2009 Awards Ceremony The 2009 winner and finalists of the Award for Excellence in Medication-Use Safety were formally recognized at an invitation-only dinner held during the 2009 ASHP Midyear Clinical Meeting in Las Vegas, Nev. A group of pharmacy professionals gathered at the Bouchon Restaurant at the Venetian Hotel on December 6, 2009, to celebrate the winner and two finalists. Attendees were treated to the premiere of a video presentation that features each site and interviews with key members of the multidisciplinary teams that implemented their medication safety initiatives.

Pictured from L to R: Mark Rosenbaum, Cardinal Health; Kelly Michienzi, Michael Kalita and Patricia Volker, WCHOB; and Janet Silvester, ASHP Foundation.

This IV medication delivery system needed to ensure the ability to adjust to diverse patient needs; include a comprehensive, customized drug  library;  and use wireless technology to provide real-time updates and data for continuous quality improvement .  An extensive education and training for nurses and pharmacists was a key element of the operational plan.

The team relied on evidence-based references; consulted with members of the Pharmacy and Therapeutics Committee, including a clinical toxicologist, for guidance on developing hard-limit alerts for medications; and sought input from front-line practitioners and engaged them in pre-implementation testing to develop a customized drug library, which includes more than 300 medication entries. 

The comprehensive educational and training program, the accompanying policies and procedures and the user-friendly design of the IV medication delivery system resulted in 99-percent compliance and use of the system.  This was a 60-percent increase compared to the rest of the health system. During the first year post-implementation, data from edits of hard- and soft-limit alerts demonstrated that errors were prevented. As the drug library was refined, preventable errors decreased by 50 percent and sustainability was demonstrated by constant drug library compliance in the ensuing 6 months.

This IV medication delivery system has been successful in preventing and reducing medication errors and provides insight as to how medications are being used. This initiative showcases the vital role that pharmacists, nurses and physicians have in ensuring that new technology is designed to optimize safe medication administration, protecting our most vulnerable patients.

Multidisciplinary Team 
Cynthia Brown, R.Ph.
Pete Castronova BSEET 
Michael Cimino, R.Ph., M.S. 
Prashant Joshi, M.D.
Michael Kalita R.Ph., M.B.A.
Sandra McDougal, R.N., M.S.N.
Kelly Michienzi, Pharm.D.  
Nadine Streleski-Flanders, B.S.N.
Nadine Tricoli-Billingsley, B.S.N.
Patricia Volker, R.N.
Mark Wujek, CBET, AAS 

2009 Finalist
 Henry Ford Hospital
Detroit, Mich.
Improving Patient Safety through a Pharmacist-Directed Anticoagulation Service
Errors in prescribing, monitoring or an omission with antithrombotics have been associated with serious adverse events in hospitalized patients. Because of the risks, Henry Ford Hospital implemented a pharmacist-directed anticoagulant service (PDAS) in order to improve the safety of patients receiving anticoagulants throughout the hospital health system.

The following were identified as areas for improvement in the medication-use process for antithrombotics: 1) dosing; 2) monitoring; 3) patient education; 4) patient transition from the inpatient to outpatient setting. The pharmacy department garnered support for a PDAS and led the multidisciplinary team that planned, initiated and implemented the service over a 10-month timeframe.  

Patient values of International Normalized Ratio (INR) greater than 5 declined by 80 percent over an 18-month timeframe. Trends suggest that patients managed by pharmacists from the anticoagulant service were more likely to achieve an INR greater than 2 during the inpatient stay and more likely to achieve a therapeutic INR prior to discharge than patients managed with the standard of care.  The rate of early follow-up with an anticoagulation clinic within 5
and 7 days of discharge was 21 percent (p=0.002) and 17 percent (p=0.001) higher, respectively, among PDAS managed patients. Patients discharged from the PDAS also required 80 percent fewer dose adjustments upon presentation to the first outpatient anticoagulation clinic visit. As compared to patients managed with the standard of care, there was a 26-percent reduction with PDAS in anticoagulation-related readmissions within 30 days of discharge. Improved management of other anticoagulants was also noted. 

Implementation of a PDAS produces significant improvement in patient safety with regard to the use of anticoagulants and improves hospital efficiency.

Multidisciplinary Team
James S. Kalus, Pharm.D., BCPS
William Conway, M.D.
Veronica Hall, R.N., M.B.A.
Michael Hudson, M.D.  
Scott Kaatz, D.O.
Gregory Krol, M.D.
Philip Kuriakose, M.D.
Nancy MacDonald, Pharm.D., BCPS
Jessica M. Schillig, Pharm.D,.  BCPS
Brian De Smet, Pharm.D., M.S.
Edward G. Szandzik, B.S. Pharm., M.B.A. 
Moses Wu, B.S. Pharm.

  The International Normalized Ratio is a value used to measure or determine the clotting tendency of blood. INR values greater than 5 are associated with an increased risk of bleeding. Values between 2 to 3 are used to prevent thrombosis and clot formation.


2009 Finalist
Rex Healthcare
Raleigh, N.C.
Stop the Traveling Clot
Increased national awareness about potentially tragic patient outcomes from venous thromboembolism (VTE) and an internal review of inpatient thromboembolic events prompted health care providers at Rex Healthcare to begin a 5-year initiative called “Stop the Traveling Clot.”

In 2004 a multidisciplinary team at Rex Healthcare began an initiative to decrease the incidence of VTE in its hospital patients. “Stop the Traveling Clot” educated all health care providers and developed a unique VTE assessment tool. The tool included a risk scoring system and recommendations for preventing VTEs. The initial program targeted a high-risk population of critically ill and post-operative patients, and results were encouraging. A series of annual educational events and six continuous improvement (Plan-Do-Check-Act or PDCA) cycles, helped refine the process and the electronic assessment tool. The tool has been embraced by the medical staff; it is used with 100 percent of all hospital admissions and repeated every 72 hours or if there is any change in level of care. The assessments are easily accessible to all providers via the electronic medical record (EMR).

“Stop the Traveling Clot” changed practice to include routine VTE risk assessment on all inpatients at admission and continuously throughout the hospital stay, increased the use of mechanical (53 percent) and pharmacologic measures (43 percent) to prevent VTE and decreased the number of patients readmitted to the hospital within 30 days with a primary diagnosis code of a thromboembolic event by 12.58 percent. Pharmacologic prophylaxis is started within 24 hours of an assessment for 100 percent of at-risk medical inpatients and 97.6 percent in at-risk surgical patients.

This dramatic increase in assessment and prevention of VTE resulted in improved prophylaxis and a demonstrated reduction of morbidity for hospitalized patients. 

Multidisciplinary Team
Jane Hughes, B.S. Pharm., M.B.A.
Roger Adkins, B.S.N.
Dawn Beach, Pharm.D.
Timothy Carter, M.D.
Ruth Ann Go, R.N.
Daniel Licatese, B.S.N.
Kathrine McKenna, (DEGREE)
Robert Mitchell, B.S. Pharm.
Allyson Perry, B.S.N.
Ginger Phelps, B.S.N.
Mary Lou Powell, M.S.N.
Liane E. Salmon, B.S.N.
Wayne Smith, M.D.
Susan Sherman, Ph.D.
Daniel Vig, M.D.
Sherry Whitt, R.N.
Christine Zone, Pharm.D.

• Awards Ceremony — 2008  
• Awards Ceremony — 2007  
• Awards Ceremony — 2006
• Awards Ceremony — 2005
• Awards Ceremony — 2004