Celebrating 10 years of ISMP CHEERS Awards 1997-2007
And the 2007 winners are...
From the December 13, 2007 issue
For 10 years, ISMP trustees have honored ISMP CHEERS Award winners who have set a standard of excellence for others to follow in the prevention of medication errors and other adverse events. The decade has yielded exceptional nominees, making the selection of annual Awardees a challenge. This year's Awardees were recognized last week at an Awards Dinner in Las Vegas, Nevada. Please join us in congratulating our 10th annual CHEERS Award winners, as follows.
CHEERS rang out for two hospitals that sought out and integrated the unique contributions of key interdisciplinary stakeholders to improve patient safety.
Brigham and Women's Hospital, in Boston, MA, was honored for its extensive implementation of smart pumps, which was accomplished through detailed mapping of the clinical workflow, involvement of front-line pump users in the creation of the smart pump library, and mentoring of nurses to facilitate use of the pumps in a way that maximizes their capabilities to help prevent errors. By involving end-users to help build the pump library, the organization was able to create warnings that were most meaningful to the users and supportive of the workflow. Lessons learned from the project have been published in a chapter of the book, The Nurse's Role in Medication Safety, available through Joint Commission Resources.
Mercy Health Center, in Oklahoma City, OK, was recognized for its unique, interdisciplinary Fall Prevention Program that considers the pharmacological effects of medications on the risk of falls. Nurses and pharmacists work together to generate a medication-specific fall risk score for each admission to the hospital. A high score triggers a pharmacist's review of the patient's full medication profile along with recommendations to reduce the risk of a fall, including suggested changes in the drugs and/or doses prescribed, laboratory surveillance, and additional patient and family education. The program has had a significant impact on safety-including a 36% reduction in injury-producing falls during the past 2½ years.
CHEERS resounded for two individuals who stepped forward, beyond their employment requirements, to voluntarily contribute their time to medication safety.
John F. Mitchell, PharmD, FASHP, Medication Safety Coordinator at the University of Michigan Health System in Ann Arbor, MI, was honored for his voluntary creation and maintenance of a "Do Not Crush" list of medications. For many years, Dr. Mitchell's list has been published and used to improve medication safety worldwide. His compilation provides a readily available reference that identifies medications whose efficacy can be affected by crushing. Few manufacturers include this information in their package inserts. Dr. Mitchell updates the "Do Not Crush" list regularly, and the list is available free to healthcare providers and consumers on ISMP's website (www.ismp.org/Tools/DoNotCrush.pdf).
Timothy Vanderveen, PharmD, MS, Vice President of Cardinal Health's Center for Safety and Clinical Excellence in San Diego, CA, received the ISMP Volunteer Award for his long-standing commitment to process improvements in medication safety, particularly with infusion pumps. In the 1990s, Dr. Vanderveen joined forces with ISMP to advance recognition of free-flow as a serious pump-related problem and to promote free-flow protection for all infusion pumps. More recently, he has been instrumental in drawing attention to the error-prone way IV drugs are prescribed using multiple dosing units (e.g., mcg/kg/minute, mcg/kg/hour) rather than in a standard fashion. He frequently volunteers to serve as a medication safety advocate and has interacted with other companies at ISMP's request to describe IV drug safety issues and suggest solutions.
CHEERS were presented to a community collaborative that forged new paths with patients and consumers to involve them in the prevention of medication errors.
Walworth County Patient Safety Council of Aurora Health Care, in Elm Grove, WI, was honored for its community demonstration project that significantly improved medication safety for local seniors. Healthcare professionals and consumers joined together to implement the Partners in Safety campaign, which distributed medication bags and forms to help community members keep track of the medications they are taking. The Council recruited outside groups-Consumers Advancing Patient Safety and Midwest Airlines-to help spread its messages about medication safety. To date, senior medication list accuracy has improved from 69% to 81% for patients who have been treated in the Aurora Health Care system.
A special CHEERS was given to the recipient of the ISMP Medication Safety Alert! Subscriber Award.
Duke University Hospital in Durham, NC, was honored for its comprehensive efforts to incorporate recommendations from the ISMP Medication Safety Alert! and other ISMP newsletters into its patient safety initiatives at every level of the organization. Each issue is circulated via email to hospital leadership and clinicians along with a bulleted list highlighting important information, and key topics are discussed at department and executive level meetings. Duke has implemented many new safety initiatives based on information presented in the newsletters, including changes in purchasing and stocking of heparin, implementation of computerized prescriber order entry, revision of its high-alert medication list, evaluation of current practices for anticoagulants, and institution of a Just Culture approach to errors.
At the CHEERS Awards Dinner, Special Recognition was presented to Robert Lam for his tremendous contributions to medication safety.
Robert Lam, RPh, Information Technology Specialist for ISMP Canada, has worked tirelessly to advance national and international medication safety initiatives, including the development of Analyze-ERR, a medication incident reporting program that is used by many hospitals in Canada and around the world. He has assisted various countries, including the US, Australia, and Spain, with the development of web-based applications for medication safety programs and surveys. His passion for medication safety and expertise in technology has been invaluable to the design, support, and maintenance of the core information technology infrastructure for ISMP Canada.
The ISMP CHEERS Awards were highlighted by the presentation of the 2007 ISMP Lifetime Achievement Award to Richard J. Croteau.
Richard J. Croteau, MD, currently an advisor to Joint Commission International, was honored for his ongoing contributions to medication safety throughout his career. He is a well-known expert in both safety and healthcare process improvement. In more than 17 years with The Joint Commission, he has been one of the key people responsible for the advancement of patient safety standards, creation and maintenance of the sentinel event database, development of the National Patient Safety Goals, and implementation of numerous other patient safety initiatives. His positive impact on medication safety can be seen across the US and abroad. Dr. Croteau has worked directly on international patient safety activities in collaboration with the WHO World Alliance for Patient Safety.
We extend thanks to our keynote speaker, Susan Sheridan, MIM, MBA, cofounder of Consumers Advancing Patient Safety (CAPS), who shared her moving personal journey through the healthcare system after two family members experienced medical system failures: Her husband, Pat, died in 2002 after his diagnosis of spinal cancer failed to be communicated to him after initial test results were available; and her son, Cal, suffered kernicterus-associated brain damage after his birth in 1995 due to untreated, high bilirubin blood levels. Since then, Susan has worked tirelessly with CAPS and the World Health Organization (WHO) to promote patient safety worldwide. We would also like to express our gratitude to the organizations and individuals who attended and/or sponsored our 10th Annual CHEERS Awards Dinner. Visit www.ismp.org/Cheers/ for a list of contributors. We look forward to another great year of improving medication safety in 2008.