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ISMP 26th Annual Cheers Awards: Hitting the Safety High Notes

This month, ISMP celebrated the 26th annual CHEERS AWARDS, which recognize individuals, organizations, and groups that have demonstrated extraordinary commitment to advancing the science, study, and practice of medication safety. This year’s winners were honored at an awards ceremony held on December 5, 2023, at the House of Blues in Anaheim, CA. Please join us in congratulating this impressive group of medication safety virtuosos, who have shown outstanding dedication to reducing adverse events and infection risks and supporting second victims of medication errors.


Boston Medical Center was recognized for its implementation of barcode medication administration (BCMA) and positive patient identification (PPID) prior to administering any medication or vaccine in ambulatory care settings. One of the 2023-2024 ISMP Targeted Medication Safety Best Practices for Hospitals calls for expanding BCMA beyond inpatient areas. Boston Medical Center began to incorporate the technology into their general and family medicine clinics in early 2023, achieving a scanning compliance rate of 98%. However, the team realized there were still gaps in their process—ambulatory clinics. Here, patients were not receiving a patient identification band, so staff were still verbally verifying patient name and date of birth prior to medication administration. Both BCMA and PPID were implemented in the pediatric clinics to address this gap, and scanning compliance has been successful at 97%. This process has averted numerous close calls, particularly in the identification of the correct patient when siblings were in the same exam room and required immunizations. In addition, through a direct computer interface with the Massachusetts Immunization Information System, vaccine documentation is automatically being sent to the state registry, improving the accuracy of patients’ vaccine records. Boston Medical Center’s end goal is successful deployment of BCMA and PPID in all 45 of its ambulatory clinics that administer medication and vaccines. 

Corewell Health in Grand Rapids, MI, was honored for eliminating inadvertent infection exposure of multi-use insulin pens in their organization by implementing the use of a patient-specific barcode on the pen to help prevent using it for multiple patients. After a gap analysis, a multidisciplinary team led by a physician assistant, a pharmacist, and an information technology analyst identified ways to prevent patient-to-patient exposures involving insulin pens. The team used a layered approach of low-, mid-, and high-level strategies over a period of three years. They built an additional layer of safety by developing an automated process in which patient-specific barcode labels are printed and applied to multi-use medications on the nursing unit. Printers were installed in each medication room and all formulary insulin pens were moved to the automated dispensing cabinet (ADC). Once insulin pens are removed from the ADC, a patient-specific label is applied before it leaves the room. Before administration, nurses scan the patient’s wristband, patient-specific barcode on the pen, and the manufacturer’s barcode. After all three scans are complete, the system allows them to proceed. Since implementation, Corewell Health has had zero patient exposures. They have shared their process at the state, local, and national levels and with Epic, who intends to include it in their software update in 2024.


One of the many highlights of the evening was the presentation of the 2023 ISMP LIFETIME ACHIEVEMENT AWARD, which is given in memory of ISMP’s late Trustee David Vogel, PharmD. The award honors individuals who have made ongoing contributions to medication safety throughout their career. This year’s honoree, Susan Donnell Scott, PhD, RN, CPPS, FAAN, has dedicated her career to developing a strong peer support for clinicians and second victims of medication errors. 

Dr. Scott’s groundbreaking research has helped define the second victim phenomenon, and increased understanding of the unique needs of healthcare team members during the aftermath of unexpected clinical events. She designed and deployed a first-of-its-kind peer support network, the forYOU Team, at the University of Missouri Health Care System in Columbia, MO. This evidence-based and holistic approach to provision of institutional support, promotes the psychological safety of staff during the period of extreme stress following emotionally challenging clinical events, and has become an international model for healthcare organizations seeking to create their own support structure. 

In addition to leading the forYOU Team, Dr. Scott currently practices as a nurse scientist at the University of Missouri Health Care System and is an adjunct associate professor at the Sinclair School of Nursing. She has partnered with other organizations, including the Agency for Healthcare Research and Quality, the American Hospital Association, The Joint Commission, the Institute for Healthcare Improvement, and Medically Induced Trauma Support Services to ensure that comprehensive second victim support interventions are accessible to healthcare institutions and practitioners around the world. 

In her acceptance remarks, Dr. Scott emphasized that offering accessible and effective support for second victims should not be seen as a choice for staff, but an expected and consistent response. She called on organizations to address second victim experiences spanning the whole spectrum of severity, and to proactively nurture a supportive environment that considers the overall well-being of healthcare professionals. She noted that each individual possesses the power to contribute to this transformative vision, irrespective of position or title. Dr. Scott expressed optimism about the future that the entire healthcare community can collectively help shape, creating workplaces that cultivate innovation, inclusivity, kindness, and positive change. 

Special Guest Speaker 

This year’s CHEERS AWARDS dinner also featured a special guest who has herself been a second victim—RaDonda Vaught, a former nurse criminally prosecuted for a fatal medication error. ISMP and many other healthcare organizations spoke out in support of RaDonda and against the criminalization of medication errors during her highly publicized trial and sentencing. In an onstage conversation with ISMP President Rita Jew, RaDonda shared her compelling story regarding the human side of medication-related mistakes and the impact of the error on everyone involved. She stressed how much ISMP and ECRI’s public statement about her case meant to her, and ways she has found some closure. She touched on the systems that, if they had been in place, could have prevented the error and why she continues to feel that speaking up about issues, including medication error reporting, is essential for organizational learning.

Thanks, and Looking Forward

We would like to express our immense gratitude to all of the organizations and individuals who attended and/or supported this year’s CHEERS AWARDS. For a list of contributors and winners, please click here, and for ways you can join us in creating a brighter future for medication safety, please click here.

ISMP wishes everyone happy holidays, and we look forward to continuing to work together on preventing medication errors and keeping patients safe in 2024.

Suggested citation:

Institute for Safe Medication Practices (ISMP). ISMP 26th Annual Cheers Awards: Hitting the safety high notes. ISMP Medication Safety Alert! Acute Care. 2023;28(25):1-2.