This month, ISMP celebrated 16 years of honoring organizations and individuals who have followed their own beat to make extraordinary advances in medication error prevention. The 2013 CHEERS awardees were recognized at a dinner held this week at the Cuba Libre restaurant in Orlando. Please join us in congratulating the following winners, who have set a superlative example for the entire healthcare community.
CHEERS rang out this year for the exceptional efforts of a hospital and a medical clinic system to help address crucial safety concerns:
Cook Children’s Medical Center in Fort Worth, TX, was commended for fully incorporating the use of barcode technology in the areas of medication storage, preparation, dispensing, and bedside administration. The technology has allowed them to implement a unique breast milk tracking system to eliminate identification errors, detect expired milk, and track correct feeding containers and storage locations. Cook Children’s also is able to fully prepare and dispense bar-coded, patient-specific, weight-based unit doses for inpatients and most outpatients—including all oral liquids, pharmacy com-pounded solutions, multi-additive IV solutions, and parenteral nutrition. The medical center is able to dispense at least four barcoded batches of patient-specific medications to each unit daily, and in key critical areas, as often as every 2 hours. A long-term team project continues to make process modifications, including redesigning armbands to 2-D barcodes so that nurses do not have to wake a sleeping child to perform a scan.
The Marshfield Clinic in Marshfield, WI, is a large, nonprofit chain of medical clinics owned by a physician group practice. The Clinic has created a comprehensive drug safety alert program to communicate FDA warnings to staff and incorporate new information into clinical practice. As a first step, the Clinic’s Drug Evaluation Committee (DEC) evaluates safety concerns identified by prescribers, the FDA, and others to determine whether internal action is warranted. In its first year, the program targeted six different drugs. Using the electronic health record, the Clinic sent letters to prescribers along with a list of patients who were prescribed the drug in question. After 3-6 months, prescribing data was assessed and compared to baseline, then revisited every 6-12 months. Data review showed that the program provided quality, up-to-date safety alerts that led to changes in drug therapy and substantial decreases in potential adverse drug events. In aggregate, nearly 10,000 total potential adverse events were identified and approximately 80% were resolved through changes in prescribing.
A healthcare organization and a government agency were lauded with CHEERS for their tireless work to prevent errors and educate practitioners and patients:
AAMI Foundation Health Technology Safety Institute (HTSI) in Arlington, VA, which is part of the Association for the Advancement of Medical Instrumentation (AAMI) Foundation, has developed valuable tools and educational resources on infusion system safety. In October 2010, AAMI and the US Food and Drug Administration (FDA) held a national summit to discuss risks with infusion systems. As a result, HTSI was formed, and a steering committee was created to follow up on the ideas generated. The committee also develops the framework for novel research projects, including a 10-hospital study aimed at reducing IV errors. Free white papers, webinars, and other programs from HTSI have focused on crucial issues such as pump integration, multiple-line infusion errors, and clinical alarm safety. HTSI also has established a National Council for Healthcare Technology Safety that serves as its multidisciplinary advisory board, helping healthcare professionals create a safer environment for patients through healthcare technology.
Centers for Disease Control and Prevention (CDC) in Atlanta, GA, has made an important contribution to medication safety with its role in two groundbreaking projects—the Safe Injection Practices Coalition and the PROTECT Initiative. Led by CDC and the Safe Injection Practices Coalition, the “One and Only” campaign targets healthcare providers and consumers in an effort to eliminate infections and outbreaks from unsafe medical injections. The campaign provides free resources, including videos, tool kits, and printed materials in English and Spanish. The PROTECT Initiative, which CDC founded, is an innovative collaboration bringing together public health agencies, professional organizations, private sector companies, patient advocates, and academic experts to keep children safe from unintentional overdoses. PROTECT has successfully promoted the addition of flow restrictors to the neck of liquid medication bottles to limit access to the medicine in the home by children and to encourage use of calibrated dosing devices (oral syringes) rather than household spoons. In a hospital setting, the flow restrictors may also help prevent accidental administration of oral liquids by the IV route.
One dedicated individual also received CHEERS for her ongoing medication safety advocacy:
Deb Saine, MS, RPh, FASHP, until recently the Medication Safety Manager at the Winchester Medical Center in Winchester, VA, was honored as a nationally recognized patient safety expert who has created invaluable safety tools. She co-authored the 2013 Medication Safety Officer’s Handbook, which is being used in more than 15 countries, and has led numerous national-level committees working to improve medication safety. She spearheaded creation of the American Society of Health-System Pharmacists Medication Safety Section Advisory Group, and served as its first chair; that group’s efforts culminated in the first annual Medication Safety Collaborative held this year. Deb has mentored students, residents and peers, which has produced new safety leaders in the US and abroad.
Special CHEERS rang out for a newsletter subscriber and an industry leader that have set a high standard for their steadfast attention to medication safety in all that they do:
The ISMP Medication Safety Alert! Subscriber Award was presented this year to Kindred Healthcare, based in Louisville, KY, for their outstanding efforts to integrate information from ISMP newsletters into the corporate and hospital processes of their long-term acute care and inpatient rehabilitation hospitals. A corporate Medication Error Subcommittee has developed numerous safety initiatives based on its review of newsletter material, and each Kindred hospital is required to perform an assessment using the Quarterly Action Agenda published in the ISMP Medication Safety Alert!
The George DiDomizio Industry Award, established in 2012 in memory of a late ISMP Board member, was given to Intelliject Inc., for pioneering advances in drug/device combination products. Intelliject has created a new EPINEPHrine delivery system using human factors engineering that combines an auto-injector with voice direction easy enough for a child to use. The product was launched by Intelliject’s commercialization partner, Sanofi, earlier this year, and is the first auto-injector with audio as well as visual cues for the emergency treatment of life-threatening allergic reactions.
One of the true highlights of the evening was the presentation of the 2013 ISMP Lifetime Achievement Award:
David Classen, MD, is an innovator who has devoted most of his career to designing healthcare information technology tools and resources for improving patient safety. He worked with ISMP to create a CPOE/EMR “flight simulator” for the Leapfrog Group and National Quality Forum (NQF) that has been used to evaluate hundreds of inpatient and ambulatory EMR systems after implementation in the US and United Kingdom. He also helped develop a method for integrating multiple hospital computer databases with pharmacy systems to signal actual or impending adverse drug events, which is being utilized by more than 500 different healthcare organizations. He served on the Institute of Medicine committee on patient safety data standards and co-chairs the NQF’s Patient Safety Common Formats Committee.
Thanks are extended to the evening’s keynote speaker, James Conway, MS, FASHP. Conway is an adjunct lecturer at the Harvard School of Public Health, and a well known expert in healthcare administration, safety, change management, and patient-centered care. He spoke about the need for strong leadership in quality and safety in the face of healthcare reform, with its “waterfall-like” impact on practitioners. He called for the development of systems that make use of science and informatics, patient-clinician partnerships, outcomes-oriented incentives, and a continuous learning culture.
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. We look forward to another great year of working together to improve medication safety in 2014.