The 13th Annual CHEERS Awards: And the Winners Are.
From the December 16, 2010 issue
For 13 years, ISMP has honored individuals and organizations whose innovation and tireless dedication have helped make significant contributions in preventing medication errors and saving patient lives. This year’s recipients were recognized at our annual awards dinner last week at the Angel (baseball) Stadium in Anaheim, CA. Please join us in congratulating the following winners, who are truly “all stars” in the field of medication safety.
CHEERS rang out this year for several hospitals and health systems that have shown how persistence, dedication, and interdisciplinary cooperation can help address crucial safety concerns:
Christiana Care Health System in Wilmington, DE, undertook a 5-year journey to improve the safe use of injectable HYDROmorphone, demonstrating the power of a grassroots effort which incorporated education and technology. To promote safe prescribing, standard dose ranges based on the patient’s age and prior opioid use were established, standard order sets were revised, and a 3-year educational campaign was conducted that utilized peer-to-peer mentoring, pocket dosing guides, and other media. The campaign resulted in incremental improvement, but the health system did not stop there. Christiana Care Health System further enhanced the safety of their medication use processes by adding computerized prescriber order entry (CPOE) alerts, which resulted in 99% of HYDROmorphone orders for elderly patients falling within the recommended dosing range. Since CPOE implementation, no moderate or severe HYDROmorphone-related adverse events have been detected or reported.
Hennepin County Medical Center (HCMC) in Minneapolis, MN, implemented a medication reconciliation process for patients discharged to nursing homes that has resulted in near-perfect accuracy. After discovering that 92% of patients with a cardiac-related diagnosis discharged to nursing homes had errors in the drugs prescribed at hospital discharge, HCMC developed an electronic discharge system—but the error rate only improved to 70%. A new process was piloted in which a clinical pharmacist and nurse coordinator reviewed all discharge orders for nursing home patients and reconciled concerns directly with the discharging physician. The change resulted in a reduced error rate to near zero for medications prescribed upon discharge and a significantly lower 30–day readmission rate for this group compared to other discharged nursing home patients. HCMC has subsequently instituted this process for all its patients discharged to nursing homes. It also has shared details with local hospitals and is seeking publication to share the process and results with a wide audience.
Lancaster General Health in Lancaster, PA, received a CHEERS Award for successfully creating a truly interdisciplinary process to integrate smart pumps, a barcode medication administration system, and electronic medical records into their medication use system. In the system the hospital has implemented, the order is electronically transferred to the IV pump, and then the barcode system reads the amount and rate at which the fluids are to infuse, automatically adjusting the pump settings to facilitate nursing care. The automated connection also sends pump information to the patient’s health record and allows pharmacists to be more involved in IV administration of solutions, which has increased utilization of pump dose-verification capabilities by 47%. The combined efforts of nurses, pharmacists, and vendors have resulted in an 89% success rate with engaging the technology and, thus, reducing the risk of programming errors. Lancaster General is one of the first health systems in the country to deploy this kind of IV interoperability beyond a pilot phase.
CHEERS resounded for a state agency that has successfully collected and used error data to fuel statewide prevention initiatives:
The Pennsylvania (PA) Patient Safety Authority serves as a model for state-run error-reporting programs and use of adverse event and near miss reports to improve patient safety. In 2004, a new mandatory state reporting program was created in PA requiring all PA hospitals, ambulatory surgery centers, and birthing centers to electronically communicate all adverse events and near misses to the Authority. ISMP is responsible for reviewing all medication-related error reports submitted to the Authority—so far, more than one million events (not all related to medications) have been reported. The Authority has published more than 200 educational articles in its journal since 2004, developed safety toolkits, and made safety tips and brochures based on collected data available to patients and healthcare professionals. Six regional liaison positions have been created in the state to help healthcare facilities implement changes. The Authority also conducts safety improvement collaboratives and has developed a web-based program that allows Pennsylvania patient safety officers to communicate with each other, share ideas, and access a customized library.
A collaborative of three organizations in North Carolina received a CHEERS Award for their efforts to spread the word about the value of Just Culture in healthcare:
The North Carolina (NC) Center for Hospital Quality and Patient Safety, North Carolina Hospital Association, and North Carolina Board of Nursing have undertaken statewide efforts to establish a Just Culture in healthcare, and also have served as a national example and resource. The Center, a nonprofit organization created by the NC Hospital Association in 2004, has engaged and supported more than 25% of hospitals in the state in the adoption of Just Culture through its collaborative programs, and provided Just Culture education throughout the state. It also has worked closely with the NC Board of Nursing on incorporating a Just Culture approach to adverse event analysis and treatment of nurses who are involved in errors. In 2008, the Board of Nursing revised its regulations to be in compliance with the tenets of a Just Culture, and its executive leaders have presented on the success of this initiative at national meetings.
CHEERS were given to an extraordinary ISMP volunteer for her exceptional assistance in helping ISMP achieve its mission:
Barbara Olson received ISMP’s Volunteer Award for continuing efforts to raise awareness of the Institute’s medication safety recommendations through emerging social networking technology. Barbara has helped showcase information from ISMP and other safety organizations in a way that resonates well with today’s healthcare professionals, from frontline nurses to hospital administrators. A former ISMP fellow and now a director of patient safety in the Clinical Services Group at HCA in Nashville, TN, she is one of only three nurses with blogs on Medscape (http://blogs.medscape.com/onyourmeds), where her posts reach an interdisciplinary audience. Barbara maintains an active patient safety presence on Twitter @SafetyNurse.
One of the highlights of CHEERS was the presentation of the 2010 ISMP Lifetime Achievement Award:
Mark Neuenschwander is considered by many to be the leading resource and authority on dispensing automation and barcode point-of-care systems, and has spent most of his career promoting their safe use. He has been a leading advocate for federal regulation requiring barcodes on all medication packaging. He also has been a prolific author on the role of technology in medication safety, writing a series of industry-acclaimed reports for reviewing and assessing automated dispensing systems as well as many articles in healthcare trade publications and chapters in two award-winning books on medication errors and one on new technology.
Thanks were also extended to the keynote speaker, John Nance, a pilot, broadcast commentator, bestselling author, and founding Board member of the National Patient Safety Foundation. Nance spoke about using lessons learned in aviation safety to revolutionize safety in healthcare. He touched on his experience using human factors principles to enhance safety, and urged healthcare professionals to continue to look for ways to address error prevention that incorporate knowledge from many different fields.
We also want to thank the organizations and individuals who attended and/or sponsored our 13th Annual CHEERS Awards dinner. 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 2011.