Ray Symposium

By Rodney Tanaka, Senior Communications Writer

POMONA, Calif. - 04/05/2010 -- In health care, making a mistake can have deadly consequences. Honest reporting of medication errors is vital for the public’s safety.

Western University of Health Sciences will shed light on this important issue with the annual Ray Symposium at 5 p.m. April 15 in the Health Education Center, 309 E. Second St., Pomona, Calif.

Keynote speaker Michael Cohen, RPh, MS, ScD, president of The Institute for Safe Medication Practices (ISMP), will talk about “Safe Medication Practices – Preventing Errors.”

ISMP operates a national medication error reporting program that allows practitioners – such as nurses, pharmacists and physicians – and consumers to report mistakes they made and mistakes they are aware of by others. All reports are confidential.

“The whole idea is for us to analyze what went wrong, not who did it,” Cohen said. “We turn that information around as intended by the person who reported it for altruistic reasons. The idea is for people to use this information proactively.”

Each year, ISMP's national Medication Errors Reporting Program (MERP) receives hundreds of error reports from health care professionals, according to the ISMP Web site. ISMP’s wholly owned corporate subsidiary, Med-E.R.R.S. (Medical Error Recognition and Revision Strategies), works directly and confidentially with the pharmaceutical industry to prevent errors that stem from confusing or misleading naming, labeling, packaging and device design.

Some problems are hard to detect during clinical trials. For the anti-smoking drug Chantix, ISMP called previously unidentified side effects to the attention of the FDA. ISMP found the potential for psychiatric side effects, suicides, occasionally hostile behavior, and an unusual number of accidents, slips and falls, Cohen said. These are now listed in product labeling, he said.

ISMP works with drug companies to improve labeling and packaging.

“We have been behind hundreds of product and practice changes,” Cohen said.

WesternU’s focus on interprofessional education aligns with ISMP’s all-inclusive approach to reporting errors.

“It has been so critically important not to be seen as a pharmacy organization,” Cohen said. “We really have worked hard not to have that image. It’s a multidisciplinary group that includes consumers.”

Cohen serves as co-editor of the ISMP Medication Safety Alert!, a biweekly newsletter sent by e-mail to more than 640,000 health professionals in the U.S., as well as to regulatory authorities and others in over 30 foreign countries. He is associate editor of the journal Hospital Pharmacy, and advisor on the editorial boards of the Journal of Infusion Nursing, Nursing 2010, Healthcare Risk Control (ECRI, Plymouth Meeting, PA), and the National Patient Safety Foundation’s Journal of Patient Safety. He also is the author of the book Medication Errors published by the American Pharmacists Association (2007).

In 2005, Dr. Cohen was awarded a MacArthur Fellowship noting his work in reducing preventable drug and drug delivery mistakes by formulating solutions and giving national visibility to the ubiquitous and serious problems of medication errors in the health care industry. In 2008, The Joint Commission and National Quality Forum awarded Dr. Cohen the prestigious John M. Eisenberg Patient Safety and Quality Award in recognition of his life-long professional commitment to promoting safe medication use and a safe medication delivery system.

“The Ray Symposium brings speakers to WesternU who can address national health care issues that appeal to the broadest possible audience,” said College of Pharmacy Dean Daniel Robinson, PharmD. “The symposium will attract students, health care providers and educators from all health disciplines, including policy makers who have a stake in improving health care and medication outcomes.”

WesternU’s College of Pharmacy organizes the annual Ray Symposium in honor of Max Ray, MS, PharmD, Dean Emeritus of the College of Pharmacy. He joined WesternU as Professor of Pharmacy Practice and Director of the Center for Pharmacy Practice and Development in 1996 and served as Dean of the College of Pharmacy from 1999 to 2006.

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