The 9th Annual ISMP CHEERS Awards: And The Winners Are..
From the December 14, 2006 issue
For 9 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 replete with outstanding examples of medication safety initiatives in 2006. And so, it was with great pleasure that we held our 9th Annual ISMP CHEERS Awards Dinner last week in Anaheim, CA, to honor these extraordinary recipients.
CHEERS rang out for two exceptional organizations that stepped forward to meet critical healthcare challenges to improve medication safety during a time of national crisis:
- KatrinaHealth.org was honored for providing a comprehensive source of medical and prescription histories for the 1.5 million evacuees from hurricane Katrina being treated by healthcare practitioners. The site, which was launched within 2 weeks of the storm, was created through unprecedented collaboration of private, public, and national organizations. The Web site also alerted users to patient allergies and allowed them to identify drug tablets and capsules by querying the database for characteristics such as color, shape, and markings.
- The Evans Army Community Hospital Soldier Readiness Process Team, from Fort Carson, CO, was recognized for its commitment to ensuring safe medication use in soldiers being deployed. With this innovative program, which has been recommended for all military branches, a pharmacist provides one-on-one counseling to soldiers regarding their medications, including safe use and storage under battlefield conditions, and receipt of refills. The pharmacist also makes recommendations regarding non-deployment status if medication therapy is not considered safe under extreme circumstances.
CHEERS were presented to two outstanding Award recipients for forging new paths with patients and other consumers to further involve them in the prevention of medical errors:
- University of Pittsburgh Medical Center (UPMC), Shadyside Campus, was honored as one of the first hospitals in the nation to invite patients and families to call for a rapid response team (RRT) to address unresolved concerns about their safety and health. Upon admission, patients and family members are encouraged to pick up the phone to report a Condition H (for "help") at any time if they fear something is seriously wrong and their concerns have not been addressed. Once a call is placed, a rapid response team arrives at the patient's bedside within minutes to respond to the concern. Initial calls have all been appropriate and have provided valuable insight into patient-staff communication.
- Ilene Corina was recognized for her grassroots patient safety advocacy as president of Persons United Limiting Substandards and Errors in Healthcare (PULSE) of New York, and co-founder of PULSE of America. PULSE, a nonprofit organization, has been working to improve patient safety by using real-life stories and experiences from patients and families affected by medical errors. PULSE offers a newsletter, support groups, and workshops to help community members become safety advocates. Ms. Corina also spearheaded the first Patient Safety Awareness Week (2002).
CHEERS resounded for two hospitals and a health system that have clearly raised the bar in their quest for medication safety through exemplary leadership:
- Hazel Hawkins Memorial Hospital (HHMH) was honored for serving as a role model for effective implementation of medication safety efforts in small organizations. HHMH, a 49-bed community hospital in Hollister, CA, has fostered an interdisciplinary medication safety initiative that has been extremely successful in creating a culture of safety, encouraging error reporting, and implementing various error reduction strategies, including expanded pharmacy services, a pharmacist on call 24 hours each day, and pharmacist rounds to help identify and reduce risk associated with drug storage and look-alike medications.
- Huntington Memorial Hospital in Pasadena, CA, a 525-bed nonprofit community hospital, was recognized for demonstrating the effect an emergency department (ED) pharmacist can have on preventing medication errors. Logging more than 65,000 ED visits annually, the hospital positioned a full-time pharmacist in the ED who evaluates medication safety issues, reviews medication orders for appropriateness, allergies, and drug interactions, provides educational inservices for staff, and leads a medication-use committee. Pediatric errors-one specific medication safety initiative-have been reduced by an impressive 50% since implementation of the service.
- The Hospital Corporation of America (HCA), based in Nashville, TN, was honored for its impressive initiative in 2000 that has since led to the use of bar coding at the bedside and electronic medical records in all 186 member hospitals. A clinical and technological team was assembled in each hospital to redesign processes, develop educational tools, provide technical expertise, and troubleshoot issues during the 6-month implementation period. HCA also required its purchasing group to award immediate contracts to pharmaceutical companies providing unit-dose medications with readable bar-code labels.
CHEERS resounded for two extraordinary individuals for their tremendous and unique contributions to improving medication safety:
- Joyce Generali, MS, RPh, FASHP, was recognized for creating the first complete list of Black Box Warnings (BBWs), the most urgent notice of serious adverse effects that the FDA can require in product labeling. Ms. Generali began compiling the list 4 years ago and has since updated it continuously and made it free to the general public at www.formularyproductions.com/blackbox/. The list encompasses every BBW from the Physician's Desk Reference, which has been cross-checked with other references. Ms. Generali is Director of the Drug Information Center at the University of Kansas Medical Center, Kansas City, KS.
- Therese Staublin, PharmD, is being honored for her outstanding volunteer work with ISMP and commitment to helping the Institute learn more about medication errors and error prevention strategies. Her interdisciplinary perspective has made her an invaluable member of the ISMP acute care and nursing newsletter advisory boards. She has provided unique input that has helped ISMP staff view safety issues in new ways and supplied fresh ideas for address-ing those issues in clinical practice. Dr. Staublin is a drug use review coordinator at St. Francis Hospital and Health Centers in Beech Grove, IN.
A very special CHEERS was given to this year's recipient of the ISMP Medication Safety Alert! Subscriber Award:
- The University of Pittsburgh Medical Center (UPMC) in Pittsburgh, PA, was honored for its sustained, long-term initiative to integrate information from the ISMP Medication Safety Alert!Ò into their organization, through real-time evaluation of ISMP recommendations compared to current UPMC practices. ISMP newsletters have inspired large-scale, interdisciplinary medication safety improvements and have also been used to support hospital drug formulary decisions, pharmacy drug use and disease state management, and pharmacy operation initiatives.
The ISMP CHEERS Awards were highlighted by the presentation of the 2006 ISMP Lifetime Achievement Award:
We would like to express our gratitude to the organizations and individuals who attended and/or sponsored our 9th Annual ISMP CHEERS Awards Dinner. Visit www.ismp.org/Cheers/ for a list of contributors and for more on this year's Award winners. We also extend thanks to our keynote speaker, Charles Denham, MD, Chairman of the Texas Medical Institute of Technology, who shared his view that the real advances in patient safety in the future will come from people, even more than technology, as healthcare providers begin to work in real teams that are inspired to do better, are driven by the truth, and are led by the heart to honor core values and to bring the joy of delivering care back into healthcare. We look forward to another great year of improving medication safety in 2007.
- Gordon Schiff, MD, is a nationally-recognized expert on medical errors. His research contributions include studies on look-alike and sound-alike drugs and errors caused by a failure to link clinical laboratory and pharmacy information systems. When accepting his Award, Dr. Schiff offered his perspective on what he called the "three rights:" the right diagnosis, as a system property; the right rationale for prescribing, based on specific criteria; and the right monitoring, particularly a linkage between lab and pharmacy systems. Dr. Schiff also touched upon other safety issues that remain problematic in healthcare, including sample use, formulary switching, disclosure of risks to patients, and look-alike drug names. Dr. Schiff, a founding member of the Chicago Patient Safety Forum, has received the Institute of Medicine of Chicago 2005 Patient Safety Leader of the Year Award. He was also recently selected by Modern Healthcare magazine as one of 30 national leaders most likely to continue to shape the face of healthcare in the future.