ISMP Announces 14th Annual Cheers Awards Recipients

Horsham, Pennsylvania—The Institute for Safe Medication Practices (ISMP) announced its 14th Annual Cheers Awards winners and Lifetime Achievement Award recipient. The annual awards dinner was held on December 6, at the New Orleans Board of Trade. The Cheers Awards honor individuals, organizations, and companies that have set a standard of excellence for others to follow in the prevention of medication errors and adverse drug events; for more information, visit www.ismp.org/Cheers/. The winners of this year’s awards are:

· Hospital Corporation of America (HCA)
Nashville, Tennessee

HCA’s leadership supported an initiative to prevent tubing and IV line misconnections, providing a superior model for creating a health system-wide safe practices framework. Gap analyses were conducted at each HCA facility; close call data from across the organization was consolidated into a single learning database; and standard procedure guidance (I-TRACE = illuminate, touch, review, act, clarify/correct, expect) was created for clinicians who access and manipulate invasive lines and tubes. More than 68,000 individuals completed online training for I-TRACE, and there was a more than 30% post-launch increase in the reporting of close calls and events associated with tubing and line issues. This provided a more accurate database to drive improvement. As a result of implementation, HCA observed a 48% increase in the number of facilities incorporating tubing and line reconciliation as a standard safety check during patient handoffs. I-TRACE has been shared with staff through safety podcasts, articles in internal publications, briefings for pharmacy directors and chief nursing officers, and an organizational social media platform.

· OhioHealth
Columbus, Ohio

OhioHealth created a plan to manage drug shortages that is impressive both for its comprehensiveness as well as the speed with which it was implemented. In spring 2011, OhioHealth determined the national shortage of sterile IV sodium and potassium phosphate to be a critical issue for patient care, and rapidly developed conservation guidelines and a substitution policy that was put into operation within 24 hours of the manufacturer’s notification. In addition, production of adult and neonatal parenteral nutrition was consolidated to just one preparation site so that every facility would not have to open and partially use vials daily. The equivalent of more than 600 single-dose vials of IV phosphate were conserved in the 30 days after the program’s full incorporation. The success of the program led OhioHealth to institute a central model for drug shortage management, with responsibility for daily tracking and responding to shortages shared across all hospitals. OhioHealth also has shared the knowledge it has gained in using this highly effective collaborative approach with other health systems.

· SCANA Pharmacy
Cayce, South Carolina

SCANA Corporation, a Fortune 500 energy-based holding company in the Southeast, is an excellent example of what can be achieved by a large employer dedicated to improving medication safety for their workforce. Company employees receive numerous medication error- prevention resources, including ISMP’s consumer newsletter, and have the ability to send medication-related questions to a licensed pharmacist outside the pharmacy through a dedicated, confidential and secure email account. An early adopter of technology for preventing dispensing errors, SCANA’s in-house pharmacy also has established a wide range of safety practices, including requiring two and often three patient identifiers whenever prescriptions are received or picked up. Weekly pharmacy staff meetings are held to review error reports and other safety issues, and post-meeting surveys are used to test the team’s knowledge on the issues discussed. SCANA continues to look for ways to improve safety for its employees, including participating in the ISMP Medication Safety Self Assessment® for Community/Ambulatory Pharmacy.

· Louis Stokes Cleveland Veterans Affairs (VA) Medical Center
SERIOUS Medication Reconciliation Clinic
Cleveland, Ohio

The departments of pharmacy and cardiology at the Cleveland VA Medical Center have created the highly effective SERIOUS medication reconciliation model. This multidisciplinary model shifts the focus from the medications to the patient, and addresses quality as well as safety.

SERIOUS asks practitioners to take seven steps: solicit information from patients; examine medication records during every inpatient admission/transfer/discharge and outpatient visit; reconcile medications taken at home with record as well as with any allergies/interactions; inform patients and caregivers about appropriate medication use; add, adjust or remove medications to improve outcomes; update patients’ charts; and share reconciled lists with next care provider, patient, and caregivers. A post-discharge SERIOUS medication reconciliation clinic staffed by pharmacists and nurse practitioners was developed for heart failure patients at the Cleveland VA Medical Center, resulting in a decrease in the 30-day readmission rate. Just over 50% of the patients seen had medication discrepancies identified during the reconciliation process.

· Advocates to Address Drug Shortage Crisis
Bona Benjamin, BS Pharm, Director of Medication-Use Quality Improvement, American Society of Health System Pharmacists (ASHP)

Erin Fox, PharmD, Manager, Drug Information Services, University of Utah Health Care

Valerie Jensen, RPh, Associate Director, Food and Drug Administration (FDA) Center for Drug

Evaluation and Research Drug Shortage Program

Bona Benjamin, Erin Fox, and Valerie Jensen have formed a unique team to address the ongoing problem of national drug shortages. Their strong leadership has raised the visibility of this serious issue and spurred a presidential executive order. Bona Benjamin coordinates ASHP’s Drug Shortages Web Resource Center. In response to rapidly escalating shortages, she helped bring together a group of stakeholder organizations at a 2010 summit to examine the problem and recommend solutions. Erin Fox directs the University of Utah Drug Information Service, which provides shortage management resources on ASHP’s publically available website and keeps the healthcare community up-to-date on the latest information available. Valerie Jensen has worked within the FDA to track shortages and drugs at risk of being in short supply work with manufacturers on solutions, preventing more than 100 critical shortages to date. All three have been highly involved with consumer and healthcare print, electronic, and broadcast media to provide information on the causes and effects of drug shortages and to advocate for change.

In addition, ISMP is giving special recognition this year to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) for more than 15 years of outstanding work in medication safety. The Council developed the definition of “medication error” that has provided a uniform basis for reporting and analysis and has been adopted by regulatory agencies and organizations such as the FDA, Centers for Medicare and Medicaid Services (CMS), and United States Pharmacopeia (USP). Other accomplishments include creating an index and taxonomy for medication errors, helping the National Alert Network distribute brief messages about serious medication error risks, and developing a statement opposing the criminalization of errors in healthcare.

The ISMP Medication Safety Alert! Subscriber Award is being presented to the Saint Vincent Hospital.

Medication Safety Sub-Committee and the Massachusetts College of Pharmacy and Health Sciences in Worcester, Massachusetts, in recognition of their ongoing commitment to using the newsletter’s quarterly action agenda. Each agenda item is researched by pharmacy students on advanced rotations at the hospital.

Process improvement suggestions then are presented to the medication safety, pharmacy & therapeutics, and patient safety committees. Action agenda information also is distributed via an internal pharmacy newsletter reaching all medical, nursing, and pharmacy staff.

The ISMP Lifetime Achievement Award is being presented to Lawrence A. Trissel, BS Pharm, FASHP. A pharmacist, research consultant, and prolific author, Trissel is best known for his Handbook on Injectable Drugs. The Handbook is the premier resource for parenteral drugs, published continuously for more than 35 years. He also has created the largest electronic clinical pharmaceutics database of its kind, was part of a National Cancer Institute team that developed more than 125 experimental drugs for clinical trials, and spent more than 15 years as the Director of Clinical Pharmaceutics Research, Division of Pharmacy at the M.D. Anderson Cancer Center. He has received numerous professional awards and honors.

Christopher Jerry delivered the keynote address for the 14th annual Cheers Awards. After the tragic loss of his 2-year-old daughter to a fatal medication error in 2006, he created the Emily Jerry Foundation to increase public awareness and identify technology and best practices that are proven to minimize the risk of errors. Jerry is a relentless patient safety advocate who spreads a message of compassion and collaboration. He has used his experience to educate healthcare practitioners all over the country.