The Institute for Safe Medication Practices

The Institute for Safe Medication Practices (ISMP) is the nations’s only nonprofit organization devoted entirely to medication error prevention and safe medication use.

The organization’s mission is to advance patient safety worldwide by empowering the healthcare community, including consumers, to prevent medication errors.

• Collect and analyze reports of medication-related hazardous conditions, near-misses, errors, and other adverse drug events

• Disseminate timely medication safety information, risk-reduction tools, and error-prevention

• Educate the healthcare community and consumers about safe medication practices, through email newsletters, journal articles, and video training exercises

• Has confidential voluntary national programs for reporting medication and vaccine errors. Seeking to learn the causes and how to prevent these errors.

  • MERP: Medication Errors Reporting Program

  • VERP: Vaccine Errors Reporting Program

• Advocate for the adoption of safe medication standards by accrediting bodies, manufacturers, policy makers, regulatory agencies, and standards-setting organizations

• Conducting research to provide evidence-based safe medication practices

Tall Man Lettering (TML)

Tall Man Lettering is a technique created by the FDA, ISMP, and The Joint Commission to help avoid medication errors between look-alike and sound-alike (LASA) medication names. It involves writing certain letters of a drug’s name in uppercase letters and leaving the rest in lowercase letters, creating a visual cue that emphasizes the differences between similar drug names.

For example, the drug names “hydralazine” and “hydroxyzine” might be written as “hydrALAzine” and “hydrOXYzine’ respectively, using TML. This helps to differentiate between the two names, reducing the risk of medication errors that could occur if the two names were mistakenly confused.

Look-alike Sound-alike Drug Pairs (LASA)

• “Look-alike sound-alike” (LASA) or “Sound-alike look-alike drugs” (SALAD) drugs are medications that have names that look or sound similar to other drugs, which can lead to confusion and potentially dangerous medication errors

• They are often similar sounding or looking names, but often have very different properties

• Confusing one drug with another can lead to terrible and sometimes fatal consequences

It is important that the dispensing of these drugs include safeguards to reduce the risk of errors and minimize harm

This may include strategies such as:

• Using both the brand and generic names on prescriptions and labels

• Including the purpose of the medication on prescriptions

• Configuring computer selection screens to prevent look-alike name from appearing consecutively

• Separating LASA drugs on different shelves

• Repeat drug information back to the person who gives the order

Error Prone Abbreviations and Symbols

Abbreviations, symbols, and dose designations are commonly used in healthcare settings for efficiency and clarity of communication

However, some of these abbreviations and symbols can be error-prone and can lead to medication errors, which can have serious consequences for patients

The Joint Commission and ISMP have assembled a list of problematic abbreviations to avoid, and if any of them occur on the prescription, make sure that they are verified and replaced with the appropriate substitution so that no errors result