Track 1: Advancing Safety Science Implementation
Session 101: A Comprehensive Framework for Patient Safety, Reliability and Clinical Excellence
- Carol Haraden, Senior Vice President, Institute for Healthcare Improvement
This session will present a framework that details the components that must be present in order to have safer care everywhere.
Session 201: The CPPS Credential: The “Value Add” for Leaders
- Karen Frush, MD, Vice President, Quality, LifePoint Health, Chief Patient Safety Officer, Duke University Health System
- Barbara Olson, BSN, MSN, CPPS, Senior Patient Safety Officer, LifePoint Health
LifePoint Health provides health care in 60+ non-urban communities across the nation. This faculty-facilitated panel will describe how and why the CPPS credential was chosen to build leadership knowledge of safety science across our organization. Panelists from representative hospitals (including CEOs; CMOs; CNOs; CFOs) will describe how the CPPS journey informs their leadership, including the influence of CPPS on priorities and outcomes in their hospitals.
Session 301: Implementing Root Cause Analysis and Action - What we've learned on our journey
- Jessica Behrhorst, System Director of Quality and Patient Safety, Ochsner Health System
- Richard D. Guthrie, Jr., MD, CPE, Chief Quality Officer, Ochsner Health System
This session will describe a journey though the implementation of the new Root Cause Analysis and Action model. This new model for RCA addressed many of the barriers seen and will provide tools to create a more sustainable model.
Session 401: Practical Tips for Healthcare Checklist Design and Implementation
- Komal Bajaj, MD, MS-HPEd, Clinical Co-Director of The Simulation Center, NYC Health + Hospitals
- Peter Bernstein, MD, MPH, Professor of Clinical Obstetrics & Gynecology and Women's Health at the Albert Einstein College of Medicine, Montefiore Medical Center
- Dena Goffman, MD, Associate Chief Quality Officer, New York Presbyterian, Morgan Stanley Children’s Hospital & Sloan Hospital for Woman, Associate professor of Women’s Health in Obstetrics and Gynecology, Columbia University Medical Center
- Alexander Hannenberg, MD, Associate Chair, Department of Anesthesiology, Newton-Wellesley Hospital
- Clinical Professor of Anesthesiology, Tufts University School of Medicine, Faculty, Safe Surgery Program, Ariadne Lab
- Colleen Lee, MS, RN, Project Manager, Division of Quality and Patient Safety New York Presbyterian Hospital
This interactive session will have participants exploring key checklist tenets. Lessons learned from the design/implementation of differing checklists will be shared. Participants will be equipped with core fundamentals of checklist design and actionable steps when contemplating checklist use.
Session 501: Product Substitution: Who Is Making the Decision?
- Maureen Frye, MSN, ANP-BC, CPPS, CPHQ, Director, Abington Jefferson Health
- Jeannine Gerolamo, MSN, BS, RN, Safety Quality Specialist, Abington Jefferson Health
This session will discuss how to implement a clinical review process that promotes clinical decision making when high risk products require an alternative selection. That process allows for risk based decision making and ensures that communication, education and consequence monitoring is in place for the safe deployment of any alternative product.
Track 2: Creating a Culture of Safety in the Workplace
Session 102: Innovations in Responding to Patient Harm
- Moderator: Thomas H. Gallagher, MD, Professor and Associate Chair, Department of Medicine, University of Washington
- Richard C. Boothman, JD, Chief Risk Officer, University of Michigan Health System
- Cheryl M. De Kleine, Esq., Senior Director, Claims Management & Litigation Counsel, Ascension Risk Services
- Timothy McDonald, MD JD, Director, Center for Open and Honest Communication, MedStar Institute for Quality and Safety
- Kenneth Sands, MD MPH, Chief Epidemiologist and Patient Safety Officer, Hospital Corporation of America (HCA)
Communication and Resolution Programs (CRPs) are emerging as an important best practice in responding to patient harm. In this interactive session, CRP leaders will present Ted-style talks highlighting an important innovation in the CRP field strategies for implementation.
Session 202: Safety Culture in the First Person: The Power of the Patient Voice
- Aaron Hamilton, MD, MBA, Medical Director, Patient Safety and Clinical Risk Management, Cleveland Clinic
- Katie Lufkin, Patient Advocate, Cleveland Clinic
- Shannon Phillips, MD, MPH, FAAP, SFHM, CPPS, Physician Lead, Clinical Transformation, Cleveland Clinic
While data reaches the analytical side of the brain, patient stories make the connection to the mission, the professional calling and the heart. A culture of safety in healthcare is nurtured by revisiting the call to be our best. Who better to make the case than a patient and/or her family? “Stephanie’s Story” is a first-hand account, in the voice of the family, where we fell short of our duty to protect. In this session, you will see the power of using a personal narrative to set the cultural tone and facilitate meaningful discourse.
Session 302: Creating a Culture of Safety: Tactical Strategies for Senior Leaders
- Tejal Gandhi, MD, MPH, CPPS, CEO, President, National Patient Safety Foundation
- Gary S. Kaplan, MD, FACMPE, Chair, NPSF Lucian Leape Institute, Chairman and CEO, Virginia Mason Health System
- Charles D. Stokes, FACHE, Executive Vice President/COO, Memorial Hermann Health System / Chairman-Elect, ACHE
This session will highlight how The American College of Healthcare Executives and the NPSF Lucian Leape Institute are partnering to develop best practices in how senior leaders build and sustain a culture of safety.
Session 402: From Patient to Providers: Supporting a Comprehensive Patient Safety Program
- Paula Beard, Executive Director, Patient Safety, Alberta Health Services
- Laurel Taylor, Senior Director, Performance Improvement, Alberta Health Services
The session will feature the full range of key elements, tools and resources used in supporting a comprehensive patient safety program.
Session 502: Assessing Speaking Up Climates for Safety and Professionalism
- William Martinez, MD, MS, Assistant Professor of Medicine, Vanderbilt University Medical Center
This session will highlight ‘speaking up’ climates as part of organizational safety culture assessment.
Track 3: Caring for the Caregiver
Session 103: Fallout from Burnout and its effect on Patient Safety
- Marie T. Brown MD FACP, Internist, Associate Professor Rush Medical College and past Governor of the American College of Physicians
Physician Burnout is associated with increased errors, lower patient satisfaction and higher exit from practice. This presentation will address causes of burnout and focus on system solutions to physician burnout.
Session 203: Addressing the Complexity of Violence & Victim Advocacy in Health Care
- Deborah Small, RN, MSN, DNP, NE-BC, CNO/Vice President Patient Care Services, Cleveland Clinic Fairview Hospital
- Mary Beth Thoburn, Director Critical Care/Emergency Services, Cleveland Clinic Fairview Hospital
- Ashley Withrow, Program Manager, Victim Advocacy, Cleveland Clinic
This session will outline the unique position of a victim advocate in a healthcare setting for both patients and employees as it relates to workplace violence and other crimes.
Session 303: Building a Hospital Staff Emotional Support Program
- Julie A. Colvin, MS, RN-BC, Associate Director of Nursing Practice, Psychiatric Mental Health Nursing Service, University of Rochester Medical Center
- Jaclyn M. Wilmarth, MS, RN, CPPS, Patient Safety Nurse, University of Rochester Medical Center
This didactic presentation describes a journey at a large academic medical center to identify, develop and provide emotional support and resources to all hospital staff. The presentation will describe the entire process from recognition of staff distress concerns through the first 18 months of the successful transition to a culture of continuous emotional staff support.
Session 403: The Impact of a Peer Support Program on Healthcare Provider Outcomes after an Adverse Event
- Jenna Merandi, PharmD, MS, CPPS, Medication Safety Coordinator, Nationwide Children's Hospital
This session will provide highlights an ongoing project aimed at characterizing the negative impact of errors or adverse events on healthcare providers. Discussion on the effectiveness of a peer support program to improve healthcare provider outcomes. Outcomes of interest included anxiety, depression, and professional quality of life.
Session 503: Removing the Needle: An Obvious Innovation for Safety
- Karen Daley, PhD, MPH, RN, FAAN, Past President, American Nursing Association (ANA), Board of Trustees of the American Nurses Foundation
- Eric M. Stone, EdM, MBA, CEO & Founder, Velano Vascular
This presentation will explore the emerging technologies and practices that make a new, safer and more compassionate standard of blood collection possible. The session will explore innovations taking root in leading health systems around the country and document why these are long-term, sustainable changes through tracked outcomes and impact.
Track 4: Innovative Technology
Session 104: OpenNotes: Patient Engagement as a Safety Strategy
- Sigall Bell, MD, Director of Patient Safety and Discovery, OpenNotes
This session will discuss the safety effects of OpenNotes as used over time.
Session 204: Utilizing in Situ Simulation to Advance Patient Safety: A Case Study from a Pediatric Emergency Department
- Adam Nicholson, MD, Clinical Advisor, Simulation, Spectrum Health System
- Susan Teman, BSN, RN, CPPS, Manager, Simulation Program, Helen DeVos Children's Hospital/Spectrum Health System
This session will provide a roadmap and evidence based tools to enable development of in situ simulation programs after reviewing a case study.
Session 304: Surveillance Monitoring on General Care Floors
- Kristina Foard, RN, MSNEd, SCRN, BSN, MSN, Nurse Practice Specialist, Wake Forest Baptist Medical Center
- Karen Luse, MSN, Clinical Informatics Specialist, Extension Healthcare
Unrecognized deterioration can result in preventable deaths in hospitalized patients, yet very little work has been done that describes implementation of surveillance monitoring on general care floors to address this gap. This presentation will describe the implementation, adoption, and implications of surveillance monitoring on 16 general care units in an academic medical center setting.
Session 404: Patient Safety Events: Getting it Right!
- Terri Benskin, MHA, RHIA, CCS, Manager, Coding and Data Management, University of Missouri Health Care
- Sue Donnell Scott, PhD, RN, CPPS, Manager, Patient Safety & Risk Management, University of Missouri Health Care
This session will discuss how to develop a intradisciplinary team to tackle documentation inconsistencies, quality of care, and coding challenges to reduce the number of reportable patient safety events.
Session 504: Prescribing Errors that Cause Harm
- Matthew Grissinger, RPh, FASCP, Director, Error Reporting Programs, Institute for Safe Medication Practices
This session will describe the results of an analysis of medications errors submitted to the PA Patient Safety Authority that were classified as serious events that originated during the prescribing process.
Track 5: Patient Safety Beyond the Walls of the Hospital
Session 105: Increasing Awareness of Patient Fall Risks in Ambulatory Setting
- Jessica Dunn, MSN, RN, CNL, Director, Ambulatory Specialty Care Nursing, Virginia Mason Medical Center
- Dana L. Nelson-Peterson, DNP, MN, RN, NEA-BC, Associate Chief Nursing Officer, Virginia Mason Medical Center
This session will highlight how to use patient safety alert data, in conjunction with borrowing from key inpatient fall prevention work, to create an Ambulatory Falls Collaborative. This team’s purpose is to increase awareness and mitigate potential fall risks factors across the ambulatory setting.
Session 205: Failsafe: Improving Patient Follow-up of Incidental Radiology Findings for ED Patients
- Steve Mrozowski, MHA, NRP, CPPS, Director Patient Safety Officer, Penn State Health, Milton S. Hershey Medical Center
- Nicole Seger, RN, MSN, CPN, Patient Safety Analyst, Penn State Health, Milton S. Hershey Medical Center
This session will describe the development and expansion of the Failsafe Program, a program designed to ensure that emergency department patients with incidental radiology findings receive follow-up after discharge from the emergency department.
Session 305: Spread of Lessons Learned from Ambulatory Safety Events
- David Allison, CPHRM, System Patient Safety Director, PeaceHealth
- Andrea Halliday, MD, System Patient Safety Officer, PeaceHealth
- Robin W. Virgin, MD, FAAFP, Patient Safety Officer, Medical Group
This session will focus on system spread across 60+ clinics sites, with 800+ providers. Case examples will be shared, and tools for implementation and tracking provided.
Session 405: Top Patient Safety Issues in the Home Setting
- Deborah Carpenter, RN, MSN, CPHQ, PMP, CPPS, Senior Study Director, Westat
- Tejal Gandhi, MD, MPH, CPPS, CEO, President, National Patient Safety Foundation
Care in the home setting is expanding as a result of rising health care costs and a growing aging population. This session will present the landscape analysis of home care and patient safety project findings. Project was to review patient safety in the home care setting.
Session 505: Leveraging Primary Care in Care Transitions
- Syed Sumair Akhtar, MD, Physician, Iora Health
- Sofiya Klein, Clinical Partner Relationship Manager, Iora Health
This session will outline concrete steps and tools an innovative primary care organization has taken to increase participation of patients and caregivers in care transition planning and to reduce patient worry during transitions along with improving the safety/completeness of the transition process.
Track 6: Medication Safety across the Continuum
Session 106: A High Reliability Approach to Safe Insulin Use
- Steven Meisel, PharmD, CPPS, System Director of Patient Safety, Fairview Health Services
This session will review insulin safety using the framework of high reliability organizations and the Just Culture model. Several tools and tactics will be shared to improve adherence to best practices.
Session 206: The Role of a Naloxone Task Force in Improving Safety
- Jonathan Cohen, MD, FCCP, Anesthesiologist / Department Patient Safety Officer, Moffitt Cancer Center
Using case studies, this session will focus on the deeper dive into naloxone use. Lessons learned along with challenges will be shared.
Session 306: Innovative Pharmacist Model Improves Patient Care
- Hayley Burgess, PharmD, Sr. Director of Clinical Pharmacy Programs, Medication Safety & System Innovations, HCA
- Joan Kramer, PharmD, BCPS, Director of Medication Safety and Systems Innovations, HCA
This session will focus on new emerging issues and innovations in medication safety by describing the advancement of medication management by streamlining clinical pharmacist workflow.
Session 406: Successful Medication Reconciliation Strategies
- Trey Jenkins, PharmD, BCPS, Medication Safety Pharmacist, Wellstar Health System
- Eunji Michelle Ko, PharmD, Patient Safety Pharmacy Resident, Brigham & Women's Hospital
- Kate Ulbricht, PharmD, MBA, CPPS, Director of Clinical and Academic Programs, Brigham & Women's Hospital
This session will follow the journeys of two healthcare systems that identified weak points in their medication reconciliation process. Tools that promote value and sustainability strategies will be discussed.
Session 506: The Real Cost of Free Sample Medications
- Kim Denty, Associate Vice President Accreditation, Patient Safety, and Clinical Site Development, Private Diagnostic Clinic - Duke University
- Krista Wilson, RN-BC, MHA, Director, Clinical Operations, Private Diagnostic Clinic, Duke University
This session will highlight how the ‘free’ medication samples actually have a significant cost to both patient and facility. The presentation will show examples of a sample medication tracking, reconciliation, patient charting, potential for drug interactions and improper labeling contribute to patient safety.
Thursday, May 18
9:45 am - 10:45 am
11:00 am - 12:00 pm
1:45 pm - 2:45 pm
Friday, May 19
9:45 am - 10:45 am
11:00 am - 12:00 pm