Before 2000, little was known about the status of medication practices in the United States, although some research had focused on adverse drug events, their causes and possible prevention strategies. In 2000, the Institute of Medicine's report To Err Is Human was published, calling national attention to patient safety in general.

Since then, according to Allen J. Vaida, the executive vice president of the Institute for Safe Medication Practices, "Hospitals have begun sharing their errors with staff and committees and learning from them. They have implemented safeguards for high-alert medications and addressed safer processes for spoken orders, handoffs, obtaining medication histories, labeling syringes and many other safe practices, but more still needs to be done."

One tool that will help hospitals maintain and improve quality standards is the 2011 ISMP Medication Safety Self-Assessment®, designed to help U.S. hospitals and health systems review and improve their safety practices and measure their progress in medication safety. Like previous self-assessment tools released in 2000 and 2004, the 2011 reassessment allows hospitals to evaluate their own medication safety practices and share what they learn by reporting their results anonymously on the Web.

An Updated Self-Assessment Tool

The 2000 self-assessment was distributed by ISMP, in partnership with the American Hospital Association and Health Research & Educational Trust, through a grant from the Commonwealth Foundation. It allowed hospitals to evaluate their medication-safety practices and confidentially submit their findings to ISMP. Participating hospitals received aggregate data for demographically similar health care organizations that helped them identify opportunities for improvement and prioritize their medication-safety initiatives. Many of these hospitals reported that they used the information to establish action plans and guide collaborative efforts to improve medication safety.

In 2004, an updated ISMP Medication Safety Self-Assessment® was distributed to all U.S. hospitals. Findings from both assessments helped the development of targeted educational resources such as the Pathways for Medication Safety® tools (

The 2011 reassessment includes questions on issues that have arisen since 2004, such as drug shortages, interchangeable IV tubing issues, and physician engagement in medication-safety activities. Responses from hospitals on these questions will help determine how today's challenges in health care have affected medication-safety systems.

"Changing the culture within organizations to continually identify risk and implement safe practices to help prevent patient harm continues to be a challenge," notes Vaida. "There still exists in many organizations a feeling that 'it can't happen here.'" Vaida added that this mindset was highlighted in a November 2010 New England Journal of Medicine article by Landrigan et al. that analyzed a study of 10 North Carolina hospitals and showed a lack of progress in many safety indicators.

While emerging technologies—electronic health records and prescribing systems, point-of-care bar-coding systems, and smart infusion pumps—are designed to capture errors and prevent them from affecting patients, Vaida points out, "The biggest challenge is for vendors to include clinical decision support in these systems and for hospitals to use it."

For more information or to participate in the assessment and help improve medication safety within your health care organization, go to, e-mail or call (215) 947-7797.

Cynthia Hedges Greising is a communications specialist with HRET.

The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.