Earlier this month, ISMP celebrated 15 years—our crystal anniversary—of honoring individuals and organizations whose innovation and tireless dedication has helped prevent medication errors and save patient lives. The 2012 Cheers awardees were recognized at a dinner attended by close to 200 individuals last week at the Mandalay Bay in Las Vegas, NV. Please join us in congratulating the following award recipients, who are true gems in the field of medication safety.
CHEERS rang out this year for the multifaceted efforts of hospitals and health systems to help address crucial safety concerns:
The forYOU Team at the University of Missouri Health System (MUHS) in Columbia, MO, created a unique rapid response process for care of the ‘second victim’ after an unanticipated clinical event. The 90-member team is a network of physicians, nurses, respiratory therapists, and other healthcare professionals who serve as ‘lifeguards’ for providers traumatized by an unanticipated event or error. Team members are located in high-risk areas and groups, such as operating rooms, pediatrics, emergency departments, and code blue teams, and are available 24 hours a day year-round. During the first 3 years since deployment, the forYOU Team has helped support 639 MUHS faculty, staff, and volunteers in one-on-one encounters, group briefings, or leadership mentoring sessions. Team members use an evidence-based model to facilitate the second victim’s transition through the six stages of emotional recovery. The forYOU team has provided dozens of national and international learning opportunities to share its process for care of the second victim.
The James A. Haley Veterans’ Hospital and Clinics in Tampa, FL, has developed and implemented a patient safety curriculum that is a superlative example of applied error-prevention education. The curriculum is being administered to a wide variety of learners, including third- and fourth-year medical students at the University of South Florida Morsani College of Medicine, internal medicine residents, staff physicians, nurses, and pharmacists. During 4-week rotations, learners attend sessions on patient safety, pharmacy processes, human factors, and identifying potential hazards in a patient’s environment of care. They gain hands-on experience by following a medication from order entry to administration and identifying vulnerable points and possible solutions. They also participate in a human factors evaluation of a medication device, and simulations representing hazards in a patient’s room. The curriculum has been presented at numerous national conferences and shared with national groups within the Veterans Health Administration (VHA).
New York Hospital Queens (NYHQ) in Flushing, NY, has developed an innovative, interdisciplinary process to support the safe use of anticoagulants. The process includes a standard computerized prescriber order entry (CPOE) order set for warfarin, communication of international normalized ratio (INR) goals, and dosing guidance. A baseline INR and INR goals are required to initiate the order. The system prompts the practitioner to view previously administered warfarin doses along with pertinent INR and other history, all presented on the same screen, when placing a new order for warfarin. All warfarin orders are re-ordered daily, and pharmacists and nurses are required to document the most recent INR during order verification and administration as additional safety checks. When the CPOE system allowed warfarin to be prescribed without an INR, there were 171 potential adverse drug events in a one-month period of time. When the system stopped prescribers from entering warfarin orders without a current INR, potential adverse events dropped to four per month.
The Committee for Safe Medication Practice at Wesley Medical Center in Wichita, KS, has improved patient-controlled analgesia (PCA) outcomes by developing and implementing a sleep apnea risk assessment model, dosing parameters, robust monitoring, and the consistent use of capnography to monitor respiratory status. The model helps evaluate all adult patients for apnea risk upon admission using a modified STOP-Bang scoring system (www.ncbi.nlm.nih.gov/pubmed/22401881). Nurses document risk in the electronic record, allowing it to be visible on the physician rounds report, admission medication reconciliation list, PCA orders, transfer orders, preoperative medication records, discharge medication lists, and the pharmacy medication profile. In addition, smart pumps offering end-tidal carbon dioxide monitoring were put into place. There was a significant post-implementation decrease in severe events, code blues, and transfers to the intensive care unit (ICU) related to PCA opioid use. The program’s success has been shared in a journal abstract and a poster presentation.
Two committed individuals also received CHEERS for their ongoing safety advocacy:
Peggi Guenter, PhD, RN, Senior Director of Clinical Practice, Advocacy, and Research Affairs for the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), was honored for her work to ensure safe use of parenteral nutrition (PN) and enteral nutrition, particularly during ongoing national drug shortages. She created a drug shortage committee that has resulted in faster approval and dissemination of new shortage-related recommendations for intravenous multivitamins, electrolytes, minerals and trace elements, cysteine, fat emulsions, and amino acid products. She partnered with the US Food and Drug Administration (FDA) to investigate alternative product sources and request the importation of these products when shortages threatened patients’ nutritional needs. Dr. Guenter created Sustain™, A.S.P.E.N.’s National Patient Registry for Nutrition Care, which helps measure PN outcomes and benchmark them against aggregate data. She has also worked with international organizations to redesign enteral connectors to prevent potentially fatal tubing misconnections.
Melissa Seamonson from Deerfield, WI, was recognized for her tireless advocacy for safe medication disposal after the tragic death of her 2-year-old son in 2011. Blake Seamonson died of an accidental drug overdose after coming into contact with a used fentaNYL patch from his great-grandmother’s nursing home. Ms. Seamonson directly approached the FDA, national patient safety organizations such as ISMP, hospitals, and long-term care facilities to spur education of the healthcare community and the public at large about safe disposal of fentaNYL patches. As a result of her outreach, the FDA issued a healthcare provider alert about the risks, and the National Alert Network (NAN) issued an alert warning that 26 children have been accidentally exposed to fentaNYL patches during the past 15 years. Despite enormous personal pain, she also has allowed her son’s case to be used as an example to bring national attention to this issue, and is currently working to start a national billboard campaign on safe medication disposal.
This year, ISMP established the George DiDomizio Industry Award in memory of a late ISMP Trustee. Before his death in July 2012, George DiDomizio served as a trusted ISMP advisor and leader in safety testing of drug names to avoid look-alike and sound-alike medication errors. The award honors members of the healthcare industry that have made important and lasting contributions to patient safety:
Sproxil and GlaxoSmithKline were presented as the first recipients of the award for their joint work to prevent the spread of counterfeit medications. Sproxil collaborated with GlaxoSmithKline in 2011 on a pilot anti-counterfeiting program with the antibiotic AMPLICOX (ampicillin and cloxacillin) distributed in Nigeria. Consumers could send a scratch-off code from the medication package via a free text message to a central toll-free phone number. The mobile service would then look up the code and send a verification text message back indicating whether the drug is genuine, potentially fake, or stolen. The location of all counterfeit drugs is also recorded. More than 1.8 million patients have already sent in more than 3 million text message verifications. The program helped identify counterfeit Ampiclox in the Nigerian market, and Sproxil has expanded into India and four other countries in Africa.
One of the highlights of the evening was the presentation of the 2012 ISMP Lifetime Achievement Award, which is given in memory of ISMP Trustee David Vogel:
James Broselow, MD, has dedicated his career to improving medication safety in the emergency pediatrics setting. Along with Dr. Robert Luten, he developed the Broselow Tape to improve treatment of acutely ill and injured children. This color-coded tool helps estimate a child’s body weight from the body length to provide proper emergency medication dosing and to help avoid errors. It is now used in nearly every emergency department in the US that treats children. Dr. Broselow also has worked to develop an international standard for pediatric drug administration and created web-based mobile app versions of his dosing system that also apply to adults.
Thanks are also extended to the evening’s keynote speaker, Robert Wachter, MD. Dr. Wachter is a Professor of Medicine at the University of California, San Francisco, and is a national leader in patient safety and healthcare quality. During his presentation, he reflected upon a decade of successes, failures, surprises, and epiphanies related to the maturation of patient safety since publication of To Err is Human, the call to action from the Institute of Medicine in 1999. He stressed that healthcare is a complex adaptive system that requires bottom-up patient safety solutions that anticipate the inherent uncertainty in healthcare. He noted that the application of information technology—which has turned out to be harder than first envisioned—is crucial, but that we need to remember to keep the actual patient, not just the “iPatient” on the technology screen, at the forefront of our care. Dr. Wachter stressed that the culture within healthcare requires a shift from working in silos to working in functional teams, with each recognizing the unique expertise that others bring to the table. While he agreed that system problems are a significant safety issue in healthcare, Dr. Wachter also called for individual accountability among the entire workforce for making safe behavioral choices.
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 our 15th anniversary. 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 2013.