ISMP’s 25th Annual Cheers Awards: Walking the Red Carpet with Safety Stars
This month, ISMP celebrated the 25th anniversary of its Cheers Awards, which recognize individuals, organizations, and groups that have demonstrated an extra-ordinary commitment to advancing the science and study of patient safety. This year’s winners were honored at an awards ceremony held on December 6, 2022, at Stoney’s Rockin’ Country in Las Vegas, NV. Another reason it was a historic event was because ISMP had the opportunity to honor its own medication safety star, President Emeritus Michael Cohen, with the Lifetime Achievement Award. Please join us in congratulating Mike and the rest of this impressive group of leaders, who have been true stars and developed innovative best practices and programs to advance patient safety.
Cheers Awards winners
Sharp HealthCare, based in San Diego, CA, was recognized for developing innovative solutions to reduce the risk of patient harm when infusing non-cytotoxic vesicant/irritant medications via peripheral intravenous (IV) lines. The multidisciplinary performance improvement team identified areas for improvement and developed guidelines to standardize processes to prevent and treat extravasations of these vesicant/irritant drugs and to support safe administration. They also capitalized on the use of technology by building rules, enhancing IV site change documentation, and providing tools at the point of care to ensure staff awareness of appropriate interventions during administration. The team, which consists of pharmacists, physicians, nurses, information specialists, and vascular access specialists, was able to significantly reduce the number of extravasation events after just 1 year.
Shifa International Hospital in Islamabad, Pakistan, was honored for implementing camera-assisted verification for chemotherapy admixture services with limited resources. In order to follow ISMP’s Targeted Medication Safety Best Practices for Hospitals, the pharmacy services team wanted to ensure that the proper ingredients and amount of each product were confirmed prior to being added to the final chemotherapy IV bag. The team put into place an affordable, workable solution that did not put additional financial strain on the hospital. With support from leadership, the project was funded for a total of approximately $915 US dollars. Shifa International Hospital’s successful initiative serves as an example of what international healthcare organizations that cannot afford advanced technology such as gravimetric analysis equipment, robotic applications, and IV workflow software can accomplish to prevent errors.
George DiDomizio Award winner
The George DiDomizio Award was established in 2012 in memory of a late ISMP Board member who advocated for greater cooperation between the medical industry and the broader healthcare community to promote safer drug products. The award was given this year to Vitalis, a pharmaceutical company based in Colombia, for its dedication to designing safer labels and packages for their medications despite the fact that it is not mandatory at the regulatory level in Latin America.
After recognizing potential safety issues with their injectable medications, Vitalis reached out to several organizations, including ISMP, for guidance. As a result, new labels were designed that include several strategies: color differentiation between products and strengths, white background to improve contrast, and more legible text with vertical orientation that can easily be read by practitioners. Dangerous abbreviations have been removed and tall man (mixed case) lettering is utilized where appropriate.
These changes were incorporated into labeling on the medication packaging, ampules, and vials, and today these products are being distributed in several countries, including Colombia, Ecuador, Peru, Chile, Panama, and Costa Rica.
Lifetime Achievement Award winner
One of the real highlights of the evening was the presentation of the 2022 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 patient safety throughout their career. This year’s honoree, Michael R. Cohen, RPh, MS, ScD (hon), DPS (hon), FASHP, has provided invaluable leadership and served as an unparalleled source of inspiration for so many healthcare practitioners.
Mike is the President Emeritus and co-founder of ISMP and has dedicated his long career to advocating for medication error prevention. Mike’s passion for medication safety began in 1974 when he was alerted to a serious adverse event with insulin at a local hospital and immediately saw the value in sharing the story to prevent the same error from occurring again.
He founded ISMP in 1994 and launched the first of the ISMP Medication Safety Alert!® publications in 1996. Those newsletters now reach over a million health professionals in the United States and more than 30 foreign countries. Mike and his colleagues at ISMP have been instrumental in bringing about countless changes in clinical practice, public policy, and drug labeling and packaging that have impacted millions of patients and healthcare professionals in the United States and internationally.
Mike is the co-founder and longtime Chairperson of the International Medication Safety Network (IMSN), and a former member of the US Food and Drug Administration (FDA) Drug Safety and Risk Management Advisory Committee and Nonprescription Drugs Advisory Committee. He currently serves as Vice Chair of the Nomenclature and Labeling Expert Committee of USP. His many awards and honors include receiving the John M. Eisenberg Patient Safety and Quality Award from the National Quality Forum and The Joint Commission and being recognized as a MacArthur Fellow by the John D. and Catherine T. MacArthur Foundation. He also received the Harvey A. K. Whitney Award from the American Society of Health-System Pharmacists (ASHP).
Mike was the keynote speaker for the 25th annual Cheers Awards and reflected on the past before looking into the future. He expressed gratitude for ISMP’s role in giving the United States a strong start on addressing the issues and barriers to medication safety that often hold healthcare initiatives back, and thanked ISMP staff for their dedication and determination to push forward. Mike also outlined some of the many advances that ISMP has fought for over the years, many of which have been and continue to be widely implemented by healthcare providers, regulators, accreditors, and industry:
Developing the terminology and concept of “high-alert medications,” and establishing a list with layered error-reduction strategies
Calling infusion pumps with a dose error-reduction system (DERS) “smart pumps”
Furthering the development and utilization of tall man (mixed case) lettering to decrease drug name mix-ups
Publishing the first scholarly article on free-flow protection for infusion pumps
Helping to get medication barcoding widely adopted
Creating vital resources such as a list of look-alike/sound-alike drugs
Maintaining a list of error-prone abbreviations that should never be used
Advocating for vinCRIStine to be dispensed and administered via a minibag instead of a syringe to prevent fatal wrong route errors
Promoting the adoption of ENFit devices to prevent tubing misconnections
Encouraging large scale changes like the adoption of the metric system for over-the-counter (OTC) and pediatric drug dosing instead of household measures, including the use of mL to avoid confusion between teaspoon and tablespoon
Starting the ISMP National Vaccine Errors Reporting Program (ISMP VERP) and warning about errors with two component vaccines
Founding the Medication Safety Officers Society (MSOS)
Improving packaging and labeling of pharmaceuticals, including advocating for expiration date standards and the adoption of premixed solutions, and ready-to-administer and ready-to-use products
Initiating summits, guidelines, self-assessments, and other tools to help organizations improve patient safety
He also touched on ISMP’s work to help elevate medication safety internationally, including development of successful ISMP affiliates in Brazil, Canada, and Spain and co-founding the International Medication Safety Network (IMSN). Mike emphasized that the world needs ISMP, and we need our supporters to continue our lifesaving work. He called on the entire healthcare community to continue helping ISMP to ensure that the powerful lessons learned from error reports are heard around the globe.
After reflecting on the lifesaving work that has been accomplished, Mike noted there is still much to be done. This includes working with State Boards to expand the concepts in ISMP’s Targeted Medication Safety Best Practices for Hospitals, into community pharmacy settings. As for the industry, he made a call to action that “we need your help” as both a source of funding for educational programs and to continue to make products safer. Mike aims to draw national attention to medication safety problems, offer healthcare providers new ways of looking at problems, and inspire change.
Thanks and looking forward
We would like to express our gratitude to all 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 you a happy, safe, and peaceful holiday season, and we look forward to continuing to work together on preventing errors and keeping patients safe in 2023.
Institute for Safe Medication Practices (ISMP). ISMP 25th Annual Cheers Awards: Walking the red carpet with safety stars. ISMP Medication Safety Alert! Acute Care. 2022;27(25):1-3.