We Have the Winning Hand: 22nd ISMP Cheers Awards
Last week, ISMP celebrated our 22nd Annual Cheers Awards, which recognize organizations, groups, and individuals who have demonstrated an extraordinary commitment to advancing patient safety. This year’s winners were honored at a dinner held at Stoney’s Rockin’ Country in Las Vegas, NV, on December 10, 2019. Please join us in congratulating this impressive group of leaders who have played their cards well to create innovative projects, programs, educational efforts, and research to prevent medication errors and improve the safety of patient care.
CHEERS Awards Winners
For more than 28 years, the Anticoagulation (AC) Forum has been educating healthcare professionals and advocating for clinical best practices in the field of anticoagulation therapy. Founded in 1991, the AC Forum has a membership of 12,000 pharmacists, physicians, and nurses, representing more than 3,000 anticoagulation practice sites that support more than 1 million patients annually. The AC Forum’s flagship program, the Anticoagulation Centers of Excellence, provides access to tools, guidelines, assessments, current literature, patient and family educational materials, and many other resources to improve patient outcomes through application of evidence-based best practices.
The AC Forum recently released a US Food and Drug Administration (FDA)-funded report, Core Elements of Anticoagulation Stewardship Programs, similar to successful stewardship campaigns involving antibiotics. The anticoagulation stewardship guide outlines ways to improve the safety and quality of patient care and reduce adverse drug events associated with anticoagulants. The guide defines 7 core elements for implementing anticoagulation stewardship programs, starting with securing administrative leadership commitment and ending with advancing education, comprehension, and competency. It also includes a checklist for evaluating current practices and a gap analysis that identifies weaknesses in oversight modalities (i.e., regulations and quality measures) for hospitals and skilled nursing facilities. The guide is available for download via the AC Forum’s website. There is no cost to join the AC Forum and all resources are free of charge.
Boston Children’s Hospital has developed a unique tiered system to respond to external medication recalls that may cause harm to patients. Staff found that pediatric patients taking certain outpatient medications at home often were not contacted when major recalls occurred and, in some cases, could be disproportionately harmed. For example, when blood pressure medications were found in leukotriene receptor antagonist containers, a single dose of the antihypertensive would be unlikely to harm most adults but could injure a child. Therefore, in 2018, the hospital pharmacy staff created an external medication recall management system to notify pediatric patients and their caregivers when significant recalls occur.
Since then, 251 recalls have been logged into the system, some involving multiple medications. Five of the recalls required an immediate response due to risk of significant patient harm. Notifications have included direct patient or caregiver contact, calling retail pharmacies, messaging by mail and email, and communication via patient portals and external webpages. The communication with retail pharmacies about the recalls has had the additional benefit of helping alert outpatient pharmacy customers who were not patients of Boston Children’s Hospital. Since most of the recalls have involved medications that were not on the hospital formulary and were not dispensed to hospitalized patients, the outpatient pediatric population may not have known about the significant recall without this notification program.
The Arizona Safe Medication Collaborative Team received special recognition during the 2019 Cheers Awards for its timely and persistent statewide advocacy for adult IV push medication safety. In just 10 months, the team has been able to pull together key stakeholders in Arizona to advocate for the adoption of best practices, including those reflected in the ISMP Safe Practice Guidelines for Adult IV Push Medications.
Surveys have been conducted with clinical nurse faculty and bedside nurses to determine what clinicians are being taught and variations in IV push practices, and an IV push competency checklist has been developed to assist with verifying skills and reinforcing knowledge. The team also contacted Micromedex and the Davis’s Drug Guide and secured their agreement to update their references using the ISMP guidelines. This dedicated group of advocates is currently working with the Arizona State Board of Nursing Scope of Practice Committee to obtain an official advisory opinion to adopt the ISMP guidelines. The team has been invited to draft the opinion, which was recently presented to the Board. Their grassroots effort has made significant progress in addressing a difficult and longstanding medication safety issue and can serve as a catalyst for change in other states as well.
George Di Domizio Award Winner
The George Di Domizio Award was established in 2012 in memory of a late ISMP trustee who advocated for greater cooperation between the medical industry and the broader healthcare community to promote safer drug products. This year’s George Di Domizio Award was presented to Dennis Tribble, PharmD, FASHP.
Dr. Tribble has shown extraordinary leadership in developing innovative technology for safe medication preparation and delivery. He has more than 30 years of experience in the field, first in hospital pharmacy management and then with the medication management automation industry. He holds more than 30 patents in healthcare automation, including the development of the first IV robotic device and the first IV workflow software. He was an early proponent of barcoding to improve the accuracy of pharmacy compounding and bedside medication administration. Dr. Tribble has served as an advisor for the ISMP Guidelines for Safe Preparation of Compounded Sterile Preparations. He is known not only for his expertise in pharmacy automation, but also for his openness, objectivity, and honesty in responding to safety-related issues.
Dr. Tribble is a founding member of the Healthcare Information and Management Systems Society Pharmacy Informatics Task Force and past chair of the American Society of Health-System Pharmacists Section of Pharmacy Informatics and Technology. He has also worked with the nonprofit Emily Jerry Foundation on increasing awareness of the need for technological solutions to reduce the risk of medication errors. He is currently Director of Medical Affairs for the Medication Management Systems at BD.
Lifetime Achievement Award Winner
The ISMP Lifetime Achievement Award, given in memory of ISMP’s late Trustee David Vogel, PharmD, honors individuals who have made ongoing contributions to patient safety throughout their career. This year’s Lifetime Achievement Award was presented to Rita Shane, PharmD, FASHP, FCSHP.
Dr. Shane has dedicated her more than 40 years of professional work to making medication use safer for patients by taking an evidence-based approach to developing innovative practices. She is currently Chief Pharmacy Officer and Professor of Medicine at Cedars-Sinai Medical Center in Los Angeles, California, and Assistant Dean of Clinical Pharmacy Services at the University of California-San Francisco School of Pharmacy.
In 2018, she co-authored legislation requiring hospital pharmacists in California to obtain medication lists for high-risk patients when they are admitted and again when they are discharged. Dr. Shane has collaborated on research that led to the approval of “tech-check-tech” by the California State Board of Pharmacy for technician-filled medication cassettes in hospitals. She introduced the concept of high-alert patients and, recently, laid bare the risks to patients caused by payer-driven biosimilar requirements. She was also one of the investigators in a multicenter study of medication errors that were prevented by emergency department pharmacists.
Dr. Shane has won numerous professional awards, including three awards from the American Society of Health-System Pharmacists—the Harvey A.K. Whitney Award, Leadership Award, and Honorary Membership Award. She has been listed among the “50 Experts Leading the Field of Patient Safety” by Becker’s Hospital Review, published more than 100 papers, and given more than 200 presentations nationally and internationally.
CHEERS Awards Keynote Presentation
The keynote speaker for the 22nd Annual Cheers Awards was Marcus Schabacker, MD, PhD, Chief Executive Officer and President of the ECRI Institute. Dr. Schabacker spoke about some of the biggest challenges facing the healthcare industry, such as the move of care delivery from the hospital to the home, aging populations and the rise of chronic diseases, significant shortages of healthcare professionals, and the persistence of medical errors. To address these problems, he expanded on the potential for emerging technology and a digital health ecosystem to help support clinicians and provide safe, secure, private, and validated healthcare that is accessible to everyone. Noting that consumers are already using digital health tools—from mobile technology to remote monitoring—he emphasized the need to overcome current digital health challenges such as poor-quality data, the negative impact on provider productivity, and potential security and privacy breaches of protected patient data. He stressed the growing need for independent, fact-based, and transparent evaluation of new technologies to ensure the quality of care and patient safety. Dr. Schabacker also addressed ISMP’s new affiliation with ECRI, pointing out ways that joining forces will make both organizations even stronger and better able to serve their common missions.
Thanks for Another Wonderful Year!
We would like to thank the organizations and individuals who attended and/or supported this year’s Cheers Awards dinner. It was a fun evening, and the entertainment included old Las Vegas music and casino tables that lured all to try their hands at poker, blackjack, and roulette. Luckily, at this event, everyone was a winner for patient safety. For a list of contributors and winners, click here, and for ways you can help ISMP continue the fight against preventable medication errors, click here. We look forward to another great year of working together to improve medication safety in 2020.