed safety alerts from ISMP, FDA, and our safety
partner, iGuard.org, personalized according to the list of
medications the consumer provides to us via a secure
database
Emailed notification of applicable drug recalls or drug
class recalls that may affect consumers, based on the list
of medications they provided.
ConsumerMedSafety.org was created to improve health
outcomes related to medication use, medication adherence,
health literacy, and patient/provider collaboration and
communication. The idea is to empower consumers to
question healthcare professionals who are prescribing,
dispensing, and administering medications to ensure potential problems are addressed to their satisfaction. The website
is funded through generous
sponsorships from private and
corporate donors. Monies will
be used to continue content
development and management
of the website, staff the
consumer error reporting
program, and further ISMP’s
mission.
We hope that you will consider
linking your pharmacy, clinic,
or office website to
ConsumerMedSafety.org, and
that you and your family will
take advantage of our unique medication alert system.
Please also keep us in mind for any safety issues you would
like communicated to a wide audience of consumers, including patients, family members, and caregivers. We welcome
your comments regarding the website ([email protected])
and will endeavor to continuously improve it to ensure it
meets the needs of consumers and makes an impact on
medication safety.
The Institute for Safe Medication Practices is an independent nonprofit agency. ISMP accepts no advertising. The contents of this
newsletter are copyrighted. ©2008 Institute for Safe Medication
Practices. Law strictly prohibits redistribution, reproduction, or republication by recipients through any means, including print, e-mail, or fax,
without written permission by ISMP.
ISMP Medication Safety Alert! Community/Ambulatory Care Edition (ISSN 1550-6290) ©2008 Institute for Safe Medication Practices (ISMP). ISMP® is an FDA
MEDWATCH partner. Call 1-800-FAIL-SAF(E) to report medication errors to the ISMP Medication Errors Reporting Program (MERP) or report on-line at www.ismp.org.
Unless noted, published errors were received through the MERP. ISMP guarantees confidentiality and security of information received and respects reporters’ wishes as
to the level of detail included in publications. Editors: Michael J. Gaunt, PharmD; Michael R. Cohen, RPh, MS, ScD; Judy Smetzer, RN, BSN. Reviewers: ISMP staff and
Tabitha Carreon, PharmD, RPh; Eddie Dunn, PharmD; Richard A. Feifer, MD; Viktoriya Feldman, PharmD; Charlotte Huber, RN, MSN; Stan Illich, RPh, MHA; Patrick
McDonnell, PharmD; Mark Nolan, RPh; Andrew Seger, PharmD; Kelly J. Stanforth, PharmD, FISMP; Kimberly Tallian, PharmD, FCSHP, FASHP; Chuck Young, RPh, CFE.
Institute for Safe Medication Practices, 200 Lakeside Drive, Suite 200, Horsham, PA 19044. Tel. 215-947-7797; Fax 215-914-1492; E-MAIL: [email protected]. This
is a peer-reviewed publication.
Copyright © 2008 ISMP. Duplication is permitted only for internal distribution at your practice site. Duplication by any means for distribution outside your site is strictly prohibited.
11th Annual ISMP Cheers Awards:
Celebrating innovation and exemplary role models
or 11 years, ISMP trustees have honored
individuals and organizations whose
innovation and tireless dedication have
helped achieve significant advances in
preventing medication errors and saving
patients’ lives. This year’s awardees were
recognized at a dinner held December 9,
2008 in Orlando, FL. Please join us in
congratulating the following award recipients as
shining examples of what can be accomplished in the
field of medication safety.
CHEERS rang out for a government agency and
nonprofit foundation that stepped forward to meet
crucial and emerging medication safety needs:
FDA Patient Safety News, FDA’s monthly video series
for healthcare personnel, was honored for producing
more than a hundred segments that feature invaluable
error-prevention information on drugs, biologics, and
medical devices. The videos illustrate how medical
errors occur and demonstrate how to mitigate those
errors. The broadcasts also provide footage on topics
such as FDA safety notifications, medical product
recalls, ISMP safety alerts, and strategies to protect
patients. The videos are free to use and distribute, and
are available through several healthcare education
networks as well as links from the FDA website
(www.fda.gov/psn) and ISMP website
(www.ismp.org).
The Sebastian Ferrero Foundation, established by
the parents of a 3-year-old boy who died from a series
of medical mistakes, including a medication overdose,
was recognized for tirelessly advocating excellence in
patient safety while treating families involved in errors
with compassion and dignity. The Foundation
(www.sebastianferrero.org), which is based in
Gainesville, FL, is raising funds to build a full-service,
state-of-the-art children’s hospital in Gainesville to
improve pediatric care, and is working with Shands
HealthCare and the University of Florida College of
Medicine to develop comprehensive patient safety
programs for local and national use.
CHEERS resounded for a group of hospitals and
health systems that banded together to provide a
new medication safety online resource:
www.HealthInfoTranslations.org was created in 2005
when three leading Ohio healthcare providers—Mount
Carmel Health System, OhioHealth, The Ohio State
University Medical Center—came together to address
health education needs for low literacy and limited
English-speaking patients. Another hospital, Nationwide
Children’s Hospital, joined the project in 2007. The
website offers free patient education materials,
including medication safety-related information, that is easy to read and prints in
English and 18 different foreign languages.
The site has been receiving on average
more than 8,000 visits a day. Additional
languages and topics continue to be
added, and the information is freely
available without copyright.
CHEERS were given to an extraordinary
individual for her outstanding contributions to
improving patient safety:
Debora Simmons, RN, MSN, CCRN, CCNS, received the
ISMP Volunteer Award for her dedication to facilitating
education and information sharing on medication error
prevention issues. She has worked closely with ISMP to
provide recommendations for the prevention of IV tubing
misconnections and advocate medication safety to
nurses, including the state board of nursing in Texas.
She also has served as an advisor to ISMP’s medication
safety newsletters, hosted ISMP’s medication safety
fellows, and helped provide nursing continuing education
credits for the Institute’s learning programs. She is a
Research Scientist at the Texas A&M Health Science
Center Rural and Community Health Institute and
Associate Director of The Patient Safety Education
Project in Houston, TX.
Very special CHEERS were given to two recipients
of the ISMP Medication Safety Alert! Subscriber
Award this year:
Community Health Network (CHN) in Indianapolis, IN,
was honored for its long-term implementation of safety
initiatives based on the Quarterly Action Agendas
published in the ISMP Medication Safety Alert!
newsletter. Over the past 7 years, CHN has developed
and refined a process for incorporating the agendas into
clinical operations and the organization’s overall
medication safety program. Examples include using
pharmacists to complete initial patient medication
histories, implementing an independent double-check of
heparin flush doses in the NICU, and developing a
system for tracking look-alike medications and
addressing their potential for harm.
UMass Memorial Medical Center in Worcester, MA,
received the award for their comprehensive internal use
of information from ISMP’s newsletters. The ISMP
Medication Safety Alert! Acute Care edition,
Community/Ambulatory Care edition, and Nurse AdviseERR newsletters are disseminated to all applicable
departments, and newsletter highlights are presented at
four staff meetings a month. The medication safety
officer reviews the newsletters on a bi-weekly basis to
identify potential areas for improvement, and sends this
information along via a weekly “lessons learned” email
and a monthly written safety report. Examples of
changes enacted include altering the dispensing
procedure for oral liquids to eliminate inadvertent IV
administration and developing chemotherapy infusion
guidelines to address fluorouracil administration errors.
The ISMP CHEERS Awards were highlighted by the
presentation of the 2008 ISMP Lifetime
Achievement Award:
Diane Cousins, RPh, former Vice President of
Healthcare Quality and Information, United States
Pharmacopeia (USP), has a long history of developing
or administering medication reporting programs,
including USP’s MEDMARX program and the former
USP-ISMP Medication Errors Reporting Program (now
an ISMP reporting program). She developed the USP
Practitioners’ Reporting Network into four nationwide
reporting programs that focus on the quality, efficacy,
and safety of over-the-counter and prescription drugs.
She also organized the first USP Advisory Panel on
Medication Errors and is a founder of the National
Coordinating Council for Medication Error Reporting and
Prevention. Cousins has received a Pinnacle Award from
the American Pharmacists Association Foundation for
her contributions to the medication use process and is a
member of The Joint Commission’s Sentinel Event
Advisory Group, a member of the editorial advisory
board for The Joint Commission’s Perspectives on
Patient Safety, and co-chair of the Pharmacy Quality
Alliance Patient Safety Cluster.
We sincerely thank the organizations and individuals
who attended and/or sponsored our 11th Annual ISMP
CHEERS Awards dinner. Visit www.ismp.org/Cheers
for a list of contributors and winners.
Thanks also are extended to our keynote speaker,
Dr. Peter Angood, Vice President & Chief Patient Safety
Officer for The Joint Commission, who gave the audience
anecdotes about his personal experiences with
medication errors and adverse drug events, and
presented his ideas on how to accelerate the long
process of changing healthcare to ensure patient safety.
His call for greater innovation and more role models for
patient safety reinforced the need to
recognize current
leaders and share
their successes so
similar efforts can be
undertaken across the
globe. We look forward
to another great year of
working together to
improve medication safety
in 2009.
ISMP Medication Safety Alert!
December 2008
page 6
Special Recognition…
Our 2008 ISMP Medication Safety Alert! Community/Ambulatory Care Clinical Advisory Board
Production of this peer reviewed newsletter would not be possible without the assistance of a reliable, talented, and well-informed clinical
advisory board. As 2008 nears an end, we want to thank each of the following members of the advisory board for their dedication to making
this newsletter a valuable medication safety resource.
Tabitha A. Carreon, PharmD, RPh, Albertson’s, LLC and University of Texas at El Paso, El Paso, TX
James T. DeVita, RPh, CVS/Caremark, Woonsocket, RI
Eddie Dunn, PharmD, University of Arkansas School of Pharmacy, Little Rock, AR
Richard A. Feifer, MD, MPH, FACP, Medco Health Solutions, Franklin Lakes, NJ
Viktoriya Feldman, PharmD, Rite Aid Corporation, Warminster, PA
Alan S. Fox, RPh, Health One, Eastlake, OH
Meghan Freyer, PharmD, CVS/Caremark, Greensboro, NC
Ronald Goldman, RPh, Tel-Drug, Horsham, PA
Charlotte Huber, RN, MSN, ECRI Institute, Plymouth Meeting, PA
Stan Illich, RPh, MHA, Evans Army Community Hospital, Fort Carson, CO
Amanda G. Kennedy, PharmD, BCPS, University of Vermont, Burlington, VT
Albert Kinsky, PharmD, Giant Food Stores, LLC, Camp Hill, PA
Mykola Malinowsky, RPh, MS, University of Minnesota Hospitals and Clinics, Fairview, Minneapolis, MN
Patrick McDonnell, PharmD, Temple University School of Pharmacy, Philadelphia, PA
Crystal Lennartz, PharmD, MBA, National Association of Chain Drug Stores, Alexandria, VA
Mark Nolan, RPh, SHAPE Healthcare Facility, SHAPE, Belgium
Andrew Seger, PharmD, Brigham & Women’s Hospital, Boston, MA
Edward J. Staffa, RPh, Mirixa, Reston, VA
Kelly Stanforth, PharmD, FISMP, OhioHealth Clinical Resource Management, Columbus, OH
Hermine Stein, DO, RPh, Brookside Family Practice & Pediatrics, Pottstown, PA
Kim Swiger, RPh, Ingles Markets Inc., Suwanee, GA
Kimberly Tallian, PharmD, BCPP, FCSHP, FASHP, University of California, San Diego Medical Center, San Diego, CA
Larry Wolfe, RPh, Walgreen Co., Litchfield Park, AZ
Chuck Young, RPh, CFE, University of Massachusetts Medical School, Boston, MA
Happy Holidays...
The staff and trustees at the Institute for Safe Medication Practices wish you joy, health, and happiness this holiday season!
ISMP Trustees
David Bates, MD, MSc
George DiDomizio, JD
McGoldrick
Michele Campbell, MSN, RNC-OB, NEA-BC
Janice Dunsavage, RPh, MS
Joel Shuster, PharmD, BCPP
Michael Cohen, RPh, MS, ScD
Russell Jenkins, MD
Mark Cziraky, PharmD, FAHA
Louis Martinelli, PharmD, PhD (Chair of the board)
J. Russell Teagarden, RPh, MA
David U, BScPhm, MScPhm
Margaret
Zane Wolf, RN, PhD, FAAN
G. Rodney Wolford
ISMP Staff
Michelle Bell, RN, BSN
Renee Brehio, MA
Cunningham, BSEE, MCSE, CAN
RPh, MS
Quarry, CPA
Nancy Globus, PharmD
Russell Jenkins, MD
Michelle Mandrack, RN, BSN
MSN
Stephanie DeGraw, PharmD
Michael Gaunt, PharmD
Donna Horn, RPh, DPh
Lena Khavinson
Kristine Needleman, RPh
Ann Shastay, RN, MSN, AOCN
Stephanie Unger, JD
Hedy Cohen, RN, BSN, MS
Lisa Shiroff
Allen Vaida, PharmD, FASHP
Michael Cohen, RPh, MS, ScD
Lauren Denney, RN, MSN, CNA, BC
Michael Gorham
Nicole Graser
Arounsavanh Khemdy
Susan Paparella, RN, MSN
Rachel Cohen, MS, RD
Sharon Dicker
Matthew Fricker,
Matthew Grissinger, RPh, FASCP, FISMP
Marci Lee, PharmD, FISMP
Brandon Pressley
Judy Smetzer, RN, BSN, FISMP
William
Mimi Spiegel
Stuart Levine, PharmD
Susan Proulx, PharmD
Kelly Stever
Heather
Nancy Tuohy, RN,