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Putting Our BOOTS ON to kick off the 19th Annual ISMP CHEERS Award
December 15, 2016

This month, ISMP rounded up an impressive group of individuals and organizations to honor and recognize with its 2016 Cheers Awards, which were presented at a gala dinner held on December 6 at Stoney’s Rockin’ Country in Las Vegas. Please join us in congratulating the following medication safety trailblazers who have created best practices, programs, and resources that are helping to prevent medication errors and improve the quality of patient care.

Cheers rang out for a large health system’s impressive leadership commitment to comprehensive implementation of the 2014-2015 ISMP Targeted Medication Safety Best Practices for Hospitals.

Ascension is the largest nonprofit health system in the US and includes 141 hospitals. Executive leadership made it a top priority to integrate all the ISMP best practices into their hospitals’ culture and operations, with the goal of improving patient safety and outcomes. Ascension identified potential barriers to implementation, established multidisciplinary teams, held monthly coaching calls, and shared tools and resources. They also conducted pre- and post-surveys and engaged an independent consulting team to evaluate compliance. This initiative resulted in an increase in best practice adoption at each site that was well above the national average. Ascension leadership has committed to engage in the same process to implement the 2016-2017 ISMP Targeted Medication Safety Best Practices for Hospitals.

A national professional organization’s safety committee received Cheers for its cumulative and interdisciplinary efforts to advance safety in every facet of parenteral nutrition support.

The American Society for Parenteral and Enteral Nutrition’s (ASPEN) Parenteral Nutrition Safety Committee significantly increased awareness and educational resources to prevent errors related to parenteral nutrition. The committee began in 2011 as a multidisciplinary task force established as a result of an ASPEN safety summit that was attended by 46 key stakeholders. It has since published numerous recommendations, including several addressing processes related to the electronic health record, parenteral prescribing order review, compounding, and labeling. The committee has conducted a safety survey and gap analysis, collected data on medication errors with parenteral nutrition, and developed tools and specific competencies for staff involved in parenteral nutrition prescribing, dispensing, and administration. In addition, the committee developed a certificate program to educate members of the healthcare team who work with parenteral nutrition about safe practices. More than 1,300 clinicians have participated in the program, and ASPEN is working towards gaining funding to share the certificate program with pharmacy residents as well.

Cheers were presented to a health system clinical group that transformed a pharmacy intervention program to ensure real-time clinical alerts and timely adjustments in patient care. 

The HCA Clinical Services Group created a Clinical Pharmacist Workflow model that uses evidence-based decision support and real-time information to alert pharmacists to opportunities for reducing the risk of patient harm from medication-related issues. This initiative identified ways to embed safety throughout the entire medication management system, from procurement to monitoring. The real-time care provided by the model led to improved productivity and streamlined workflow. Between 2014 and 2015, the model was deployed in 153 HCA–affiliated hospitals, with a 48% decrease in adverse drug events since implementation. In addition, hundreds of interventions have led to reduced risk for patients. For example, pharmacists have partnered with nursing to intercept incorrect patient weights using multiple triggers that may suggest an incorrect entry. The Clinical Pharmacist Workflow model also has allowed pharmacists to participate in more patient care related activities, such as multidisciplinary team rounds and providing medication history and reconciliation services.

Cheers rang out for a nonprofit coalition that has played a vital role in immunization education and advocacy aimed at both healthcare professionals and consumers.

The Immunization Action Coalition (IAC), created and sustained by its unique partnership with the US Centers for Disease Control and Prevention (CDC), helps facilitate communication about the safety, efficacy, and use of vaccines within the broad immunization community of patients, parents, healthcare organizations, and government health agencies. It works to reduce the incidence of 23 vaccine-preventable diseases by raising immunization rates and preventing vaccine errors, including omissions. The Coalition has developed free resources, including hundreds of highly reviewed and updated educational materials for healthcare providers and patients, and maintains a website for healthcare professionals (www.immunize.org) and a website for the general public (www.vaccineinformation.org). Providers and patients can find the answers to dozens of frequently asked questions about all vaccines available in the US on these sites. Its online publications include the weekly email information service, IAC Express, the quarterly periodicals Needle Tips and Vaccinate Adults!, and the popular feature “Ask the Experts.”

An outstanding individual received loud Cheers for his tireless work to improve medication safety in the operating room and during the delivery of anesthesia.

Dr. Robert Stoelting has devoted his career to spearheading efforts to improve the safety of patients undergoing anesthesia and in the operating room. During his nearly 20 years as President of the Anesthesia Patient Safety Foundation, he has helped advocate for crucial medication safety initiatives, provide vital educational programs and workshops, and offer free resources for error reduction, including a newsletter with worldwide circulation of more than 122,000 copies per issue. Dr. Stoelting’s dedication to collaboration has led to numerous national consensus conferences that have brought together a wide range of stakeholders to address topics such as patient-controlled analgesia, use of high-alert medications, labeling of medications in the operating room, and use of pharmacy-prepared syringes by anesthesia providers. The combined impact of Dr. Stoelting and the Foundation’s initiatives, along with others in the field, has been a 10- to 20-fold reduction in mortality and catastrophic morbidity for healthy patients undergoing routine anesthesia.

One individual with significant career-long contributions to patient safety was honored with a special Cheers —the 2016 ISMP Lifetime Achievement Award.

David Marx, JD, is a true pioneer in the safety world, from developing human factors risk modeling methods to being the father of the “Just Culture” accountability model. He has more than two decades of experience in transforming workplaces in high-risk industries to achieve highly reliable outcomes and has brought lessons learned from aviation, aerospace, and transportation into the healthcare arena. Marx, who is currently CEO of Outcome Engenuity, has authored a patient safety guide for the National Institutes of Health and advises the US Agency for Healthcare Research and Quality (AHRQ) on safety issues. He also has authored two books on workplace accountability, Whack-a-Mole: The Price We Pay for Expecting Perfection, and Dave’s Subs: A Novel Story about Workplace Accountability.

During his acceptance speech, Marx described the pillars that are required to support patient safety in healthcare:

Systems Engineering: The interdisciplinary science of designing and managing the complex processes, equipment, interfaces, and the environment in healthcare, in a manner that maximizes patient safety and reliability.

Root Cause Analysis (RCA) and Causal Diagramming: Identifying the root causes that led to an actual or potential adverse outcome, and then creating a visualization of the relationship between the given outcome, all the behavioral and system factors that influenced the outcome, and the causes behind each behavioral or system factor.

Human Factors and Behavioral Economics: Understanding the psychological, social, cognitive, and emotional factors that drive human behavioral choices and cause human error, and using that information in the design of systems and processes to complement human capabilities, the implementation of change strategies, and the just management of staff behavioral choices. 

Just Culture and the Law: A safety-supportive model of shared accountability where healthcare institutions are accountable for the systems they design; for supporting the safe behavioral choices of patients, visitors, and staff; and for responding to staff behaviors in a fair and just manner. In turn, staff are accountable for the quality of their behavioral choices (human error is not a behavioral choice) and for reporting hazards, errors, and system vulnerabilities. Legal reform may be necessary to better support patient safety, as our current legal system often punishes human error and supports a severity bias towards the outcome.

Socio-technical Probabilistic Risk Assessment (ST-PRA) and Model-based Risk Management: Prospective vulnerability analyses that link process failures with scientifically derived estimates of process failure rates, human error rates, and behavioral norms, yielding a more accurate picture of why and how often these failures affect patient outcomes. These analyses track all possible pathways that can lead to an adverse outcome and allow all combinations of tasks, behavioral choices, and system failures to be considered in combination with one another when formulating a risk-mitigation plan.

One of the highlights of the evening was a noteworthy presentation from the Cheers Keynote Speaker about protecting young children from accidental overdoses.

Sincere thanks are extended to the evening’s keynote speaker, Daniel Budnitz, MD, MPH, Capt., USPHS. Dr. Budnitz directs the Medication Safety Program at the CDC and has authored more than 50 publications on medication safety, public health surveillance, and injury prevention. He presented a public health approach to reduce medication overdoses in children less than 5 years old, touching upon real-world successes such as the PROTECT Initiative, an innovative collaboration bringing together public health agencies, private sector companies, professional organizations, consumer advocates, and academic experts to develop strategies to keep children safe from unintentional overdoses.

Since the 1970s Poison Prevention Packaging Act, which required child-resistant caps for most medications, mortality from overdoses has declined dramatically in children less than 5 years of age. However, emergency department (ED) visits and hospitalizations due to overdoses in this age group increased between 2000-2011. To help address this, the industry has begun packaging some medications in unit doses, with each oral solid dose in individual child-resistant packaging to prevent access to large quantities of unauthorized medications if the packaging is breached. The use of flow restrictors in bottles of oral liquid medications was also instrumental in reducing morbidity and mortality from unauthorized access to medications. Due to these packaging advances, along with metric-only dosing and dosing devices, and parent education about safe drug storage, ED visits due to unauthorized access to medications in children less than 5 years has decreased since 2011.  

We also would like to thank the organizations and individuals who attended and/or supported this year’s Cheers Awards and helped us celebrate these extraordinary leaders. Visit www.ismp.org/Cheers for a list of contributors and winners, and visit www.ismp.org/support for ways you can help ISMP continue to fight against preventable medication errors.

We look forward to another great year of working together to improve medication safety in 2017!

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