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Path to New Beginnings: ISMP 24th Annual Cheers Awards

This month, ISMP celebrated its 24th Annual Cheers Awards, which recognize individuals, organizations, and groups that have demonstrated extraordinary commitment to advancing the science and practice of patient safety. This year’s winners were honored at a virtual awards ceremony on December 7, 2021. Please join us in congratulating this year’s Cheers Awards winners, an impressive group of leaders and organizations that have left their footprints on the Path to New Beginnings by developing innovative best practices and programs that prevent medication errors and protect patients.

Cheers Awards Winners

City of Hope Cancer Center’s Protocol Content Administrators Team has promoted patient safety and research integrity by ensuring the accuracy of all elements of investigational treatment plans. The City of Hope Cancer Center, located in Duarte, California, 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, looking for discrepancies and vulnerabilities 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 protocol content administrators team has made 493 clarifications, mostly in protocols. More than 20% of those clarifications have had a positive impact on patient safety. Additionally, the team collaborates with internal and external investigators and research personnel and has created standardized and safe protocol templates for investigator-initiated trials.

Inova Health System’s Intravenous Insulin Team has shown extraordinary persistence in improving the safety of intravenous (IV) regular insulin administration. Inova is a nonprofit healthcare provider in northern Virginia. The system’s pharmacy medication safety team has collaborated with other disciplines to implement error-reduction strategies, including requiring IV push regular insulin prescribing via order sets with dosing limits and linking the orders to ensure the dispensing of an appropriate needleless, Luer lock insulin syringe for proper measurement and administration. The team also ensured that orders for IV push regular insulin include an image of the appropriate syringe to be used in the medication administration record. Many ISMP tools and guidelines were utilized during the process, and a significant reduction in severe hypoglycemic events has resulted over the last year.

The KIDs List Collaborators developed the first available list of drugs that should be avoided or used with caution in pediatric patients. In 2017, the Pediatric Pharmacy Association (PPA) commissioned seven pediatric pharmacists to compile a list of drugs potentially inappropriate for use in pediatric patients. Those pharmacists were 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 goal was to improve the safe use of medications in pediatric patients and to inspire future medication safety research in children. After 3 years of literature reviews and gathering expert opinions, the KIDs List was published in the April 2020 issue of the Journal of Pediatric Pharmacology and Therapeutics. The KIDs List will be updated at least every 5 years, and the team intends to include other healthcare disciplines in the development of future versions.

The St. James’s Hospital Medication Safety Minute team, based in Dublin, Ireland, created an innovative system of delivering weekly micro-learning sessions related to safe medication prescribing. The team developed a two-slide presentation for each bite-size “safety minute” that physicians can access at their convenience. Initially, the goal was to provide medication safety education in 60 seconds or less for physicians, who have limited time due to multiple competing priorities. Considerable evidence exists that key information provided in short, easily digestible units of learning increases the reader’s recollection and receptiveness to changing behaviors. 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, and shared on social media with a dedicated Twitter handle. Over the last 4 years, the team has created and distributed 126 weekly Medication Safety Minutes, most of which are available in a free online resource as a digital flipbook.

Raymond J. Muller, RPh, MS, FASHP received a Volunteer Award for 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 medication packaging and labeling and look-alike drug names. Ray was instrumental in helping ISMP to publish a series of newsletter articles on significant product-related issues with investigational drugs and to develop practical recommendations and solutions for the US Food and Drug Administration (FDA), clinical trial sponsors, and clinical trial practice 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 prescribing information to prevent inadvertent and deadly intrathecal administration. He has been a steadfast advocate of this safe practice and will never give up until accidental intrathecal administration of vinCRIStine no longer occurs. 

Tabba Heart Institute in Karachi, Pakistan, was honored for launching a proactive international initiative in a low- to middle-income country to eliminate concentrated electrolytes from floor stock and patient care units. The pharmacy department embarked on the project after another hospital in Pakistan experienced an event in which a 9-month-old baby girl died after receiving the wrong drug, potassium chloride for injection concentrate, which was available in vials on the patient care 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. Instead, costly pharmacy revisions were necessary for pharmacists to prepare and dispense potassium-containing solutions. The initiative’s success helps increase awareness of the need for similar efforts among international healthcare providers and for increased availability of affordable premixed solutions around the globe.

Lifetime Achievement Award Winner

One of the highlights of the evening was the presentation of the 2021 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, Patricia (Patti) Kienle, RPh, MPA, BCSCP, FASHP, has served as an outstanding leader and role model throughout her longstanding commitment to medication safety.

Patti 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 the Director of Accreditation and Medication Safety for Cardinal Health. 

Kienle 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. She 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. 

In her acceptance remarks, Kienle stressed that medication safety is a “team sport” that involves almost all healthcare disciplines. She encouraged everyone in the healthcare community to consider what they can do as individuals, within their organizations and in the broader world of health policy, to advance safe medication use. She highlighted that practitioners and healthcare systems can do more to advance patient safety. Pharmacists and nurses can do more to provide each other with valuable insight into how medication errors occur. Healthcare systems can do more to share best practices and involve practitioners with a fresh set of eyes to identify possible risks. She emphasized that we each should have a singular focus to share our knowledge of processes with our colleagues and to learn from each other. And finally, she urged everyone to commit to promoting efforts to keep patients safe in our home states, provinces, and countries.

Thanks and Looking Forward

We would like to express our sincere 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 on the path to a brighter future for medication safety, please click here. If you were not able to attend the virtual Cheers Awards this year, you can view a recording of the event posted on the ISMP website by clicking here.   

ISMP wishes you a happy, safe, and peaceful holiday, and we look forward to continuing to work together on preventing errors and keeping practitioners and patients safe in 2022.