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2003 CHEERS for medication safety: Celebrating excellence

From the December 18, 2003 issue

With medication safety taking center stage in many healthcare organizations, 2003 has clearly been a year distinguished by hard work from countless individuals and groups who deserve recognition. Last week, ISMP had the opportunity to do just that, as we held our Sixth Annual CHEERS Awards Dinner in New Orleans to honor several of these extraordinary organizations, companies, and individuals who have set a standard of excellence in medication error prevention.

Loud CHEERS rang out for two individuals whose extraordinary dedication to medication safety has influenced many. Philip Johnson, MS, RPh, from H. Lee Moffitt Cancer Center and Research Institute in Tampa, FL, was honored for bringing the issue of medication safety to our public schools. As a representative to the Florida School Health and Education Consortium, Mr. Johnson published a 2003 landmark resource manual, Medication Use in Schools, which is already being used in the school systems in 23 states. Daniel Sheridan, MS, RPh, from Marion General Hospital in Marion, OH, was the first recipient of our ISMP Volunteer Award, which recognizes an individual who selflessly collaborates with ISMP staff to further medication error prevention. Mr. Sheridan's voluntary participation in our work has clearly improved our ability to provide relevant, sound, practical recommendations on medication error prevention.

Three CHEERS Awards recipients were honored for bringing groups together from different healthcare organizations to achieve remarkable results. The VHA Medication Error Prevention Initiative Conducted in its New England Region was recognized for facilitating substantial improvements in 21 of its member hospitals using the ISMP Medication Safety Self-Assessment(r) (Lesar T, Mattis A, Anderson E, et al. Using the ISMP Medication Safety Self-Assessment(r) to improve medication use processes. Jt Comm J Qual Saf 2003; 29(5):211-26). The Pittsburgh Regional Healthcare Initiative was honored for implementing, throughout its 44 member health systems, proven safety strategies for antibiotics, glycemic-control agents, anticoagulants, and opioids. Impressively, competing hospitals in this region agreed to share sensitive data on medication errors and work together to improve patient outcomes. The Massachusetts Coalition for the Prevention of Medical Errors was recognized for adopting a proven reconciliation process for verifying medications upon admission and discharge among its 42 member hospitals. The coalition also accomplished the most challenging task of gathering policy makers, representatives from public health and licensing bodies, healthcare leaders, and frontline clinicians to discuss accountability and how various models can be applied fairly and effectively to better achieve patient safety.

Technology received two resounding CHEERS this year. First, "smart pump technology" was recognized as a significant error reduction strategy for medications administered via infusion pumps. Alaris Medical Systems, B. Braun, and Baxter Healthcare accepted the award in recognition of their contribution to this technology. Next, Lehigh Valley Hospital and Health Networks, in Allentown, PA, was honored for its steadfast commitment to improving patient safety through adoption of best practices, including technology. In 2003, the hospital successfully implemented bedside bar coding to close the technology loop, which also includes electronic prescribing, pharmacy robotics, and electronic medication administration records. There were several CHEERS Awards recipients that were honored for their noteworthy commitment to medication safety during 2003. The American Society of Health-System Pharmacists (ASHP) was recognized for its comprehensive drug shortage resource center, online self-assessments and surveys, educational programs, and unquestionable influence on the federal bar-coding regulations, patient safety legislation, and the National Quality Forum recommendations, Safe Practices for Better Healthcare: A Consensus Report. The Joint Commission on Accreditation of Healthcare Organizations (JC) was honored for its 2003 National Patient Safety Goals, several of which are related to medication use, and the 2004 Medication Management Standards (introduced in 2003). Eli Lilly and Company, the sole CHEERS Awards recipient among pharmaceutical companies, was recognized for its use of tall man letters on product labels in response to error reports, its commitment to placing bar codes on oral and injectable product labels, and its unrestricted funding for several nonbranded medication safety projects that are widely applicable to many healthcare providers.

A very special CHEERS was awarded to this year's recipient of the ISMP Medication Safety Alert!? Subscriber Award, Advocate South Suburban Hospital, located near Chicago. During the past year, the hospital clearly used the newsletter as a cornerstone for its proactive error reduction efforts, incorporating many of the newsletter's recommendations into practice decisions and medication system improvements. Grove General Hospital, Grove, OK, received an honorable mention in this category. Special CHEERS recognition was also presented to Elliott Sternberg, MD, from Saint Joseph Health System, CA and TX, for "Mr. Rich Goes to the Hospital," an innovative and humorous PowerPoint presentation on the serious issue of medical errors. Attendees at the Awards Dinner had the pleasure of viewing his presentation, as well as taking home a copy for use in their organizations.

The CHEERS Awards concluded with the presentation of the Lifetime Achievement Award to Donald Berwick, MD, MPP, President and CEO of the Institute for Healthcare Improvement. For more than a decade, Dr. Berwick has worked to accelerate healthcare quality improvement by fostering collaboration, not competition, among healthcare organizations. In accepting the award, Dr. Berwick talked about the need for "quiet courage" among committed people to openly admit what is broken in the health system, and to take action to fix it. He called upon practitioners to face reality and reveal the defects in our work; to question even our most deeply held beliefs about the forms that care can take; to cooperate with each other by laying aside professional and disciplinary prerogatives; to stop being satisfied with the status quo; and to be impatient about the need for change. In summing up the elements of change, Dr. Berwick noted that creative ideas, consistency of purpose, a strong will to change, persistence, and cooperation were paramount to improving patient safety.

We thank the organizations and individuals who attended and/or sponsored our event this year. See for a list of contributors and more information about the award winners.

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