Ciara Kirke. Clinical Lead - Medication Safety, Quality Improvement Directorate. Medication Safety Manager

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1 Curriculum vitae PERSONAL INFORMATION Ciara Kirke WORK EXPERIENCE May 2015 Present Clinical Lead - Medication Safety, Quality Improvement Directorate Health Service Executive (Ireland) Leading the national medication safety quality improvement programme, including: Delivering an improvement collaborative with 32 hospitals to prevent VTE (blood clots) in hospitalised patients, Delivering standardised medication record (chart) templates to facilitate safer medication practices, Supporting the delivery of ISMP medication safety training for 100 healthcare professionals Involved in advising, educating and training, research and projects to reduce harm associated with medication or its omission, nationally and internationally October 2004 May 2015 Medication Safety Manager Tallaght Hospital (AMNCH) (Ireland) Lead the medication safety reporting and learning programme and system improvements arising from the programme. Quality improvement to reduce harm to patients from medication use, including priority areas high-risk medication (insulin, anticoagulants, sedatives, opioids and anti-infectives) and medicines reconciliation. Strategic involvement with local, national and international groups to improve patient safety, quality improvement and patient-centeredness and bring about far-reaching reforms and system improvements with medication use. July 2000 October 2004 Senior Clinical and Medicines Information Pharmacist, Deputy clinical pharmacy services manager Mater Misericordiae University Hospital (Ireland) Clinical pharmacist to all areas, including critical care, psychiatry, medical, surgical. Management of manpower and budgets in clinical pharmacy services. Medicines information pharmacist, formulary management, wound care guidance. Education and training of pharmacy, medical and nursing staff. February 1999 July 2000 Resident Pharmacist Royal Infirmary of Edinburgh (United Kingdom) Clinical pharmacy, dispensary, aseptics, radiopharmacy and medicines information EDUCATION AND TRAINING November 2015 December 2016 Improvement Advisor Institute for Healthcare Improvement (United States) The Science of Improvement: W.E. Deming's System of Profound Knowledge The Model for Improvement Scoping Improvement Efforts: Using effective chartering techniques to appropriately and efficiently scope projects and link them to the organisation's business objectives. Understanding Systems and Processes: Using driver diagrams and other analytic tools to better understand the system and key interactions. Focus on Data for Improvement: Using both qualitative and quantitative data; learning methods for obtaining, organising and displaying data and statistical process control (SPC) for analysing data run charts, Pareto diagrams, frequency plots, and Shewhart control charts. Understanding Relationships: Using two-way tables, scatter plots, and casual models. 3/2/17 European Union, Page 1 / 7

2 Gathering Information: Using surveys, benchmarking, idea generation methods, forms of data collection, and operational definitions. Developing Powerful Ideas for Change: Honing several methods for developing changes that can lead to improvement including creative brainstorming. Testing Changes: Determining the appropriate scale for a test of change and effectively planning the appropriate steps. Implementing Changes: Gaining the expertise to know when to move from testing to implementation, how to build proven changes into the fabric of the organisation, and how to hold the gains. Spreading Changes: Understanding when and under what conditions successful spread can occur. Decision Making: Understanding prediction and judgment biases and decision traps. Collaboration and Teamwork: Using proven methods to work more effectively with colleagues, organise and lead improvement teams, and handle difficult conversations, and develop consultative skills. Planned Experimentation: Designing experiments to test the impact of multiple changes on process outcomes; assess the impact of each change and the interaction of among all changes Quality Improvement Expert Coach Royal College of Physicians of Ireland (Ireland) Quality improvement Coaching Teaching Mentoring Facilitating October 2011 September 2012 Diploma in Leadership and Quality in Healthcare Royal College of Physicians in Ireland (Ireland) Main subjects covered: Quality improvement, improvement science, Model for Improvement. Measurement for improvement, Statistical Process Control. Six sigma, Lean. Leadership, Psychology, Change management Bringing an action-learning quality improvement project to completion (Increasing the Effectiveness of Medicines Reconciliation) September 2007 May 2008 Graduate Diploma in Healthcare (Risk Management and Quality) University College Dublin (Ireland) Medical law, legislation, regulations Medical ethics, consent, confidentiality, research ethics Statistics, quality control/assurance, quality improvement Clinical risk management September 2000 July 2003 M.Sc. Clinical Pharmacy with Distinction Queen s University, Belfast (United Kingdom) Clinical pharmacy, including Cardiology, Infection, Gastroenterology, Dermatology, Endocrinology, Central nervous system, Respiratory, Surgery, Research and statistics. MSc thesis "Invasive aspergillosis in heart transplant recipients" December 1998 Present Member of Pharmaceutical Society of Ireland 3/2/17 European Union, Page 2 / 7

3 Pharmaceutical Society of Ireland (Ireland) Legislation and regulations pertaining to pharmacy practice Practice of pharmacy October 1993 June 1997 B.Sc. (Pharm.) (Hons) University of Dublin, Trinity College (Ireland) Pharmacology, Pharmaceutics, Pharmaceutical Chemistry, Pharmacognosy, Practice of Pharmacy Physiology, Biochemistry, Microbiology Physics, Chemistry, Biology, Mathematics, Statistics October 2004 Present Short courses or other qualifications Consequence UK, CIS, IHI, NHS Institute (United Kingdom) Formal training in Root Cause Analysis (Consequence UK), Systems Analysis (Clinical Indemnity Scheme), Process Improvement (Continuous Improvement, Six Sigma DMAIC training), Meeting Facilitation Skills, Measurement for Quality Improvement (Institute for Healthcare Improvement (IHI) mini-course), Lean Six Sigma (IHI mini-course) and Facilitating for Quality Improvement (NHS Institute for Innovation and Improvement/IHI mini-course). ADDITIONAL INFORMATION Expertise Quality improvement and its application to improving medication safety Medication safety, medication error prevention, reporting, analysis. Adverse drug reactions - diagnosis, reporting, analysis, prevention. Patient safety. Education and training on medication safety, quality improvement, patient safety and related topics. Medicines reconciliation Improving in-hospital glycaemic control Thromboprophylaxis Drug allergy and anaphylaxis Safe use of anticoagulants Analgesia Procedural sedation Antimicrobial safety and optimal use Publications Kirke C. Improving Medication Reconciliation. In Tully MP and Dean Franklin B. Safety in Medication Use. Chapter 12, example 2. CRC Press 2016 Ronan M and Kirke C. We push, pump and drip-drop, but what are our patients getting? Observation of intravenous medication preparation and administration practices. Int J Pharmacy Practice 2015 Apr; 23 (Supp 1)4-5 Relihan E, Kirke C, Creed M, on behalf of the Irish Medication Safety Network. Safety Alert: Risk of Cross-Contamination with Insulin Pens. December 2013 Egan S, Murphy P, Fennell J, Kelly S, Hickey M, McLean C, Pate M, Kirke C, Whiriskey A, Wall N, McCullagh E, Murphy J, Delaney T. Utilising Six Sigma to Improve Once Daily Gentamicin Dosing and Therapeutic Drug Monitoring Performance. BMJ Qual Safety, 2012 Dec;21(12): Kirke C, Creed M, Lynch R and O Connor M on behalf of the Irish Medication Safety Network. Briefing Document: Reducing Preventable Harm to Patients with Known Drug Allergies and Safety Alert: 3/2/17 European Union, Page 3 / 7

4 Allergy and Anaphylaxis to Known Drug Allergens. October 2012 Deasy E, Kirke C, Naddy H, Henman M. Do patients know how to use sublingual glyceryl trinitrate? IPU Review November 2011 Kirke C and O Hanlon N on behalf of the Irish Medication Safety Network. Safety Alert New Oral Anticoagulants and Antiplatelet Agents Bleeding Risks. August 2011 Kirke C, Delaney T, Quinlan A. Prescribing and Administration of Known Allergens. Clinical Indemnity Scheme Newsletter, March 2011 p2-3. Kirke C, O Brien P, O Hanlon N. Irish Medication Safety Network: working together to improve patient safety. EJHP Practice (1) p37 Kirke C. Safety Alert Rivaroxaban and Dabigatran. IPU Review September 2010, p12 Kirke C on behalf of the Irish Medication Safety Network. Safety Alert Oral Methotrexate. May 2010 Kirke C et al, Medication Safety in Hospitals. Irish Medical Journal Nov/Dec (10) p Kirke C. Safety Briefing Strong Opioid Transdermal Patches. Clinical Indemnity Scheme Newsletter, December 2008 Kirke C. Strong Opioid Transdermal Patches. Irish Pharmacy Journal. October /November 2008; Kirke, C. Building a Culture of Patient Safety Report of the Commission on Patient Safety and Quality Assurance. IPU Review October 2008 p10-13 Farooq M., Kirke C., Foley K. Documentation of drug allergy on drug chart in patients presenting for surgery. Irish Journal of Medical Science, September (3):243-5 Kirke C. Safety Briefing Methotrexate. Clinical Indemnity Scheme Newsletter, June Kirke C. Medication Safety Briefing. Irish Pharmacy Journal. December 2007/January 2008;490 Kirke C, Tighe P, Colohan G, Harnett B, Creaton G, Delaney T. A Collaborative Study of Medication Safety in Four Irish Hospitals. Irish Pharmacy Journal. February 2007; Kirke C. Fungal infections in heart transplant recipients in Ireland risk factors for occurrence and strategies for prevention and treatment. MSc (Clin Pharm), Presented at Infectious Diseases Society of America conference 2006 by Fennell JP. O'Connor PA, McCormack O, Gavin C, Dungan R, Kirke C, McCormack D, O'Byrne J, Stephens M, McManus F, Walsh M. Methylprednisolone in acute spinal cord injuries. Irish Journal of Medical Science, Jan-Mar (1):24-6. Kirke C, Strawbridge J. Managing Wound Management. Irish Pharmacy Journal, July (7): Poster presentations at conferences: Ronan M, Kirke C, Lynch A, Ennis S. We push, pump and drip drop.. But what are our patients getting? Observation of IV medication preparation and administration practices. Presented at Tallaght Hospital Clinical Audit & Quality Improvement Day, 2014 and Health Services Research and Pharmacy Practice Conference 2015 Poster at American Society of Health-System Pharmacists, Summer Meeting, 2015 Hospital Pharmacists Association of Ireland Annual Educational Meeting, 2015 (winner 2nd place best poster) and 7th All Ireland Pharmacy Conference, Dundalk, 2015 Reynolds J, Byrne S and Kirke C. Quantifying and characterising prescribing error on admission and during admission to an acute hospital. American Society of Health-System Pharmacists, Summer Meeting, 2015 Hospital Pharmacists Association of Ireland Annual Educational Meeting, th All Ireland Pharmacy Conference, Dundalk, 2015 Kirke C, McMahon E, OConnor S, Martin C. Improving fluid safety for paediatric patients. Winner best poster, Tallaght Hospital Clinical Audit & Quality Improvement Day, 2014 Curry L, Connolly J, Kirke C, Fahey D, McMahon B. Role of new medical device technology in quality improvements in patient care. Tallaght Hospital Clinical Audit & Quality Improvement Day, 2014 Kirke C. Improving the Effectiveness of Medicines Reconciliation. 3/2/17 European Union, Page 4 / 7

5 International Forum for Quality and Safety in Healthcare, 2013 Highly commended at Hospital Pharmacists Association of Ireland (HPAI) Annual Educational Meeting, 2013 Kirke, C, Allen, A, Fitzsimons, M, McManamly C, Deasy E, O Riordan, C, Whiriskey, A, Lelieur, F, O Byrne, J. Quick tool to track clinical pharmacy activity and prescribing discrepancy rate and its applications HPAI Annual Educational Meeting, 2013 McGowan A, Hayde J, Kirke C. An audit of the non-administration of prescribed medication Highly commended at HPAI Annual Educational Meeting, 2012 Kirke C, O Brien P, O Hanlon N. The Irish Medication Safety Network: Spreading Safe Medication Practices. International Forum for Quality and Safety in Healthcare, 2011 HPAI Annual Educational Meeting, 2011 Patient Safety Congress, Birmingham, May 2011 Deasy E, Kirke C, Naddy H. Do patients know how to use GTN spray? HPAI Annual Educational Meeting, Egan S, Hickey M, Murphy PG, Kelly S, Mc Lean C, Pate M, Wall N, Fielding C, Corcoran S, Allen A, Wall C, O Connor A, Kirke C, Whiriskey A, Mc Cullagh E, Murphy J, Delaney T. Utilising Six Sigma Process Improvement Methodology to Improve Gentamicin Dosing and Therapeutic Drug Monitoring Practice. HPAI Annual Educational Meeting, Kirke C, Tighe P, Colohan G, Harnett B, Creaton G, Delaney T. Collaboration and standardisation to improve the quality of medication safety information. International Forum for Quality and Safety in Healthcare, 2008 Morris, C, Gowing C, Seoighe A, Kirke C. Can we improve the management of drug allergies and anaphylaxis? HPAI Annual Educational Meeting, Davin D, O Sullivan A, Moran S, Grimes T, Kirke C, Pate M, Maher V, Fallon N, Ingram S, Finn C, Flynn N. Medicines for Your Heart a multidisciplinary, process driven approach to developing a series of patient information cards for use in a cardiac rehabilitation setting. HPAI Annual Educational Meeting, Shine, E, Deasy, E, Kirke, C, Ryder, S. Audit of Drug Allergy Documentation. HPAI Annual Educational Meeting, 2007 Egan S, Doyle M, Kirke C. The establishment of an antimicrobial usage database and the demonstration of its use as an audit tool to investigate the appropriateness of prescribing of the antimicrobial piperacillin-tazobactam. HPAI Annual Educational Meeting, 2006 Kirke C. Patient Safety Involving Medication Use Recent Advances. HPAI Annual Educational Meeting, 2005 Kirke C. Invasive fungal infections in heart transplant recipients in Ireland, HPAI Annual Educational Meeting, 2004, winning third prize. Pharmaceutical Society of Ireland annual conference, 2003 Irish Transplantation Society Annual Meeting, Kirke C, Strawbridge J. Managing Wound Management. Hospital Pharmacists Association of Ireland Annual Educational Meeting, Projects See publications and posters. Main areas: Quality improvement Medication safety, medication error, adverse drug reactions, adverse drug events. Improving in-hospital glycaemic control (quality improvement project) 3/2/17 European Union, Page 5 / 7

6 Prescribing error Medicines reconciliation Improving thromboprophylaxis to reduce risk of venous thromboembolism in hospitalised patients. Drug allergy and anaphylaxis Anticoagulant safety Analgesia Procedural sedation Antimicrobial safety and optimal use Invasive aspergillosis in heart transplantation Wound management Memberships Member of World Health Organisation medication safety Patient Safety Challenge expert consultation group Member of the Naming Review Group and Scientific Committee medication error expert, European Medicines Agency Member of the International Medication Safety Network Member of Medication Safety Officers Society Founder and member of the Irish Medication Safety Network, Member of Health Information and Quality Authority advisory groups - medication safety monitoring (current) and medication reconciliation project (2013) National Clinical Effectiveness Committee clinical guideline reviewer Member of the Pharmaceutical Society of Ireland Member of the Medication Safety Forum Medication error expert for Health Products Regulatory Agency MSc in Clinical Pharmacy course tutor, medication safety, University College Cork Contributor to quality improvement, leadership and safe prescribing courses, Royal College of Physicians in Ireland Other Relevant Information Key presentations: Transitions in Care. Presentation and report delivered at World Health Organisation Global Patient Safety Challenge meeting and at the WHO Global Consultation Setting Priorities for Global Patient Safety, Delivering as an IsQua webinar, 2017 Quality improvement, measurement, venous thromboembolism, guidelines, patient and healthcare professional involvement, understanding processes, testing changes etc. Preventing VTE improvement collaborative, 2016 and 2017 Practical experiences of risk minimization. European Medicines Agency PCWP HCPWP Workshop, 2015 and Pharmacovilance Conference, Copenhagen, 2016 Various presentations on aspects of medication safety and quality improvement, Mozambique Department of Health delegation, Health and Social Care Northern Ireland delegation, Medication Safety Intensive Course, St Vincent s Hospital Medication Safety Conference, Beaumont Hospital, Irish Association of Critical Care Nurses Conference, Pre-assessment Conference, Mayo University Hospital Quality Improvement Conference. Optimising anticoagulation safety. Workshop at Irish Anticoagulation Forum, 2015 Safer Medication Systems: Quality by Design. RCPI Diploma in Patient Safety, 2014, 2015 Quality Improvement. Workshops for pharmacists at Hospital Pharmacists Association of Ireland Annual Educational Conference. For SHO and Registrars, RCPI, 2014 Improving the effectiveness of medicines reconciliation. Delivering Safer Care Conference Belfast, 2014 No Sneezing Matter Drug Anaphylaxis and Allergy, Irish Medication Safety Network Conference, /2/17 European Union, Page 6 / 7

7 Medication Safety in Ireland, International Medication Safety Network Meeting, Paris 2013 Packaging and Labelling Problems and Solutions, International Medication Safety Network Public Event, Paris 2013 Prescribing Skills. Workshop for Paediatric SHOs, RCPI, 2013 A Journey to Improvement. To Diploma in Leadership and Quality in Healthcare, RCPI, 2013 and Coaching support to Diploma students, RCPI 2015, 2016, 2017 Safety Alerts and their Impact on Resources, Irish Medication Safety Network Conference, 2012 Improving Medication Safety in Hospitals. 2 workshops at European Society for Clinical Pharmacy Conference, 2011 Safe Sedation in Endoscopy Beyond the Bowel. 9th Annual GI Study Day, AMNCH, 2011 Medication Safety in Paediatrics, Children s University Hospital, Temple Street, Quality and Patient Safety Event, 2011 Epilepsy, Irish Centre for Continuing Pharmacy Education, 2011 Analysis and standardisation of medication safety reports. Irish Medication Safety Network Conference, Farmleigh, 2010 Medication Safety. Irish Centre for Continuing Pharmacy Education, 2010 Safe Medication Management Standards and Education. Medication Safety Forum, 2010 Building a Culture of Patient Safety - Report of the Commission on Patient Safety and Quality Assurance. Oncology/Haematology/Aseptics Study Day, 2008 Towards a Culture of Medication Safety What Can Nursing and Midwifery Leaders Do? Regional Nursing/ Midwifery Study Day, Cork, 2008 Paediatric Medication Safety. Paediatric Forum, Clinical Indemnity Scheme, 2007 Medication Safety. European Health Managers Conference, Dublin, 2006 Adverse Drug Reactions. Irish Centre for Continuing Postgraduate Pharmacy Education , Trinity College Dublin M.Sc. (Hospital Pharmacy) 2006 Drive out Fear Closing the Loop on Medication Safety Incident Management. ISQSH Conference. Winner of National Quality in Healthcare Award Medication Safety. MSc (Hospital Pharmacy), Dublin University, 2005 Medication Safety. HOPE Exchange, 2005 Risk Management of Medicines. Irish Centre for Continuing Pharmacy Education, 2005 Medication Safety the Tallaght Experience. Grand Rounds, Galway Hospitals, 2005 Analgesia. H. Dip. in Pain Management, UCD School of Nursing and Midwifery, 2002, 2003 Analgesia; Drugs used in Psychiatry. Pilot nurse prescribers, RCSI School of Nursing, /2/17 European Union, Page 7 / 7