Interview with Matt Grissinger RPh, FISMP, FASCP, Director of Error Reporting Programs at ISMP

Links to ISMP and other details mentioned in this episode

ISMP Organizational Website: Home | Institute For Safe Medication Practices (ismp.org)

ISMP Twitter: Institute for Safe Medication Practices (ISMP) (@ismp_org) / Twitter

ISMP Facebook: Institute for Safe Medication Practices | Facebook

ISMP LinkedIn: Institute for Safe Medication Practices (ISMP): Overview | LinkedIn

ISMP Instagram: ISMP (@ismp_org) • Instagram photos and videos

Medication Safety Officers Society Website: Medication Safety Officers Society- MSOS | (medsafetyofficer.org)

ISMP's Consumer Medication Safety Website: ConsumerMedSafety.org - Prevent Medication Errors - Consumer Med Safety

Matt Grissinger ISMP Bio

Mike Cohen ISMP Bio

Hospital Pharmacy

ASHP Midyear in December 

NCCMERP, National Coordinating Council for Medication Error Reporting and Prevention

Temple University

Thomas Jefferson University

Joint Commission

Medicare

ECRI

ASHP

FDA

Background information

Today’s episode is an interview with Matt Grissinger, Director of Error Reporting Programs at ISMP, the Institute for Safe Medication Practices. Matt earned his Bachelor of Science Degree 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. He first joined ISMP in 2000 as an ISMP Safe Medication Management Fellow. His responsibilities include working with healthcare practitioners and institutions to provide education about medication errors and their prevention, and reviewing medication errors that have been voluntarily submitted by practitioners to ISMP’s National Medication Errors Reporting Programs (MERP).  See Matt Grissinger’s full bio on the ISMP website.  He has held numerous leadership positions and has contributed to a number of publications.  In addition, he’s an adjunct assistant professor for Temple University School of Pharmacy.  

The Institute for Safe Medication Practices (ISMP) is the nation’s first 501c(3) nonprofit organization devoted entirely to preventing medication errors. ISMP is known and respected for its medication safety information. For more than 25 years, it also has served as a vital force for progress. ISMP’s advocacy work alone has resulted in numerous necessary changes in clinical practice, public policy, and drug labeling and packaging.

Among its many initiatives, ISMP runs the only national voluntary practitioner medication error reporting program, publishes newsletters with real-time error information read and trusted throughout the global healthcare community, and offers a wide range of unique educational programs, tools, and guidelines. In 2020, ISMP formally affiliated with ECRI to create one of the largest healthcare quality and safety entities in the world, and ECRI and the ISMP PSO is a federally certified patient safety organization by the U.S. Department of Health and Human Services.

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 life-saving work. Visit www.ismp.org and follow @ismp1 to learn more. 

Highlights from the interview

How does ISMP use its voice?

ISMP is the voice of the medication use process.  ISMP looks at and addresses problems with the medication use process. Unless pharmacists and other practitioners speak up and tell ISMP about medication use problems, ISMP doesn’t know about them.  Unsafe conditions, errors, etc. need to be reported, investigated, and shared around the world so others learn why things are going wrong and strategies to prevent harm to patients. 

ISMP publishes a variety of newsletters, gives presentations (Example: ASHP Midyear in December), provides webinars, and offers in-person consulting at hospitals/outpatient pharmacies to do a proactive risk assessment, which looks at the medication use process to see what needs improvement.  Over time and through publications in trade journals, education programs, etc. ISMP has grown their influence.

How did ISMP get started?

Mike Cohen founded ISMP and is the current President.  His passion for medication safety began in the 1970’s, when he shared information about a serious insulin-related adverse event in his workplace with Hospital Pharmacy.  The information was shared in story format.

How does ISMP define a medication error?  

Use the definition created by NCCMERP (National Coordinating Council for Medication Error Reporting and Prevention).  Medication errors differ depending on the setting they happen in and how they happen.   

Who should report medication errors to ISMP?  

ISMP accepts reports from consumers and any healthcare practitioner. ISMP is a qualitative reporting program, not a quantitative reporting program.  The story and the details are important to creating a clear picture of what happened in order to improve processes or develop strategies.  People don’t remember bar graphs, they remember stories.  Personal stories are powerful. Matt shared a memorable story about a fentanyl patch and the death of a child. What can we learn from the story? Counseling about proper storage and disposal could have saved the child’s life.

What are some important features about ISMP’s website?  

ISMP’s website is a wealth of information.  Pharmacists, pharmacy students, and other healthcare professionals should access the tools and resources on the website.  A good place to start is the self-assessments for pharmacies.  The assessments lead to great conversations that improve safety.  Discussing the lists (Confused Drug Names, Error-Prone Abbreviations, etc) can also create awareness about medication safety issues.  

How do pharmacy schools use information from ISMP to inform students?

ISMP provides its newsletter to schools of pharmacy at no cost.  Two schools of pharmacy that include classes on medication safety topics are Temple University and Thomas Jefferson University.  Matt Grissinger teaches at Temple.  Although he is not familiar with the curriculum at all schools of pharmacy, he would like to see pharmacy students learn more about medication safety and safe medication use processes. Students need to understand context in a variety of settings, including the ICU, operating room, med-surg floor, and more.

What is a notable achievement ISMP has made?  

Being cited/referenced by numerous sources (for example Joint Commission and Medicare) is an achievement. ISMP tries to change organizations, lives, and processes.  

Does ISMP have any important partnerships? 

Matt mentioned two: ECRI (also based in Pennsylvania) and ASHP.

Are there any myths about ISMP?  

Yes.  ISMP is not a regulatory body, and they do not receive government funding.  

What challenges does ISMP face?

Permanent change in healthcare Affecting change in volume Uniform safe practices across the board Sharing knowledge Standardizing processes Getting everyone on board

How can pharmacists, pharmacy students, and pharmacy technicians get the most out of ISMP? 

Read the newsletter subscriptions Use ISMP’s self-assessment tools and other tools on the website. Tell ISMP your stories and workplace concerns. They can lead to change.

Learn about medication errors and why they happen.  We need to get our pharmacy leaders to dig for details about what worries their staff about safe medication use practices.  

Thank you for listening to episode 107 of The Pharmacist’s Voice ® Podcast!  Please subscribe or follow on your favorite podcast player.