Awardees Focused on Safety Technology, Second Victims
The Institute for Safe Medication Practices (ISMP) is proud to announce the 26th Annual Cheers Award winners, who have shown outstanding dedication to reducing adverse events and infection exposure, and a Lifetime Award Winner who has focused her career on helping support practitioners involved in accidental errors that harm patients. This year’s speaker will be RaDonda Vaught, a former nurse prosecuted for her role in a fatal medication error in one of the highest profile healthcare-related criminal cases in recent years.
The awards ceremony will be held on Tuesday, December 5, 2023, at the House of Blues in Anaheim, CA. The ISMP Cheers Awards honor individuals, organizations, and companies that have set a standard of excellence in medication safety; for more information, click here.
The winners of this year’s ISMP Cheers Awards are:
-
Boston Medical Center
Boston, MA
Boston Medical Center’s Medication Safety and Quality Committee is receiving a Cheers Award for its implementation of barcode medication administration (BCMA) and positive patient identification (PPID) 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 compliance rate of 98%. However, the team realized there were gaps in their process—ambulatory clinic patients did not receive a patient identification band, so staff were still verbally verifying 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 currently stands 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 requiring 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
Grand Rapids, MI
The Corewell Health Medication Safety Team is being honored for eliminating inadvertent infection exposure with patient-specific scanning of multi-use insulin pens in their organization. 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, best practice alerts appear. Since implementation, Corewell Health West has had zero patient exposures. They have shared their process at the state, local, and national level and with Epic, which intends to include it in their software in 2024.
The ISMP Lifetime Achievement Award is being presented to Susan Donnell Scott PhD, RN, CPPS, FAAN for her dedication to developing 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 health care 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 (MUHC) 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 and is an adjunct associate professor at the Sinclair School of Nursing. She has partnered with a wide range of other organizations, including the Agency for Healthcare Research and Quality, American Hospital Association, The Joint Commission, Institute for Healthcare Improvement, and Medically Induced Trauma Support Services to ensure that comprehensive second victim support interventions are accessible to healthcare institutions around the globe.
This year’s Cheers Awards speaker will be RaDonda Vaught, a former nurse criminally prosecuted for a fatal medication error who has a compelling story to tell. RaDonda holds a BSN from Western Kentucky University and while working as a registered nurse, committed a medication error that ended the life of a patient in 2017. She self-reported her error and provided detailed information to help prevent similar mistakes in the future but was convicted of two felony charges and lost her nursing license in what was one of the highest profile healthcare-related criminal cases in recent years. ISMP and many other healthcare organizations have spoken out in support of RaDonda and against the criminalization of medication errors. Today she is a passionate advocate for system-based medication safety and improvement and speaks about the impact this sentinel event has had on her life and her profession.
Contact
Renee Brehio, Medication Safety Analyst and Editor, rbrehio@ismp.org
About the Institute for Safe Medication Practices
The Institute for Safe Medication Practices (ISMP) is the nation’s first 501c (3) nonprofit organization devoted entirely to preventing medication errors. ISMP is known and respected for its medication safety information. For more than 30 years, it also has served as a vital force for progress. ISMP’s advocacy work alone has resulted in numerous necessary changes in clinical practice, public policy, and drug labeling and packaging. Among its many initiatives, ISMP runs the only national voluntary practitioner medication error reporting program, publishes newsletters with real-time error information read and trusted throughout the global healthcare community, and offers a wide range of unique educational programs, tools, and guidelines. In 2020, ISMP formally affiliated with ECRI to create one of the largest healthcare quality and safety entities in the world, and ECRI and the ISMP PSO is a federally certified patient safety organization by the U.S. Department of Health and Human Services. As an independent watchdog organization, ISMP receives no advertising revenue and depends entirely on charitable donations, educational grants, newsletter subscriptions, and volunteer efforts to pursue its life-saving work.
