The Institute for Safe Medication Practices (ISMP) is proud to announce its 24th Annual Cheers Awards winners. The awards ceremony will be held as a virtual event on Tuesday, December 7, 2021. The ISMP Cheers Awards honor individuals, organizations, and companies that have set a standard of excellence for others to follow in the prevention of medication errors and adverse drug events; for more information, visit: https://www.ismp.org/cheers-awards.
The winners of this year’s awards are:
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City of Hope Protocol Content Administrators
Duarte, CA
The City of Hope Cancer Center’s Protocol Content Administrators (PCA) team is receiving a Cheers Award for their work in promoting safety and research integrity by ensuring the accuracy of all elements pertaining to investigational treatment plans. The City of Hope Cancer Center typically has more than 700 clinical trials open at a time. The team conducts a comprehensive review of every clinical trial protocol, lab manual, and pharmacy manual for discrepancies that could lead to medication errors. They also review and customize each patient’s treatment plan in the electronic medical record to help prevent errors and increase transparency, efficiency, and continuity of care. As of July 2021, the PCA team has made 493 clarifications, mostly in protocols, more than 20% of which have had a positive patient safety impact.
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Inova Health System
Fairfax, VA
Inova Health System’s Intravenous (IV) Insulin Team: Push It, Push It Real Safe, is being recognized with a Cheers Award for their persistence in improving the safety of IV regular insulin administration. Inova’s pharmacy medication team has collaborated with other disciplines to implement error-reduction strategies, including restricting regular insulin to the IV route, requiring regular insulin prescribing via order sets with dosing limits, linking orders for IV push regular insulin to ensure dispensing of an appropriate needleless luer lock insulin syringe, and including an image of the appropriate syringe to be used for administration in the medication administration record. The team also has ensured that commercially available premixed regular insulin is being used for IV infusions. Many ISMP tools and guidelines have been utilized during the process, and over the last year there has been a significant reduction in severe hypoglycemic events.
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KIDs List Collaborative
Commissioned by the Pediatric Pharmacy Association (PPA)
Authors: Rachel S. Meyers, PharmD; Jennifer Thackray, PharmD; Kelly L. Matson, PharmD; Christopher McPherson, PharmD; Lisa Lubsch, PharmD; Robert C. Hellinga, PharmD; and David S. Hoff, PharmD
The KIDs List is being honored as the first available list of drugs that should be “avoided” or “used with caution” in pediatric patients. In 2017, PPA commissioned a team of pediatric pharmacists to compile a list of drugs potentially inappropriate for use in pediatric patients, similar to the Beers Criteria used for the elderly population. The goal was to improve the safe use of medications in pediatric patients and inspire future research on medication safety in children. After three years of literature review and gathering expert opinions, the KIDs List was published in the March 2020 issue of the Journal of Pediatric Pharmacology and Therapeutics. The article is open access, making it free to use for the entire healthcare community. The KIDs List will be updated every five years, and the team intends to include other healthcare disciplines in the development and review of future versions.
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The Medication Safety Minute
St James’s Hospital, Dublin, Ireland
The St James’s Hospital Medication Safety Minute team is receiving a Cheers Award for their innovative system of delivering weekly micro-learning sessions related to safe prescribing. The team developed a two-slide presentation for each “safety minute”—consisting of a question or a teaser and an answer—that hospital physicians with limited time can access at their convenience. From the start, the safety minutes have been made available to a wider audience. They are used by 24 additional hospitals in Ireland, shared with undergraduate and postgraduate students at local colleges in Ireland, and shared on social media with a dedicated Twitter handle (@medsafetymin). Over the last four years, the team has created and distributed 126 weekly safety minutes, which are available as a free online access resource in the form of a digital flipbook.
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Raymond J. Muller, RPh, MS, FASHP
Director of Pharmacy Quality, Safety, and Training Programs
Memorial Sloan Kettering Cancer Center (MSK)
New York, NY
Ray Muller is being honored with a Volunteer Award for his decades of altruistic service to ISMP as a clinical advisor on oncology-related medication errors. He has helped address dozens of potentially harmful issues, particularly with packaging/labeling and look-alike drug names, and often has been the first healthcare professional to alert ISMP to safety concerns with new oncology medications entering the market. Ray was instrumental in helping ISMP publish a series of newsletter articles on significant product-related issues with investigational drugs and develop practical recommendations and solutions for the U.S. Food and Drug Administration (FDA), clinical trial sponsors, and clinical trial sites. In addition, he joined ISMP in influencing FDA to recommend minibag administration of vinCRIStine and to remove syringe administration as an option from the approved prescribing information to prevent inadvertent and deadly intrathecal administration.
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Medication Safety Initiative on Safe Use of Concentrated Electrolytes
Tabba Heart Institute, Karachi, Pakistan
Tabba Heart Institute is receiving a Cheers Award for its proactive initiative to eliminate concentrated electrolytes from floor stock and patient care units. The pharmacy department decided to embark on the project after another hospital in Pakistan had an event in which a 9-month-old baby girl died after receiving the wrong drug, potassium chloride for injection concentrate, which was only available in vials on the unit. Hospital leadership fully supported and funded the initiative despite significant challenges, including the fact that commercially available premixed IV fluids containing potassium chloride are not available in Pakistan. The Tabba Heart Institute initiative’s success helps increase awareness of the need for similar efforts among international healthcare providers and for affordable premixed solutions to be made more widely available around the globe.
The ISMP Lifetime Achievement Award is being presented to Patricia Kienle, RPh, MPA, BCSCP, FASHP, for her leadership and longstanding commitment to medication safety. Kienle is one of the nation’s foremost experts on medication management as well as accreditation and regulatory issues, especially in the areas of sterile compounding, hazardous drugs, and radiopharmaceuticals. She has almost a half century of experience helping healthcare administrators develop and execute comprehensive medication management programs in acute and non-acute care environments, and currently is Director of Accreditation and Medication Safety for Cardinal Health. Kienle has completed an executive fellowship in patient safety at Virginia Commonwealth University and frequently offers her expertise on areas that impact error prevention, including serving as an educational resource for USP’s <797> sterile compounding standards. She is a former board member of ISMP and the American Society of Health-System Pharmacists (ASHP) and has served as president of the Pennsylvania Society of Hospital Pharmacists. She is a current member and past vice-chair of USP’s Compounding Expert Committee and has served on The Joint Commission’s Medication Compounding Technical Advisory Panel. Kienle has earned numerous state and national awards, including the ASHP Award for Distinguished Pharmacy Leadership, the ASHP John W. Webb Lecture Award, and the USP Award for Outstanding Contributions to the Standards (˂825> Expert Panel). She has been awarded a U.S. patent for a safe and ergonomic storage system for medical supplies.
Journalists who wish to attend the virtual awards ceremony should contact Renee Brehio at 614-376-0212, or [email protected].