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18th Annual ISMP CHEERS Awards
Looking into the Future for Medication Safety
December 17, 2015

This month, ISMP honored organizations and individuals who have given us a glimpse into what is to come in the field of medication error prevention by creating future-thinking best practices and programs. The 2015 ISMP CHEERS awardees were recognized at a dinner held in New Orleans on December 8. Please join us in congratulating the following winners.

CHEERS rang out for two outstanding individuals for their exceptional efforts advocating for patient and medication safety:

Jason Adelman, MD, MS, Chief Patient Safety Officer and Associate Chief Quality Officer at New York-Presbyterian Hospital/Columbia University Medical Center in New York, NY, is a leader in the use of information technology (IT) to enhance patient safety. His latest research is on the frequency and causes of wrong patient errors. Dr. Adelman developed and tested the Wrong-Patient Retract-and-Reorder tool, which identifies electronic orders that may have been mistakenly placed in the wrong patient’s medical record. He used the tool in a 2-year study that showed a distinct naming convention for newborns can reduce the frequency of wrong patient errors in the neonatal intensive care unit (NICU) setting. For example, instead of naming newborns as “Babyboy Jones” or “Babygirl Jones,” his new naming convention incorporates the mother’s first name, “Wendysboy Jones” or “Wendysgirl Jones.” He is currently conducting a study to assess the relationship between the number of electronic medical records open when placing an order and the risk of entering the order on the wrong patient’s record.  

Eric Kastango, MBA, RPh, FASHP, President and CEO of Clinical IQ, LLC, based in Florham Park, NJ, was recognized for his ongoing work related to sterile compounding safety. Kastango was instrumental in bringing about greater understanding of the causes of sterile compounding errors and the reasons behind slow adoption of technology and best practices. He served as an elected member of the United States Pharmacopeia (USP) Sterile Compounding Committee from 2005-2013, contributed to USP <797>, and helped create a sterile compounding compliance gap analysis tool. He is a teacher, author, and speaker who advocates addressing the causes of compounding errors, including the decline in perceived importance of compounding and dispensing processes, lack of standardization around best practices, training based on variable traditions handed down from one pharmacist to another, and learned workplace tolerance of risk.

CHEERS rang out for the persistent and interdisciplinary efforts of a health system to address crucial pediatric medication safety concerns:

Aurora Health Care in Milwaukee, WI, created an interdisciplinary Neonatal Medication Standardization Workgroup to improve and standardize the safe preparation and administration of common intermittent neonatal medications via an infusion pump. The health system’s 5 hospitals with NICUs were using different methods for central line administration of intermittent medications via syringe pump. Some hospitals were dispensing syringes with 1 mL of overfill to allow for administration of the full dose without flushing, which risked overdoses. The others were dispensing syringes with 0.1 mL of overfill, which required flushing the residual drug through the tubing and a risk of infection. The workgroup sought input from medical staff, nursing, and pharmacy to standardize to a single process. When they had difficulty reaching consensus, a subgroup worked with their intravenous tubing vendor to create a semi-closed system for flushing lines that reduced the risk of infections. This flush method has been successfully implemented across the entire system with no cases of infection.

A small group of safety-minded practitioners also received CHEERS for their tireless work to ensure safe transition to a new enteral connector system:

Eric A. Johnson, PhD, Medication Safety Project Manager, Sean P. O’Neill, PharmD, Medication Safety Officer, and Jamie Sklar, RN, BSN, MS, CCRN-K, Medication Safety Nurse, from The Children’s Hospital of Philadelphia (CHOP) helped bring national attention to workflow problems and potentially serious dosing inaccuracies when administering liquid medications to infants and children using ENFit enteral syringes that were previously on track for full implementation by early 2016. The group tested samples of the ENFit syringes and found clinically significant under- or overdosing of medication caused by the volume (0.2 mL) in the syringe’s dead space. They compiled data showing that more than 80 medications are typically used daily in volumes less than 2 mL in a children’s hospital, with 1,250 doses prepared each day. In July 2015, CHOP, in partnership with ISMP and ASHP, coordinated and hosted a national meeting to address those concerns. Their efforts led to postponement of full implementation of ENFit connectors and resulted in a change in the syringe design.

Special CHEERS rang out for a unique industry member that demonstrated exceptional efforts to improve medication safety:

The George DiDomizio Award was established in 2012 in memory of a late ISMP Board member to honor a company in the healthcare industry that helps prevent medication errors. This year, the Award was given to CredibleMeds for its work as a resource for the safe use of medicines and its special focus on drugs that increase the risk of torsades de pointes, a potentially lethal cardiac arrhythmia. The CredibleMeds website was created by the nonprofit AZCERT (Arizona Center for Education and Research on Therapeutics), and provides a wide variety of prescribing and teaching tools. CredibleMeds conducts a rigorous, independent analysis of evidence and assigns drugs to lists based on their relative risk of causing torsades de pointes; these lists are free, and more than 48,000 visitors use the website annually. Hospital systems have incorporated the CredibleMeds drug list into their electronic prescribing alert systems to identify patients at risk for sudden death.

One individual with significant career-long contributions to medication safety was honored with a special CHEERS the 2015 ISMP Lifetime Achievement Award:

John Grabenstein, RPh, PhD, has spent most of his more than 35-year career advocating for vaccine safety. He is the author of a Centers for Disease Control and Prevention (CDC)-recognized curriculum for pharmacy-based immunization delivery and has spoken in the past about errors with immunologics at the CDC’s National Immunization Conference. Dr. Grabenstein also has published more than 300 articles and co-authored a chapter on vaccine errors in the book Medication Errors. He has served as a clinical advisor to ISMP and as a member of ISMP’s acute care newsletter advisory board. He is a former director of the Military Vaccine Agency and is currently the Executive Director for Global Health & Medical Affairs for Merck Vaccines.

During his acceptance speech, Dr. Grabenstein challenged healthcare providers of all disciplines to ensure that patients and consumers they encounter are protected from vaccine-preventable diseases. He urged, “Don’t let people walk out of your facility vulnerable—get them the protection they need. Undelivered vaccines are of no value.” He also encouraged healthcare providers to be sure patients have an up-to-date record of all immunizations. He noted that it was probably easier to find a pet’s immunization record than an adult’s or child’s immunization record.

During the CHEERS gala, the ISMP staff and Board of Directors awarded Special Recognition to one of its longest and most valuable members:

Russell Jenkins, MD, ISMP’s Medical Director Emeritus, was honored for his more than 20 years of service to ISMP and many invaluable contributions to the field of medication safety. Dr. Jenkins became ISMP’s medical director and a board member soon after ISMP became a nonprofit agency in 1994. His willingness and ability to personally reach out and touch healthcare providers to help them gain understanding of crucial medication safety vulnerabilities and to implement strategies to prevent errors is unequivocal. Russ’s relevant personal stories and sense of humor allowed ISMP to interact informally and formally with healthcare professionals, including physicians, in ways that helped raise awareness of medication hazards and inspired a new willingness to change.  

One of the true highlights of the evening was a heartfelt presentation from the CHEERS Keynote Speaker:

Many thanks are extended to the evening’s Keynote Speaker, Derek Gillespie, RPh, who was faced with the enormous burden and challenge of responding to a fatal medication error that originated in a hospital pharmacy while he was pharmacy director. The event happened just prior to the December 2014 American Society of Health-System Pharmacists Midyear Clinical Meeting. In a moving address, he spoke about the experience of leading a pharmacy team through a time of uncertainty and transformational change, and using what he has learned to make a positive difference for patients in the future. ISMP plans to share more of Derek’s presentation, from the perspective of the “third victim” of a fatal event, in an early 2016 newsletter. Stay tuned for Derek’s poignant story of the pharmacy’s and hospital’s “road to redemption.” 

We also would like to thank the organizations and individuals who attended and/or supported this year’s CHEERS Awards dinner and helped us celebrate these extraordinary leaders. Visit www.ismp.org/Cheers for a list of contributors and winners, and www.ismp.org/support for ways you can help ISMP continue to play an important role in the fight against preventable medication errors. We look forward to another great year of working together to improve medication safety in 2016.

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