From the December 15, 2005 issue
For 8 years, ISMP trustees have carried out the challenging task of selecting distinguished CHEERS Award recipients from among many worthy nominees. This year was no exception-the pool of potential recipients was wide, varied, and replete with outstanding examples of medication safety initiatives undertaken in 2005. And so, it was with great pleasure that we held our 8th Annual ISMP CHEERS Awards Dinner last week in Las Vegas, NV, to honor some of these extraordinary organizations and individuals. CHEERS resounded for two Award recipients who successfully brought medication safety to the forefront within their respective specialty areas:
· The Association of periOperative Registered Nurses (AORN) was honored for widely disseminating a tool kit to help reduce the risk of medication errors in operating room settings. The tool kit includes resources to address labeling of containers in the sterile field, based in part on a 2004 ISMP Medication Safety Self Assessment for Hospitals finding that only 41% of hospitals had labeled all containers in surgical settings.
· Tribute was paid to Lorri Zipperer, cybrarian, for her tireless efforts to expand the role of library science professionals in the medication safety movement. She is the creator of Partnering for Patient Empowerment through Community Awareness (PPECA), a hospital-library collaborative that provides consumers with the opportunity to hear presentations on patient safety by a multidisciplinary panel of healthcare providers at their local libraries.
CHEERS rang out for three Award recipients who brought an interdisciplinary group of healthcare stakeholders together to work towards improving patient safety:
· CLARION, a student committee of the Center for Health Interprofessional Programs at the University of Minnesota Academic Health Center, was recognized for developing a competition that brings together healthcare professionals from different disciplines-medicine, pharmacy, nursing, public health, and healthcare administration-to solve patient safety problems. The competition was expanded nationally in 2005.
· Johns Hopkins Community Physicians, in Baltimore, MD, were honored for addressing interdisciplinary medication safety issues in the community, with a particular focus on non-licensed personnel who administer medications. Other elements of their medication safety campaign include a substantial awards program for staff who recommend safety improvements and an interdisciplinary clinical care committee.
· The Patient Safety Rounds program at Dana-Farber Cancer Institute in Boston, MA, was acknowledged for involving clinical and patient champions on its Patient Safety Rounds. As part of the rounds, patients interview other patients about their perceptions of safe care, during which safety concerns not previously identified by staff have been uncovered. Likewise, peer-to-peer interaction with designated clinical champions elicited more responses from staff.
CHEERS were presented to a pharmacy corporation for forging new paths for others to follow in an effort to improve safety:
· Target Corporation was recognized for its bold step in launching a redesigned pharmacy vial and container, known as the ClearRxSM system, which will hopefully spark similar changes throughout the community pharmacy industry. Created by graphic artist Debra Adler after her grandparents were involved in a medication error, it offers many safety features, including larger text, placement of the most important information at the top of the label, and attached medication information cards.
CHEERS rang out for two healthcare organizations that have clearly raised the bar in their quest for medication safety through exemplary leadership:
· Tribute was paid to St. John's Mercy Medical Center in St. Louis, MO, for its widespread application of technology and evidence-based practices, including implementation of automated medication dispensing cabinets, bedside point-of-care bar-coding technology, and migration of seven unit-based pharmacists to high-risk medication-use areas. Impressive outcomes have been achieved.
· Fostoria Community Hospital, a 25-bed critical access hospital in Fostoria, OH, was recognized for its development of a companion tool for the Broselow Emergency Pediatric Tape to address a high-risk area-administration of nonstandard drugs and solutions to children during emergency situations. The tool has been made widely available to other hospitals, proving that a small facility can have a large impact on patient safety on a national level.
CHEERS were awarded to three exceptional individuals for their tremendous contributions to improving patient safety:
· John Gosbee, MD, MS, was honored for his work in applying the study of human factors to patient safety. As one of the country's foremost experts in the field, Dr. Gosbee has authored a groundbreaking series of articles on human factors in the Joint Commission Journal on Quality and Safety, and has published a book, Using Human Factors to Improve Patient Safety. Through his publications, Dr. Gosbee has shared methods for deeper analysis of adverse events and provided tools to ensure more effective and lasting error-reduction strategies.
· David Marx, JD, was recognized as a safety innovator and developer of the Just Culture accountability model, which has won widespread praise for helping to balance individual and health system accountability for errors. In developing the Just Culture model, Mr. Marx has brought to healthcare the lessons learned from more than a decade of experience in transforming workplaces in other high-risk industries, including aviation and transportation.
· Tribute was paid to Joanne Kowiatek, RPh, MPM, from the University of Pittsburgh Medical Center in Pittsburgh, PA, for her outstanding volunteer work with ISMP and her impressive commitment to helping the Institute learn more about medication errors and error-prevention strategies. Her wealth of experience and interdisciplinary perspective on medication safety has also made her an invaluable member of the ISMP Nurse Advise-ERR advisory board.
A very special CHEERS was given to this year's recipient of the ISMP Medication Safety Alert! Subscriber Award:
· The Cleveland Clinic Foundation in Cleveland, OH, was honored for its large-scale implementation of recommendations from the ISMP Medication Safety Alert! and other ISMP newsletters. The Foundation created an intervention tool to record actions taken as a result of newsletter recommendations, assign them a risk priority number, and measure outcomes. One of many examples of large-scale improvements inspired by the ISMP Medication Safety Alert! was initiation of a hospital-wide effort to improve safe dosing of IV HYDROmorphone.
The ISMP CHEERS Awards were highlighted by the presentation of the 2005 ISMP Lifetime Achievement Award: Herbert S. Carlin, DSc, MSc, RPh, President of Pharmaceutical Management Insight, was honored for his long history of outstanding leadership on medication-use issues, particularly safe naming and labeling of drug products. Through service on the USP Nomenclature Committee and the FDA-USP Product Labeling Committee, Dr. Carlin has played a large role in bringing about labeling and packaging changes to address serious safety issues, including the use of black caps for potassium chloride vials only.
We would like to express our gratitude to the organizations and individuals who attended and/or sponsored our 8th Annual ISMP CHEERS Awards Dinner.
Click here for a list of contributors and more on this year's Award winners.
We also extend thanks to our keynote speaker, Billy Tauzin, former US Congressman and current President and CEO of the Pharmaceutical Research and Manufacturers of America, who promised to work closely with ISMP to reduce product-related medication errors. We look forward to another great year of working together to improve medication safety in 2006.