For 14 years, ISMP has honored individuals and organizations whose innovation and tireless dedication have helped make significant achievements in preventing medication errors and saving patient lives. This year’s ISMP Cheers Awards winners were recognized at a gala held last week in New Orleans. Please join us in congratulating the following award recipients, who are truly remarkable for their achievements in medication safety.
Cheers rang out for several hospitals and health systems that showed how innovation and teamwork can help address crucial safety concerns:
The Hospital Corporation of America (HCA) in Nashville, TN, conducted an initiative to prevent tubing and IV line misconnections that provides a superior model for others to follow. A standard line reconciliation guidance called I-TRACE (Illuminate the area; Touch and trace the line; Review before proceeding; Act if mismatch discovered; Clarify and correct concerns; Expect to use this process every time) was created and shared with staff through podcasts, internal publications, briefings, and an organizational social media platform. More than 68,000 individuals completed online training for I-TRACE, and there was more than a 30% post-launch increase in the reporting of close calls associated with tubing and line issues that were identified and corrected when using I-TRACE.
OhioHealth in Columbus, OH, created a plan to manage drug shortages that is impressive for its comprehensiveness, interdisciplinary teamwork, and speed with which it can react to drug shortages. In response to the shortage of sterile IV sodium and potassium phosphate earlier this year, OhioHealth developed system-wide guidelines and consolidated parenteral nutrition preparation within 24 hours of learning about the shortage. More than 600 vials of IV phosphate were conserved in 30 days. The effort led OhioHealth to institute a central model for drug shortage management that has increased operational efficiency, strengthened relationships between pharmacy personnel within the system, and opened the door for further partnerships.
Louis Stokes Cleveland Veterans Affairs (VA) Medical Center SERIOUS Medication Reconciliation Clinic in Cleveland, OH, created a highly effective outpatient medication reconciliation process called SERIOUS, during which a team of nurses and pharmacists: Solicit information from patients about home medications; Examine medication records during every inpatient and outpatient visit; Reconcile the list of home medications; Inform patients and caregivers about appropriate medication use; Optimize outcomes by adding, adjusting, or discontinuing medications; Update the patient’s orders; and Share reconciled list with the next care provider. A post-discharge SERIOUS clinic developed for heart failure patients at the Cleveland VA Medical Center resulted in a decrease in the 30-day readmission rate from 19% to 8%. Half of the patients seen in the clinic had medication discrepancies identified during the reconciliation process.
Cheers resounded for a large employer—SCANA Corporation, a Fortune 500 energy company in the Southeast—dedicated to improving medication safety for its workforce:
SCANA Pharmacy in Cayce, SC, provides all employees with a wide range of medication error-prevention resources, including ISMP’s consumer newsletter. Employees have access to presentations on various disease states and medications, and can request pharmacy consultations. They can directly correspond with a pharmacist via a dedicated, secure email account. An early adopter of technology, SCANA’s pharmacy has established a wide range of safety practices. As a large employer, the company’s dedication to medication safety is exceptional.
A group of committed individuals received Cheers for their ongoing advocacy work in the area of drug shortages:
Bona Benjamin, BS Pharm, Erin Fox, PharmD, and Valerie Jensen, RPh, have formed a powerful team addressing the drug shortages crisis. They have raised the visibility of this serious issue to a national level, which spurred a recent presidential executive order—the first of its kind—to address drug shortages. Bona Benjamin coordinates the American Society of Health-System Pharmacists (ASHP) Drug Shortages Web Resource Center and helped organize a 2010 summit to examine the problem and recommend solutions. Erin Fox directs the University of Utah Drug Information Service, which provides shortage information on ASHP’s website to keep the healthcare community up-to-date. Valerie Jensen, Associate Director of the FDA Center for Drug Evaluation and Research Drug Shortage Program, tracks shortages and works with manufacturers on solutions, preventing more than 100 critical shortages to date.
This year’s ISMP Medication Safety Alert! Subscriber Award was presented to Saint Vincent Hospital Medication Safety Committee and the Massachusetts College of Pharmacy and Health Sciences in recognition of their ongoing commitment to using the newsletter’s Quarterly Action Agenda (QAA). During advanced rotations at the hospital, pharmacy students investigate each QAA item, meet with staff and administration from various departments that may be impacted by the issue, and formally present the item with suggested improvements at safety meetings. The recommendations often result in system-wide changes.
ISMP also gave special recognition this year to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) for more than 15 years of work in medication safety, which includes creating an index and taxonomy for medication errors, and helping the National Alert Network distribute messages about serious medication risks.
One of the highlights of the evening was the presentation of the 2011 ISMP Lifetime Achievement Award:
Lawrence A. Trissel, BS Pharm, FASHP, is best known for his Handbook on Injectable Drugs, the premier resource for parenteral drugs that has been published continuously for more than 35 years. He also has created the largest electronic clinical pharmaceutics database of its kind, and spent more than 15 years as the Director of Clinical Pharmaceutics Research, Division of Pharmacy at the M.D. Anderson Cancer Center. During his acceptance speech, Mr. Trissel urged schools of pharmacy to include more education and research on clinical pharmaceutics. Mr. Trissel noted that the 17th edition of the Handbook on Injectable Drugs included only 43 new studies, representing an 80% reduction in new studies than in previous years.
Thanks are extended to the evening’s keynote speaker, Christopher Jerry. After the tragic loss of his 2-year-old daughter to a fatal medication error in 2006, he created the Emily Jerry Foundation (http://emilyjerryfoundation.org/). Mr. Jerry stressed the power of compassion and collaboration in advancing safety, and shared how he has publicly forgiven and become close to the pharmacist who received jail time for his involvement in Emily’s fatal error.
We also thank the organizations and individuals who attended and/or sponsored our 14th Annual ISMP Cheers Awards dinner. Visit www.ismp.org/Cheers for a list of contributors and winners. We look forward to another great year of working together to improve medication safety in 2012.