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If You See Something, Say Something: Patient Safety Edition

“If you see something, say something,” a slogan embraced after 9/11, has encouraged people to be vigilant and identify potential threats to preserve safety. Michael Cohen, founder of the Institute for Safe Medication Practices (IMSP), has taken this mantra to heart and made it the basis of this organization’s work.

In an interview published in Patient Safety, Cohen shared that ISMP’s goal is to “collect healthcare workers’ stories and reports about medications errors to improve patient safety.” By providing an outlet for healthcare professionals to share their experiences or concerns, ISMP embraces the notion of being vigilant for the greater good. Cohen shared a recent example of how his organization is working to enhance patient safety. As pharmacists have reported that “many other vaccines that have an age-related component to the dosing” get “mixed up,” Cohen has been communicating with the FDA’s Division of Medication Error Prevention and Analysis regarding the pediatric covid vaccine.

In addition to focusing on vaccines, IMSD has also done extensive work with “high-alert” drugs, defined as drugs for which errors are likely to cause injury and even fatality. IMSP has a listing of these substances on its website.

How IMSP Improves Patient Safety

  1. Collecting stories “from the field” is the first – and most important – step. Cohen reflected that “the nurses, the doctors, the pharmacists” are “very, very willing to make information available,” citing their “altruism.” These individual reports all stem from the desire to address a problem before it happens to someone else.
  1. With information in hand, the next step is to “get information out there to the wide audience, both nationally and internationally.” Based on the information they collect, IMSP reports out to “the public, to the FDA, to USP, to the industry, to individual companies.” ISMP maintains a database that enables them to “get a really good feel for how often something is happening.” IMSP has also created videos and is hoping to generate some podcasts so that even more people can access information about medication concerns as well as ways to prevent errors.
  1. As a result of their efforts, ISMP has had a significant impact on both practice-related and product-related issues surrounding patient safety. Cohen acknowledged that “we’ve been able to effect product changes on the level of thousands of product labeling changes over the years.”

A Flaw in the System

Step one in this system is collecting data from the field. The data collected in this system is valid. It is also reliable. It is just not complete. Relying on nurses and doctors to provide information means that we are not getting the whole picture.

In our experience, not all doctors and nurses are forthcoming about these errors. We have been advocating for patient safety for years and have found that until you pinch the wallets of healthcare providers, you will not have system-wide changes that can help decrease medication errors and improve patient safety.

Still Work to Do

While it is comforting to know that organizations like IMSP exist to encourage medication error reporting and then to use this reporting to not only educate healthcare workers but also to advocate for change, the fact remains that these errors persist, and patients sometimes suffer because of them.

If you or someone you love has been the victim of a medication error, please contact our experienced Cleveland malpractice lawyers to discuss your options for legal recourse and for obtaining the compensation you deserve. To schedule your free consultation, call 216-287-0900 or contact us online today.