Building Bridges to Safety: ISMP 23rd Annual Cheers Awards
This month, ISMP celebrated its 23rd Annual Cheers Awards, which recognize individuals, organizations, and groups that have demonstrated an extraordinary commitment to advancing the science and study of patient safety. This year’s winners were honored at our first virtual Awards ceremony on December 8, 2020. Please join us in congratulating this year’s Cheers Awards winners, an impressive group of leaders who have helped create innovative solutions by building bridges to advance medication safety.
Cheers Awards Winners
Mary E. Burkhardt, MS, RPh, FASHP, FSMSO, was honored with a distinct Cheers Award, an ISMP Volunteer Award, for her decades of altruistic service to ISMP. She has tirelessly volunteered her time to many ISMP programs, projects, and advisory groups, and has contributed valuable suggestions and recommendations. Mary authored two chapters in ISMP’s book, Medication Errors, 2nd Edition, and worked on the development, pilot testing, and use of ISMP’s medication safety self assessments, including the Medication Safety Self Assessment for High-Alert Medications, and the soon-to-be launched Medication Safety Self Assessment for Perioperative Settings.
She also has mentored ISMP Fellows as well as other practitioners just starting out in their careers and is often called upon for advice or to answer questions. Mary has been dedicated to keeping the lines of communication open with ISMP, often taking the initiative to reach out and share new knowledge. She has been a valuable asset in helping ISMP achieve its mission. Currently, she is a National Pharmacy Executive at the Veterans Affairs (VA) National Center for Patient Safety in Ann Arbor, Michigan.
The Choctaw Nation Health Services Authority (CNHSA), located in rural southeastern Oklahoma, was honored with a Cheers Award for employing a full-time medication safety officer in a unique setting, enabling the implementation of a wide range of impressive medication safety initiatives. After ISMP published a white paper in 2018, encouraging all healthcare organizations to establish a full-time medication safety position, CNHSA expanded its auxiliary position to a full-time, dedicated professional to make past safety achievements more widespread and sustainable.
Establishment of a full-time medication safety officer position also helped CNHSA create an extensive and proactive improvement process and medication safety program unsurpassed in other tribal health organizations. A few notable medication safety initiatives include publication of a system-wide Medication Safety Newsletter, implementation of the ISMP Targeted Medication Safety Best Practices for Hospitals, and monthly review and mitigation of both internal and external medication errors and hazards. CNHSA now serves as a strong advocate for dedicating significant resources to medication safety in rural healthcare systems and has shared its experiences at a regional Indian Health Service conference.
Einstein Medical Center Montgomery in East Norriton, Pennsylvania, was honored with a Cheers Award for its development and implementation of a novel screening tool, the Einstein Montgomery Opioid-induced Ventilatory Impairment Assessment (EMOVIA©). There are other screening tools available to assess issues with ventilation of patients on opioids, but unlike EMOVIA, the recommended actions are physician-driven. EMOVIA interventions are nurse-driven and immediate, allowing nurses to treat patients in real time, and empowering them to intervene immediately using nursing judgment and following an established protocol.
EMOVIA is the only tool that supports the use of continuous electronic monitoring using capnography, which is considered the gold standard for managing patients at risk for opioid-induced ventilatory impairment. Implementation of EMOVIA at the medical center has helped code blues remain at zero for medical-surgical patients receiving opioids and has reduced unplanned intubations by 55% in this same patient population. The organization has shared its processes and lessons learned with the healthcare community at the regional, state, and national levels.
The HCA West Florida Division received a distinct Cheers Award, an ISMP Subscriber Award, for the consistent distribution and use of information provided in ISMP newsletters, and the resulting improvements in medication safety across their 15 hospitals. The division’s interdisciplinary Medication Safety Committee has been instrumental in implementing key safety strategies published in the ISMP Action Agenda as well as various ISMP guidelines and assessment tools.
Currently, the ISMP Targeted Medication Safety Best Practices for Hospitals are being used as a guide to perform medication safety audits and medication safety rounds in nursing units within each facility to identify vulnerable areas. ISMP guidelines associated with smart infusion pumps, automated dispensing cabinets, and safe electronic communication have been used to implement strategies to minimize risk. Also, participation in the ISMP Medication Safety Self Assessment for High-Alert Medications has resulted in dozens of division-wide improvements. In addition, order sets and policies have been standardized, and a quarterly division-wide newsletter has been created to communicate important information and progress in medication safety improvement to staff.
Tina M. Suess, MHA, BSN, RN-BC, CPHIMS, CPPS, was honored with a Cheers Award for providing exceptional leadership in the healthcare information technology industry on a national level, as well as in her own community hospital. Over her career, she has become known as a forward-thinking expert on several medication use technologies, including barcoding access across the entire medication use process and smart pump-electronic health record interoperability. She has consistently served as a liaison between clinical and information technology services, ensuring a patient-centric approach to the use of medication safety technology.
She has participated in alpha- and beta-testing for emerging technologies, conducted research, and shared her knowledge through numerous national, state, and local presentations as well as journal publications. Tina also has provided ISMP with input on the challenges and achievements possible with infusion-related technologies, using her unique perspective on technology adaptation in a real-life setting. She is currently Manager of Medication Safety Integration for Penn Medicine Lancaster General Health in Lancaster, Pennsylvania.
George Di Domizio Award Winner
The George Di Domizio 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 Mary Baker, PharmD, MBA, FASPEN, for consistently serving as a valuable resource to ISMP regarding pharmaceutical product manufacturing.
Dr. Baker has more than 30 years of experience in the industry, and is currently the Senior Director, Sterile Injectables, in Pfizer’s Biopharmaceuticals Group in Lake Forest, Illinois. She has provided ISMP with essential insight from the industry side and helped gather information and direct ISMP to credible sources for a wide variety of topics outside of her area of expertise. Dr. Baker has served as Vice Chair of the USP Nomenclature and Labeling Expert Committee and holds an adjunct faculty appointment at Purdue University College of Pharmacy. She has received numerous awards and honors throughout her career, including USP’s Award of Recognition, Purdue College of Pharmacy Distinguished Alumna, and the Purdue Pharmacy Women’s Leadership Award.
Lifetime Achievement Award Winner
One of the highlights of the evening was the presentation of the 2020 ISMP Lifetime Achievement Award, given in memory of ISMP’s late Trustee David Vogel, PharmD, which honors individuals who have made ongoing contributions to patient safety throughout their career. This year’s honoree, David Cousins, BPharm, MSc, FRPharmS, PhD, has tirelessly pursued development of a safe medication policy agenda in the United Kingdom (UK) that has since been modeled around the world.
As chief pharmacist at the Derbyshire Royal Infirmary in Derby, he played a leading role in raising awareness of medication safety in the UK. Together with Dr. David Upton, Dr. Cousins wrote a monthly column on medication errors in the journal Hospital Pharmacy Practice. He served as head of safe medication practice at the former National Patient Safety Agency (NPSA) and then NHS England for 12 years, helping develop the National Reporting and Learning System and issue patient safety alerts. He was a key author of the “Design for Safety” publication series, illustrating how good design can help minimize risk to patients arising from labeling and packaging of medicines. He also authored a 2014 patient safety alert requiring every NHS organization in England to appoint a medication safety officer.
In 2017, as part of his work with the organization Healthcare at Home, Dr. Cousins designed and implemented a comprehensive safety incident reporting and learning system for the home care setting. He is a founding member and committee member of the International Medication Safety Network (IMSN), and during his retirement has been advising and publishing reports for the patient charity, Action against Medical Accidents (AvMA).
In his acceptance remarks, Dr. Cousins described his advocacy journey to improve medication safety in the UK. His presentation covered some of the barriers he encountered along the way, including the need for greater transparency and openness to learning about errors and addressing risk. Dr. Cousins also described how he has worked with ISMP and other organizations to shine a greater light on the need for medication error prevention.
During the Awards ceremony, ISMP President Michael Cohen presented highlights of what ISMP has accomplished this year with your help, including the release of special free editions of the ISMP newsletter devoted to the information healthcare practitioners needed for response efforts related to the coronavirus disease 2019 (COVID-19) pandemic. Dr. Cohen emphasized that ISMP could not have achieved our shared medication safety goals without loyal supporters who submit medication and vaccine error reports to ISMP, provide us with feedback on our safety recommendations, read and incorporate the advice from our newsletters, or make a donation.
ECRI President and Chief Executive Officer (CEO) Marcus Schabacker spoke about the impact that the ISMP-ECRI partnership has had on patient safety and where the field of healthcare is headed in the future. Dr. Schabacker noted that one of the biggest areas of change has been in point-of-care delivery, and that the rapid adoption of telehealth and remote care that arose during the pandemic will likely continue to expand.
A Heartfelt Thanks to All
ISMP would like to thank all of the organizations and individuals who attended and/or supported this year’s Cheers Awards. Visit our website for a list of contributors and winners, and for ways you can join us in building more bridges to medication safety. If you were not able to attend this year’s virtual Cheers Awards, you can view a recording of the event posted on ISMP’s website.
ISMP also salutes all of the healthcare heroes and essential workers who have shown bravery and resilience and gotten us through this unprecedented year. You move us, you inspire us, and we are so grateful for you. We look forward to continuing to work together on preventing medication errors and keeping practitioners and patients safe in 2021.