Cultivating Patient Safety

Transcription

1 presents 13th Annual 2011 PATIENT SAFETY CONGRESS Cultivating Patient Safety It s In Our Hands: Sharing Accountability and Responsibility May 25 27, 2011 Gaylord National Hotel & Convention Center Washington, DC (National Harbor, Maryland) PROGRAM npsfcongress.org

2 2011 CONGRESS PLANNING COMMITTEE Co-Chairs: Doug Bonacum, MBA, BS Vice President, Safety Management Kaiser Permanente Barbara J. Youngberg, JD, MSW, BSN, FASHRM Visiting Professor of Law Beazley Institute for Health Law and Policy Loyola University Chicago School of Law Peter Angood, MD, FRCS(C), FACS, FCCM Medical Director, GE Patient Safety Organization Richard Boothman, AB, JD Chief Risk Officer, University of Michigan Health System Jeffrey B. Cooper, PhD Executive Director, Center for Medical Simulation, Professor of Anaesthesia, Harvard Medical School, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital Diane Cousins, RPh Appointed Expert to the Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety Jane Englebright, PhD, RN Chief Nursing Officer, Hospital Corporation of America Frank Federico, RPh Executive Director, Strategic Partners, Institute for Healthcare Improvement Helen Haskell Mothers Against Medical Error, The Empowered Patient Coalition John Hickner, MD, MSc Chairman of Family Medicine and Vice Chair for Research, Medicine Institute, Cleveland Clinic Main Campus Gerald Hickson, MD Joseph C. Ross Chair in Medical Education and Administration, Associate Dean for Clinical Affairs, Director, Center for Patient and Professional Advocacy, Vanderbilt University Medical Center Caroline Jacobs, MSEd, MPH, Senior Vice President, Patient Safety, Accreditation and Regulatory Services, New York City Health and Hospitals Corporation Heidi King, MS, FACHE Deputy Director, TRICARE Management Activity, DoD Patient Safety Program Ben Moulton, JD, MPH Senior Legal Advisor, Foundation for Informed Medical Decision Making Mary Beth Navarra-Sirio, RN, MBA Vice President and Patient Safety Officer, McKesson Diane C. Pinakiewicz, MBA President, National Patient Safety Foundation Manisha Shah, MBA, RT Vice President, Programs National Patient Safety Foundation Ronni P. Solomon Executive Vice President and General Counsel, ECRI Institute CONTENTS Welcome Congress Schedule Wednesday Thursday Friday Continuing Education Credit Simulations at the Congress NPSF Awards Meet the Experts Poster Presentations Schedule At A Glance centerfold Supporters Exhibitors Faculty General Information NPSF Staff Diane C. Pinakiewicz President David Coletta Vice President, Strategic Alliances Tom Novak Vice President, Finance & Administration Manisha Shah Vice President, Programs Kenneth Grubbs Assistant Vice President, Programs Julie Bastien Senior Director, Programs Katelyn Ley Assistant, Programs Tristan Mangindin Program Coordinator Patricia McTiernan Senior Director, Communications & Information Resources Claire Myers Manager, ASPPS Membership Services Annabel Osburn Administrative Assistant Allison Perry Senior Director, Programs Sara Reardon Senior Director, Programs Christopher Salway Manager, Finance Elma Sanders Manager, Communications Anita Spielman Director, Information Resources & Research Sophia Terry Assistant, Programs 268 Summer Street, Sixth Floor Boston, MA Cultivating Patient Safety 2 NPSF Annual Patient Safety Congress 2011

3 Cultivating Patient Safety It s in Our Hands: Sharing Accountability and Responsibility 13th Annual NPSF Patient Safety Congress Pre-Congress May 25 Congress May 26 27, 2011 Gaylord National, Washington, DC Welcome to the 2011 NPSF Patient Safety Congress The patient safety movement has experienced tremendous change and growth over the past decade. As patient safety professionals and advocates, we applaud the efforts made and successes achieved so far. Yet there is still so much more that needs to be done. Every day seems to bring new data about the gaps in our systems and the failures of accountability at all levels of the healthcare industry as well as new methods of mending those gaps, creating a culture that is accountable and transparent and moving forward. The recent Partnership for Patients initiative announced by the US Department of Health and Human Services and the Centers for Medicare and Medicaid Services has buoyed the patient safety movement at a critical time. By bringing focus and financial support to issues surrounding patient safety, the federal government is now a strong and committed partner in this work. This year s Congress theme truly projects the role each of us must play from here: It s in our hands. We all share accountability and responsibility for cultivating patient safety. Whether you are a provider or a patient, a hospital leader or a patient safety advocate, the 2011 NPSF Patient Safety Congress has something for you. This year s program has been carefully designed by leaders in the field to provide real-world tools, resources, and evidence-based solutions to safety issues. We hope you make the most of this time learning from patient safety experts, networking with peers who share your challenges, and increasing your expertise. Be sure to save some time to explore the exhibit hall, which for the second year also serves as a Learning & Simulation Center. With interactive demonstrations facilitated by leaders in simulation learning techniques, this educational setting captures the spirit so central to the Patient Safety Congress. To our distinguished faculty, we offer our sincere appreciation for their insights, commitment, and passion. And thanks to all of you, our colleagues and friends from across the healthcare spectrum, for joining us. We extend a warm welcome to each of you. Doug Bonacum, MBA, BS Barbara J. Youngberg, JD, MSW, BSN, FASHRM 2011 Congress Co-Chair 2011 Congress Co-Chair Cultivating Patient Safety 3 NPSF Annual Patient Safety Congress 2011

4 Wednesday Please see the centerfold of this booklet for your convenient Schedule At A Glance, including locations of all events. Registration will be open Tuesday, May 24, from 4:00 to 6:00pm PRE-CONGRESS DAY 7:00 AM 5:00 PM Registration Open 8:00 AM 5:00 PM Leadership Day Getting Comfortable: Leadership s Role in Driving Personal, Professional and Organizational Accountability 7.5 contact hours for physicians, pharmacists L04-P, nurses (9.0 for Iowa nurses), healthcare risk management, and healthcare executives Chair: Barbara J. Youngberg, JD, MSW, BSN, FASHRM, Visiting Professor of Law, Beazley Institute for Health Law and Policy, Loyola University Chicago School of Law Faculty: Richard Boothman, AB, JD, Chief Risk Officer, University of Michigan Health System Carolyn Corvi, Chair, Virginia Mason Health System/Virginia Mason Medical Center Board of Directors Cathie Furman, RN, MHA, Senior Vice President, Quality and Compliance, Virginia Mason Health System Gerald Hickson, MD, Joseph C. Ross Chair in Medical Education and Administration, Associate Dean for Clinical Affairs, Director, Center for Patient and Professional Advocacy, Vanderbilt University Medical Center Bryan Sexton, PhD, Director of Patient Safety, Training and Research, Duke University Health System The NPSF Patient Safety Congress Leadership Day program is created exclusively for C-Suite and board-level attendees, and will focus on personal and collective behavior for accountability. The day s discussion will be augmented by an interactive survey utilizing the audience response system, followed by a case study to kick start the day. Throughout the day participants will examine and explore key issues at the forefront of driving sustainable change. Describe specific organizational barriers that impede progress or sustainability in accountability and patient safety (barriers include: lack of appropriate systems, ineffective reporting, lack of expertise, lack of resources, and lack of will perhaps brought on by competing priorities) Devise specific tactics which may be utilized by healthcare leaders to overcome these barriers Identify strategies for aligning incentives in the organization to reward patient safety activities Adopt from real-life best practices strategies to create meaningful and sustainable organizational and cultural change Explain methods of changing the peer-review paradigms for personal accountability, having nonjudgmental conversations and creating awareness interventions Four full-day programs run concurrently on Pre-Congress Day. Individual registration and attendance are limited to one program only. 8:00 AM 5:15 PM Patient Safety contact hours for physicians, pharmacists L05-P, nurses (9.0 for Iowa nurses), healthcare risk management, and healthcare executives Chair: Doug Bonacum, MBA, BS, Vice President, Safety Management, Kaiser Permanente Faculty: Jason Adelman, MD, MS, Patient Safety Officer, Associate Director, Attending Service, Montefiore Medical Center, Assistant Professor of Medicine, Albert Einstein College of Medicine Suzanne Graham, RN, PhD, Executive Director of Patient Safety, California Regions, Kaiser Permanente Linda Williams, RN, MSI, Program Specialist and Cybrarian, VA National Center for Patient Safety This course is intended for managers who are new to patient safety (for example, having less than two years experience as a Patient Safety Officer) and for those in operations and administration looking to learn more about the topic. Participants will gain familiarity with patient safety principles and realworld techniques through case-study methodology. They will dissect a video-based case from a number of perspectives including: human error and drift, human factors and systems design, just culture, and healthcare literacy, and they will develop a corrective action plan to solidify learnings from the day. After drilling down on the featured case, the group will conclude the day at a more strategic level through a dialogue facilitated by a seasoned patient safety leader covering the key elements of an effective patient safety program. In sum, participants will walk away with practical problem-solving skills and a high-level roadmap to guide their own organizational programs. Describe the elements of an effective patient safety management program and demonstrate practical problem-solving skills to address difficult challenges Outline the drivers of human performance and the application of human factors engineering to improve outcomes Adopt just culture principles to address real problems in a way that fosters an environment of trust but one in which everyone is clear about where the line is drawn between acceptable and unacceptable behaviors Explain the impact of healthcare literacy on outcomes and provide three practical strategies for improving performance Cultivating Patient Safety 4 NPSF Annual Patient Safety Congress 2011

5 Wednesday 8:30 AM 5:00 PM Measurement Boot Camp Strategies and Tactics for the Real World 7.0 contact hours for physicians, pharmacists L05-P, nurses (8.4 for Iowa nurses), healthcare risk management, and healthcare executives Co-Chairs: Peter Angood, MD, FRCS(C), FACS, FCCM, Medical Director, GE Patient Safety Organization Frank Federico, RPh, Executive Director, Strategic Partners, Institute for Healthcare Improvement Faculty: Helen Burstin, MD, MPH, Senior Vice President for Performance Measures, National Quality Forum Stephen R. Grossbart, PhD, Senior Vice President and Chief Quality Officer, Center for Patient Safety and Clinical Transformation, Catholic Health Partners Amy Helwig, MD, MS, Medical Officer, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality Steve Horner, MBA, RN, Vice President, Clinical Analytics, Clinical Services Group, HCA John Morley, MD, Medical Director, Health Systems Management, New York State Department of Health Office Elizabeth Mort, MD, MPH, Vice President, Quality and Safety, Associate Chief Medical Officer, Massachusetts General Hospital David Skolnik, Co-Founder and Director, Citizens for Patient Safety Patty Skolnik, Founder and CEO, Citizens for Patient Safety This full-day program dives into measurement techniques designed to evaluate the effectiveness of patient safety efforts. The hands-on workshop will provide attendees the critical training and skills for measuring success and targeting areas for improvement. Investigate existing types of measures, the organizations that publish measures and how/when to use them in determining organizational focus of measurement efforts Outline the differences in measurement processes and strategies when measuring for improvement, judgment, and public reporting Explain how measurement results help to identify the range of internal organizational performance differences for organizations Identify differences among available public reporting documents and provide insights for learning from other organizations data Express insights on how to convert measurement results and information into organizational change 9:00 AM 4:30 PM Community Engagement 6.0 contact hours for physicians, pharmacists L05-P, nurses (7.2 for Iowa nurses), healthcare risk management, and healthcare executives Chair: Linda Kenney, Executive Director, Medically Induced Trauma Support Services Faculty: Barbara Hodne, DO, FAAFP, Medical Director, House of Mercy Clinic, Family Medicine of Urbandale Alicia Knight, RN, Transition of Care Health Coach, Quality Department, Mercy Clinics Administration Del Konopka, RN, MS, Education Coordinator, Quality Department, Mercy Clinics Administration Ben Moulton, JD, MPH, Senior Legal Advisor, Foundation for Informed Medical Decision Making Geri Schimmel, RN, BSN, MS, LHRM, Director of Patient Safety Partnership, Baptist Health South Florida Manisha Shah, MBA, RT, Vice President of Programs, National Patient Safety Foundation Yvonne Zawodny, RN, LHRM, CPHRM, Corporate Assistant Vice President of Risk Management/Patient Safety, Baptist Health South Florida This unique program provides perspective and ideas to support engaging communities in patient safety work. Faculty will discuss how community members, patients and families, clinicians, and staff are engaged in collaborative efforts to improve patient safety; describe their journey toward effective partnership; and explain how new communication strategies such as simulation training are changing the way providers are interacting with patients and delivering safer care. Faculty will also share a new toolkit that can be used to further engage patients and families on this journey of collaborative care. Identify how community members, patients and families, clinicians, and staff are currently engaged in collaborative efforts with healthcare providers and organizations to improve patient safety Prepare to communicate more effectively among community members, patients, families, clinicians, and staff in collaborative patient safety endeavors Describe the importance of building a framework for a culture of patient- and family-centered care Identify the value of the first-hand perspective of patient and family advisors List two actionable ideas to take back to their organization to implement to enhance patient- and family-centered care efforts 6:00 PM 8:00 PM Learning & Simulation Center: Simulations, Exhibits, Posters, Opening Reception All Pre-Congress and Congress Attendees: Please join us at the Congress Opening Reception. Cultivating Patient Safety 5 NPSF Annual Patient Safety Congress 2011

6 Thursday THURSDAY 7:00 AM 6:00 PM Registration Open 7:00 AM 8:00 AM Continental Breakfast 7:00 AM 8:00 AM Stand Up for Patient Safety Member Breakfast (by invitation) Presentation of National Patient Safety Foundation Stand Up for Patient Safety Management Award Recipient: Franciscan St. Anthony Health - Michigan City, Sentinel Lymph Node Visualization Rates Presentation of Patient Safety Initiative at America s Public Hospitals Leadership Award Recipient: Harborview Medical Center 8:00 AM 8:15 AM Welcome and Opening Remarks Presentation of The Doctors Company Foundation Young Physicians Patient Safety Awards Recipients: Andrey Ostrovsky, Boston University School of Medicine Noah Rosenberg, University of Massachusetts Medical School Dan Henderson, University of Connecticut School of Medicine, Harvard School of Public Health Christopher Thom, University of Virginia Mengyao Liang, University of Illinois at Chicago Wael Salem, Mayo Medical School Presentation of National Patient Safety Foundation Chairman s Medal Recipient: Robert Connors, MD, President, Helen DeVos Children s Hospital 8:15 AM 9:30 AM Lucian Leape Institute Town Hall Plenary Distinguished members of the Lucian Leape Institute at the National Patient Safety Foundation will share their thoughts on this most critical time for patient safety work, the impact of healthcare reform on our progress, and what key levers will bring about true and meaningful change. The Institute was formed in 2007 and is dedicated to providing thought leadership and strategic vision for the field of patient safety. Composed of national thought leaders with a common interest in patient safety, the Institute functions as a think tank to identify new approaches to improving patient safety, calling for the innovation necessary to expedite the work, create significant, sustainable improvements in culture, process, and outcomes, and encourage key stakeholders to assume critical roles in advancing patient safety. MEMBERS OF THE LUCIAN LEAPE INSTITUTE Lucian L. Leape, MD Chair, Lucian Leape Institute Adjunct Professor of Health Policy Harvard School of Public Health Diane C. Pinakiewicz, MBA President, Lucian Leape Institute President, National Patient Safety Foundation ~ Carolyn M. Clancy, MD Director, Agency for Healthcare Research and Quality James B. Conway, MS Adjunct Faculty, Harvard School of Public Health Susan Edgman-Levitan, PA Executive Director, John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital James A. Guest President, Consumers Union 9:45 AM 10:45 AM Breakout Sessions Gary S. Kaplan, MD, FACMPE Chairman and CEO, Virginia Mason Medical Center Julianne M. Morath, RN, MS Chief Quality and Safety Officer, Vanderbilt Medical Center Dennis S. O Leary, MD President Emeritus, The Joint Commission Paul O Neill Former Chairman and CEO, Alcoa, 72nd Secretary of the US Treasury David M. Lawrence, MD LLI Member Emeritus Chairman and CEO (retired), Kaiser Foundation Health Plan Inc. and Kaiser Foundation Hospitals Pamela A. Thompson, MS, RN, FAAN LLI Member Ex-officio Immediate Past Chair, NPSF Board of Directors, CEO, American Organization of Nurse Executives Assuring Accountability and Mindfulness across the Continuum of Care SESSION 101: Building an Integrated Outpatient Safety Program 1.0 contact hours for physicians, pharmacists L05-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Ruthie Goldberg, MHA, Group Leader, Southern California Clinical Operations, Kaiser Permanente Michael Kanter, MD, Medical Director, Quality and Clinical Analysis, Southern California Permanente Medical Group Kaiser Permanente Southern California s Outpatient Safety Program is comprised of multiple ongoing safety nets for catching, tracking, and following up with abnormal lab results, medication monitoring, and patients with potentially harmful interactions risk. This program covers our 3.3 million members and leverages our integrated delivery system and comprehensive electronic medical record. All safety nets ensure each case is tracked until either the proper follow-up occurs or patient refusal, non-compliance, or contraindication is documented in the electronic medical record, closing the case. Identify where opportunities might exist in their organizations to systematically address patient safety issues outside of the traditional inpatient setting Specify patient populations within four primary areas of outpatient safety: medication monitoring, potentially harmful interaction avoidance, necessary follow-up care, and diagnosis detection Prepare an outpatient safety program by creating a series of centralized safety nets to catch important tests not properly followed up, drugs not properly monitored, and missed follow-up care Cultivating Patient Safety 6 NPSF Annual Patient Safety Congress 2011

7 Thursday Breakout Sessions are organized in six theme tracks Session numbers ending in -01: Assuring Accountability and Mindfulness across the Continuum of Care Session numbers ending in -02: Building Processes to Drive Personal and Collective Accountability Session numbers ending in -03: Healthcare Reform and Accountability Session numbers ending in -04: Innovation & Hot Topics Session numbers ending in -05: Shared Decision Making to Promote Accountability between Patients and Providers Session numbers ending in -06: Teamwork and Communication for Enhanced Accountability Building Processes to Drive Personal and Collective Accountability SESSION 102: Building Personal and Collective Accountability: The Role of a Project Bundle 1.0 contact hours for physicians, pharmacists L05-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Richard Boothman, AB, JD, Chief Risk Officer, University of Michigan Health System Darrell Skip Campbell, MD, Chief Medical Officer, University of Michigan Medical School Gerald Hickson, MD, Joseph C. Ross Chair in Medical Education and Administration, Associate Dean for Clinical Affairs, Director, Center for Patient and Professional Advocacy, Vanderbilt University Medical Center So many improvement needs, so little time, and everyone is not always enthusiastic.... Quality and safety officers are inundated with opportunities for improvement driven by local events or by government and regulatory body mandates. How can a safety leader maximize the chance of success in making medicine kinder and safer? The session will focus on use of a Project Bundle to assess readiness to launch and troubleshoot when progress is slow. Several safety initiatives will be described and use of the bundle illustrated. Participants will be encouraged to take the tool to each session in the Building Processes to Drive Personal and Collective Accountability track. Describe the components of a Project Bundle to assess readiness to implement quality and safety initiatives Analyze which components of the Project Bundle may be lacking in their organization Adopt the Project Bundle to troubleshoot when organizational initiatives fail or stop progressing Healthcare Reform and Accountability SESSION 103: MHA Keystone: A Model for Rapid Implementation of Evidence-Based Best Practice and Cultural Improvement 1.0 contact hours for physicians, pharmacists L04-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Laura Appel, Vice President, Federal Policy and Advocacy, Michigan Health and Hospital Association Sam Watson, Senior Vice President for Patient Safety and Quality, Michigan Health and Hospital Association, Executive Director of the MHA Keystone Center for Patient Safety Achieving the rapid deployment of evidence-based practice sought by the enactment of the Patient Protection and Affordable Care Act through the proposed Center for Quality Improvement and Patient Safety will require a novel approach using a private/public partnership. The session will present how the MHA Keystone Center rapidly disseminates evidence-based practice to large numbers of hospitals at a state level as well as a foundation for a national project, using the collaborative model for transformational change developed by Dr. Peter Pronovost: Engage, Educate, Execute and Evaluate. The activities supporting each step of the process vary by project, but are always detailed and evidence-based to ensure meaningful data and significant opportunity for improvement. At the heart of each collaborative is a focus on improving organizational culture using change principles and behavioral science. This intervention, called the Comprehensive Unit-based Safety Program (CUSP), integrates communication, teamwork, and leadership to create and support a harm-free patient care culture. Evaluate how a regional collaborative model can be used to increase the use of evidence-based best practice Outline how the use of a patient safety culture improvement program can support sustainability of evidence-based interventions Explain how a thorough data collection and reporting process can be used to support the successful adoption of evidence-based best practices and ultimately support long-term sustainability Innovation & Hot Topics SESSION 104: ProvenCare Perinatal: Utilizing the Electronic Health Record to Reliably Deliver Guideline- and Evidence-based Care for Perinatal Populations 1.0 contact hours for physicians, pharmacists L04-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Hans P. Cassagnol, MD, FACOG, Chair of Performance Improvement, Director of Obstetrics and Gynecology, Geisinger Health System Harry O. Mateer, MD, Director of Obstetrics, Geisinger Medical Center ProvenCare Perinatal is an improvement initiative implemented to reduce unwarranted variation and ensure best practice is delivered to every patient who enters the Geisinger system for obstetrical care. A multidisciplinary team was assembled to assess the current workflow, review guideline- and evidence-based literature, and create and implement a new electronic workflow that guides frontline staff to reliably provide the right care at the right time for every patient. Outcomes have improved for both mothers and infants across all 22 Geisinger obstetrical clinics since ProvenCare went live in 2008/2009. Prepare to drive reliable, guideline- and evidence-based care to improve patient safety and outcomes by utilizing the electronic health record Plan how to optimize team participation in redesigning the electronic workflow Outline how to achieve consensus on best-practice measures and a standardized electronic workflow across multiple clinic sites spanning a wide geography Cultivating Patient Safety 7 NPSF Annual Patient Safety Congress 2011

8 Thursday Shared Decision Making to Promote Accountability between Patients and Providers SESSION 105: Partnering with Patients: A Bed s Eye View of Patient Safety 1.0 contact hours for physicians, pharmacists L05-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Tiffany Christensen, CEO, Sick Girl Speaks Partnering with Patients: A Bed s Eye View of Patient Safety is a unique program originating from Duke Medicine s Patient Advocacy Council and Patient Safety Office. In this presentation, Tiffany Christensen author, national speaker, and two-time double lung transplant recipient provides a glimpse into the private thoughts and experiences of patients. Building on these insights, Christensen lays out a philosophy, strategies, and a plan for using TeamSTEPPS as the foundation for true patient/professional partnering. A road map will be included for those health systems interested in replicating the Duke model of including patients and families in TeamSTEPPS training. Identify, name, and understand the key issues patients and families face when experiencing a sudden health event, chronic illness, or end of life Prepare a plan to coach professionals on the most effective ways to use TeamSTEPPS strategies, skills, and tools with patients and families List the specific steps to replicating the Duke Health System s model of incorporating patients and families in the TeamSTEPPS training Teamwork and Communication for Enhanced Accountability SESSION 106: Disruptive Behavior Affects Communication and Teamwork 1.0 contact hours for physicians, pharmacists L04-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Franchesca Charney, RN, BS, MSHA, CPHRM, CPHQ, CPSO, FASHRM, Director, Educational Programs, Pennsylvania Patient Safety Authority Charlotte Huber, RN, MSN, Patient Safety Analyst/Consultant, ECRI Institute This presentation examines the issues that surround the use of the chain of command when disruptive clinician behaviors are encountered or when there are concerns about a patient s condition or the care they are receiving when these concerns are related to operational issues. The actions organizations can take to eliminate clinicians inappropriate behaviors and attitudes in order to boost effective communication, teamwork, and collaboration and improve patient safety will be discussed. Describe how highly effective healthcare teams optimize their use of information, people, and resources to achieve the best clinical outcomes List how the three phases of the TeamSTEPPS delivery system can advance the quality, safety, and efficiency of health care Explain how a reporting surveillance system can recognize patterns of unprofessional behavior 11:00 AM 12:00 PM Breakout Sessions Assuring Accountability and Mindfulness across the Continuum of Care SESSION 201: Ambulatory Patient Safety: How Human Processes and HIT Can Combine to Improve Test Results Tracking in Ambulatory Practices 1.0 contact hours for physicians, pharmacists L04-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Claire Horton, MD, Associate Medical Director, San Francisco General Hospital, Assistant Professor of Medicine, University of California at San Francisco Urmimala Sarkar, MD, MPH, Assistant Professor, General Internal Medicine, University of California at San Francisco The purpose of this workshop is to convene both researchers and clinical/ operational leadership to: 1) review the current state of test results tracking and potential errors that can occur in this arena, and point out the relevant safety terminology; 2) explore how improving ambulatory safety requires the intersection of health information technology (HIT) and human processes, using test results tracking as a case study; and 3) establish an ambulatory patient safety learning collaborative to foster sharing and dissemination of innovations regarding test tracking and other ambulatory safety challenges. Outline the current state of test results tracking and potential errors that can occur in this arena, and employ the terminology relevant to ambulatory patient safety Demonstrate skills in developing work processes that dovetail with HIT functionality to improve management of test results, a core patient safety issue in ambulatory care Assemble ambulatory safety/health IT best practices, examining how institutions with varied HIT penetration can improve ambulatory safety Building Processes to Drive Personal and Collective Accountability SESSION 202: A Reliable Process for Safe Handovers 1.0 contact hours for physicians, pharmacists L05-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Stephen Muething, MD, Assistant Vice President for Patient Safety, Cincinnati Children s Hospital, Associate Professor, University of Cincinnati Derek Wheeler, MD, FAAP, FCCP, FCCM, Clinical Director, Division of Critical Care Medicine, Cincinnati Children s Hospital, Associate Professor of Clinical Pediatrics, University of Cincinnati Handovers present a significant risk for unanticipated occurrences that harm patients. At Cincinnati Children s Hospital, we studied safety events resulting in delayed recognition of clinical deterioration. Outline the structure of a system to improve situation awareness and eliminate serious harm across 16 inpatient units Describe an approach for improvement from cause analysis through pilot testing, spread, and continuous learning Healthcare Reform and Accountability SESSION 203: Health Information Technology Farzad Mostashari, MD, ScM, National Coordinator, Health Information Technology, Office of the National Coordinator, US Department of Health and Human Services Cultivating Patient Safety 8 NPSF Annual Patient Safety Congress 2011

9 Thursday Innovation & Hot Topics SESSION 204: Diagnostic Error and Clinical Decision Support 1.0 contact hours for physicians, pharmacists L05-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Art Papier, MD, Associate Professor, University of Rochester College of Medicine Accountable care and medical home models of care position the primary care clinician as a key decision maker in driving down costs while increasing quality and patient safety. This session will describe the broad challenge of diagnosis for primary care; how diagnostic error outpaces other types of error such as medication and surgical error; and how decision support can empower primary care clinicians. Case examples will be used. Recent research focusing on diagnostic clinical decision support within the context of a telemedicine project in Southern California will serve as an example of how clinical decision support can integrate with the electronic health record and drive accountability. Describe the impact and significance of diagnostic error in patient safety and quality of care List the cognitive and perceptual causes of diagnostic error Define clinical diagnostic decision support and understand how diagnostic decision support can sustain accountability within the context of the electronic medical environment Shared Decision Making to Promote Accountability between Patients and Providers SESSION 205: Facilitating Shared Decision Making in Primary Care and Specialty Practices 1.0 contact hours for physicians, pharmacists L04-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Karen Sepucha, PhD, Director, Health Decision Sciences Center, Massachusetts General Hospital Leigh Simmons, MD, Physician Fellow, John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital The presenters will discuss how using a shared decision making process improves patient physician communication around critical decisions, and thus enhances the safety and accountability of a healthcare organization. They will give an overview of the shared decision making program in the Massachusetts General Hospital primary care and specialty practices. They also will discuss how their organization has applied principles of shared decision making broadly and consistently across a large and diverse patient population and will present their experiences expanding the program from primary care to specialty care groups at Massachusetts General Hospital. Analyze ways in which shared decision making concepts can be applied in the primary care and specialty settings to address a variety of health conditions and decisions in preventive care and disease management Evaluate how video decision aids can facilitate shared decision making between patients and their physicians Describe ways in which physicians and patients can be engaged in the process of using decision aids to provide high-quality care and ensure consistent use of shared decision making principles in daily practice Teamwork and Communication for Enhanced Accountability SESSION 206: Improving Teamwork and Communication: It s Not for Amateurs Anymore 1.0 contact hours for physicians, pharmacists L04-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Karen Miguel, RN, BSN, MM-H, Patient Safety Officer, Massachusetts General Hospital Robert Sheridan, RTR, Director, Interventional Radiology, Massachusetts General Hospital This session is intended to provide participants with the understanding necessary to support an effective teamwork program in their facility. Focus will be on the three key phases of a robust teamwork program: 1) Assessing the need and gaining leadership buy-in; 2) Carefully planning, training, and implementing the behaviors; and 3) Developing a long-term well-orchestrated sustainment plan. The interactive session includes an overview of the program and the MGH experience to date, plus a review of the tactical steps taken to sustain the efforts. Participants will come away from the session with a clear understanding of how to get a program off the ground, the pitfalls to avoid, and clear strategies to sustain for the long-term. Explain how improved communication skills and team practices can directly impact staff satisfaction and patient outcomes Outline how to improve staff perception of safety and gain an understanding of the importance of teamwork in health care Prepare to avoid the pitfalls of an ineffective program 12:00 PM 1:45 PM Learning & Simulation Center: Simulations, Exhibits, Posters, Lunch 1:45 PM 3:15 PM Breakout Sessions Assuring Accountability and Mindfulness across the Continuum of Care SESSION 301: Improving Care Coordination across the Continuum: Families and Healthcare Providers 1.5 contact hours for physicians, pharmacists L04-P, nurses (1.8 for Iowa nurses), healthcare risk management, and healthcare executives Michele Lizzi, RN, BSN, Care Coordination Counselor, The Children s Hospital of Philadelphia Symme W. Trachtenberg, MSW, LSW, Director of Community Education, The Children s Hospital of Philadelphia This session will focus on the work of the Care Coordination Counselor, the development of the organizational Care Binder, the Community Resources for Families database, and the Care Coordination Network. The Care Coordination Counselor will demonstrate how to provide assistance to patients with complicated medical and psycho-social issues, requiring primary and specialty care within multiple healthcare systems. Focus will be given to the Care Binder program that educates patients, as well as caregivers, on how to contribute to the overall coordination of the patient s health care, led by the disciplines of nursing and social work. The development of the Community Resources for Families database and the Care Coordination Network of healthcare providers and family members will be described, including how the roles, programs, and materials have been integrated in Cultivating Patient Safety 9 NPSF Annual Patient Safety Congress 2011

10 Thursday the community and other healthcare systems. There will be an interactive demonstration of the Care Binder and Community Resources for Families database. Produce and implement an action plan for care coordination across the continuum Identify and implement roles, resources, and programs to support care coordination across the continuum Devise methods to strengthen and sustain care coordination mechanisms, including providing training and tools to patients, families, and providers to enhance competencies in this area Building Processes to Drive Personal and Collective Accountability SESSION 302: Transforming Peer Review: Medical Staff and Registered Nurse Perspectives 1.5 contact hours for physicians, pharmacists L04-P, nurses (1.8 for Iowa nurses), healthcare risk management, and healthcare executives Jeffrey S. Desmond, MD, Service Chief for Adult Emergency, University of Michigan Health System Carol Shaffer, RN, PhD, CIP, Research Coordinator, Reston Hospital Center Heather Wurster, RN, MPH, Executive Director of Medical Affairs, Office of Clinical Affairs, University of Michigan Health System Part I: University of Michigan Health System This presentation will focus on how to engage physicians to take ownership of the peer review process to reflect measures they feel are important, and to build off that engagement. UMHS models efforts to overcome barriers and physician resistance to implementation of peer review, from the 2001 inception of a comprehensive program mandating department-level identification of specific performance metrics. Part II: Reston Hospital Center Peer review performance appraisal has been widely recognized for contributing to accountability for performance, improving professional relationships, empowering nurses, and assuring quality of patient care. This presentation describes how development of a performance appraisal instrument empowered clinical staff nurses in defining their own standards of practice based on published standards, codes of ethics, and the Synergy Model. Explain the value of peer review in assuring the accountability and autonomy of registered nurses State the processes involved in leading staff nurses to define and measure standards of professional practice List the desirable characteristics of an effective instrument for peer review performance appraisals Healthcare Reform and Accountability SESSION 303: Creating a Quality Roadmap for the New Health Reform Nancy E. Foster, Vice President, Quality and Patient Safety Policy, American Hospital Association Innovation & Hot Topics SESSION 304: Achieving Patient Safety through Wireless Electronic Transfusion Verification System and Bar Code Scanning 1.5 contact hours for physicians, pharmacists L04-P, nurses (1.8 for Iowa nurses), healthcare risk management, and healthcare executives Jessica Persons, MSN, RN, BC, Clinical Educator in Nursing Informatics, St. Luke s Episcopal Hospital Judy Ho, MSN, RN, ACNS-BC, CPHQ, Education Specialist, St. Luke s Episcopal Hospital Kimberly W. Erlandson, RN, MPH, CPHQ, Quality Management Coordinator, University of Iowa Hospitals and Clinics John Kemp, MD, Director of Clinical Laboratories, University of Iowa Hospitals and Clinics Part I: St. Luke s Episcopal Hospital A nonpunitive approach called Healthcare Alliance Safety Partnership (HASP) was utilized to investigate a transfusion error. The result was a plan to utilize wireless electronic transfusion verification technology. It took 18 months to implement the new system. Transfusion safety was significantly enhanced. Part II: University of Iowa Hospitals and Clinics A comprehensive bar code scanning software program for the transfusion process was developed and deployed. Six years of experience have shown that the system may be 10 to 20 times safer than most transfusion systems. This system may provide a basis for the development of future programming standards. Describe how to engage individuals to participate in root cause analysis in a nonpunitive environment Describe the mechanisms by which bar code scanning enhances transfusion safety State the implementation challenges and future prospects for bar code scanning in blood transfusion Shared Decision Making to Promote Accountability between Patients and Providers SESSION 305: Shared Decision Making: National Resource Center at Mayo 1.5 contact hours for physicians, pharmacists L04-P, nurses (1.8 for Iowa nurses), healthcare risk management, and healthcare executives Annie LeBlanc, PhD, Postdoctoral Fellow in Health Services Research, Mayo Clinic Larry Morrissey, MD, Medical Director of Quality Improvement, Stillwater Medical Group Nilay D. Shah, PhD, Senior Associate Consultant, Health Care Policy and Research, Assistant Professor of Health Services Research, Mayo Clinic This session will present an overview of the shared decision making initiatives and innovations of the Shared Decision Making National Resource Center at the Mayo Clinic and of the Minnesota Shared Decision Making Collaborative. These initiatives contribute to the advancement of patientcentered medical care, with a focus on care for preference-sensitive decisions including those for preventive care decisions and for acute and chronic conditions. In addition, we will present evidence from implementing shared decision making in different care settings including ambulatory care, hospitals, and emergency rooms. Define shared decision making in the context of patient safety Prepare examples of models for implementing shared decision making in routine practice Outline examples of decision aids used in practice settings, including at the point of care List the objectives and services of the Shared Decision Making National Resource Center and the Minnesota Shared Decision Making Collaborative Cultivating Patient Safety 10 NPSF Annual Patient Safety Congress 2011

11 thursday FRIday Teamwork and Communication for Enhanced Accountability SESSION 306: Improving Patient Safety by Focusing on Unit Leaders and Frontline Staff 1.5 contact hours for physicians, pharmacists L05-P, nurses (1.8 for Iowa nurses), healthcare risk management, and healthcare executives Mary Oldenkamp, RN, Senior Director, Performance Improvement, VHA Upper Midwest Rob Welch, MD, Vice President, Clinical Affairs, VHA Upper Midwest This presentation will discuss the analysis of the AHRQ Survey on Patient Safety data that led to the identification of the highest leverage point for change namely, the role of the unit leader in eliminating blame and fear from the work environment. Thirty-four VHA Upper Midwest hospitals are participating in collaborative learning based on this work. Ten Domains of Patient Safety, derived from the literature and input from VHAUM members, provide the framework for this initiative and will be briefly reviewed. The content of meetings, site visits, and webinars will be shared, along with the strategy to engage hospital leadership at all levels. This is a presentation of work in progress, as follow-up AHRQ survey results will not yet be available by the conference date. Identify three unit leader behaviors that foster personal accountability on the part of frontline staff Prepare a plan to define a safety focus in their work unit, and align staff using: a unit-based culture of safety behavior survey tool, a desired future culture-based exercise, and communication strategies such as appreciative inquiry Identify the key drivers of the Patient Safety Grade as determined by the AHRQ Survey on Patient Safety 3:30 PM 5:30 PM Plenary: The Music Paradigm with Conductor Roger Nierenberg and the National Symphony Orchestra 1.0 contact hours for physicians, pharmacists L04-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Employing the powerful metaphor of a symphony orchestra to illustrate the complexities and nuances of dynamic organizations, conductor Roger Nierenberg will address the critical issues of accountability and responsibility and how these challenges impact health care today. This event, with a full professional orchestra, goes far beyond traditional lecture formats and is a resonant learning event and a moving personal and team journey unlike any other. Describe how the relationship between an organization and its leadership influences organizational culture, accountability, and outcomes Describe how an understanding of leadership dynamics can be applied to the development of strategies for successfully engaging an entire workforce Demonstrate methods used for creating effective communication across intra-organizational boundaries 5:30 PM 7:30 PM Learning & Simulation Center: Simulations, Exhibits, Posters, Reception 5:45 PM 6:45 PM Book Signing: Maestro Roger Nierenberg In the Learning & Simulation Center 7:15 PM 8:30 PM Board & Faculty Reception (by invitation) FRIDAY 7:00 AM 10:00 AM Registration Open Visit the NPSF booth and leave your business card for a chance to win a free registration for the 2012 NPSF Congress. Winners will be drawn at 1:00pm on Friday and must be present to win. 7:00 AM 8:00 AM Continental Breakfast 7:00 AM 7:50 AM BREAKFAST SESSIONS Using Podcasts to Equip and Engage Frontline Clinical Leaders Jason Hickok, MBA, RN, Assistant Vice President, Patient Safety and infection Prevention, HCA Kathryn Mitchell, MBA, Manager, Patient Safety, HCA This experiential learning session will outline how a large multi-hospital organization utilized podcasting technology as a platform to disseminate foundational patient safety principles to frontline clinical leaders. Patient Safety University (PSU) is a series of podcast lessons in which patient safety principles are discussed in the context of actual events. Join us for a demonstration of the lesson development process, an overview of the software and technology platform, and a review of our metrics. Participants will observe the real-time recording and web publication of a 5-minute mini-podcast. CLARION: Developing Interprofessionalism at the University of Minnesota Heather Dekan, General Executive Chair, CLARION Brandon Ferlas, PDIII, College of Pharmacy, University of Minnesota Saundra Hartmann, Coordinating Chair, CLARION Bethany Hyde, MHA Candidate, Class of 2011, University of Minnesota CLARION focuses on the professional development of AHC students and includes lessons in leadership, teamwork, communication, analytical reasoning, conflict resolution, and business practices. Participation in CLARION leads students to a more sophisticated understanding of the healthcare system in which they will practice. Our presentation will highlight the efforts CLARION has made to enhance awareness of and education in interprofessionalism and patient safety. Cultivating Patient Safety 11 NPSF Annual Patient Safety Congress 2011

12 Friday Operating Room Team Training to Improve Patient Safety: Using a Surgical Safety Checklist with Outcomes Metrics by the American College of Surgeons National Surgical Quality Improvement Program Scott Ellner, DO, MPH, Director of Surgical Quality, Saint Francis Hospital and Medical Center This session will report on a study intended to determine the impact of a standardized pre-operative briefing and post-operative debriefing comprehensive surgical safety checklist on patient safety and quality. After operating room team training in safety and implementation of a comprehensive surgical safety checklist, a significant reduction in 30-day postoperative complications through outcomes measurement by the American College of Surgeons National Surgical Quality Improvement Program database was identified. The study also evaluated the ability of surgical team training in conjunction with checklists to modify surgical team safety behavior as evidenced by a validated Safety Attitudes Questionnaire (SAQ), resulting in improved communication with hand-offs in the perioperative phases of surgical care. 8:00 AM 9:30 AM Presentation of National Patient Safety Foundation Socius Award Recipient: Massachusetts General Hospital and Massachusetts General Physicians Organization, Program to Coordinate Care for High-Risk Medicare Patients Plenary: Healthcare Simulation Live on Stage 1.5 contact hours for physicians, pharmacists L05-P, nurses (1.8 for Iowa nurses), healthcare risk management, and healthcare executives Jeffrey B. Cooper, PhD, Executive Director, Center for Medical Simulation, Professor of Anaesthesia, Harvard Medical School, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital Lisa Jacobson, MD, Attending Physician, Washington Hospital Center, Medstar Health Connie M. Lopez, RNC-OB, MSN, CNS, CPHRM, National Leader, Simulationbased Education and Training, National Risk Management and Patient Safety, Kaiser Permanente Haru Okuda, MD, FACEP, National Medical Director, SimLEARN, Veterans Health Administration Paul Preston, MD, Department of Anesthesia, San Francisco Medical Center, Physician Safety Educator, The Permanente Medical Group Robin Wootten, MBA, RN, Executive Director, Society for Simulation in Healthcare This plenary will offer a live simulation experience that will demonstrate how healthcare simulation can be used as a hands-on methodology for teaching critical patient safety topics to improve the delivery of health care. This interactive session will include audience participation while a team of leading simulation experts presents a real-case scenario and effective debriefing techniques. As every organization strives for safer patient care, simulation is becoming a national standard for delivering robust methods and techniques for improving patient safety. Attendees will gain a foundational knowledge around healthcare simulation and a deeper understanding of and appreciation for ways in which simulation may be applied to diverse, multidisciplinary healthcare environments. Describe how simulation can be used as a patient safety tool Describe the breadth of applications of simulation techniques and technologies Demonstrate skills for enhancing communication and teamwork education through the use of simulation scenarios Explain how simulation and time for debriefing provide important tasktraining opportunities for clinicians and staff Devise techniques to help their organization meet national regulatory standards 9:45 AM 11:15 AM Breakout Sessions Assuring Accountability and Mindfulness across the Continuum of Care SESSION 401: Center for Professional and Peer Support 1.5 contact hours for physicians, pharmacists L04-P, nurses (1.8 for Iowa nurses), healthcare risk management, and healthcare executives Jo Shapiro, MD, Chief, Division of Otolaryngology, Director, Center for Professionalism and Peer Support, Brigham and Women s Hospital There is a growing understanding of the relationship between healthcare s institutional culture that is, how we interact with each other each day and the quality of patient care. As a negative example, The Joint Commission has made the explicit link between disruptive behavior and its risk to safe patient care. As institutional leaders, we are dedicated to promoting a culture of trust where there is highly professional and respectful behavior between all healthcare team members. In this session, using role play, didactics, and facilitated group discussion, we will examine factors contributing to professionalism and discuss how to build an institutional program to support professional interactions throughout the institution, holding both the individual and the institution accountable for the culture we create. We will demonstrate professionalism training programs, remediation programs, and assessment opportunities. Identify the facilitators and barriers to respectful, professional interactions Devise strategies for overcoming such barriers Adopt tools discussed in the workshop to develop an institutional professionalism program Building Processes to Drive Personal and Collective Accountability SESSION 402: Having the Right Tools and the Willingness to Use Them 1.5 contact hours for physicians, pharmacists L05-P, nurses (1.8 for Iowa nurses), healthcare risk management, and healthcare executives Sean Berenholtz, MD, MHS, FCCM, Associate Professor, Johns Hopkins University School of Medicine and Bloomberg School of Public Health This session will describe a successful statewide effort to improve culture and reduce healthcare-associated infections in more than 100 Michigan ICUs. Forecast the impact of hospital-acquired infections on preventable morbidity and mortality Describe one successful approach used to reduce ventilator-associated pneumonia in over 100 Michigan ICUs Describe the role of the Comprehensive Unit-based Safety Program to improve teamwork and safety culture in successful efforts to reduce hospital-acquired infections Cultivating Patient Safety 12 NPSF Annual Patient Safety Congress 2011

13 FRIday Healthcare Reform and Accountability SESSION 403: Is Medical Radiation Safe? Can It Be Safer? 1.5 contact hours for physicians, pharmacists L05-P, nurses (1.8 for Iowa nurses), healthcare risk management, and healthcare executives William Hendee, PhD, Distinguished Professor of Radiology, Radiation Oncology, Biophysics, and Community and Public Health, Medical College of Wisconsin Jason Launders, MSc, Senior Project Officer, ECRI Institute Kathleen Shostek, RN, ARM, BBA, FASHRM, CPHRM, Senior Risk Management Analyst, ECRI Institute Injuries and risks from medical radiation have been discussed recently in both scientific publications and the public media. A focus on radiation doses and risks from medical imaging studies, especially computed tomography, has revealed unnecessary studies and excessive doses caused by use of inappropriate examination protocols. Several grievous injuries and some deaths have been reported in radiation therapy where high doses of radiation are used to treat patients with cancer. This session will review recent work in which the causes of these problems have been the subject of detailed examination within the disciplines of radiation and radiation oncology, resulting in several recommendations and actions for improvements in the use of radiation for diagnosis and treatment. Outline the causes of overuse and errors of medical radiation that subject patients to unnecessary risks of injury and long-term cancer induction Explain these risks in the context of the benefits derived from the diagnostic and therapeutic applications of medical radiation Endorse actions being taken to implement recommendations to reduce injuries and risks from medical radiation Innovation & Hot Topics SESSION 404: Camera s Rolling... Action. Simulation Training Incorporating the Patient Care Experience 1.5 contact hours for physicians, pharmacists L04-P, nurses (1.8 for Iowa nurses), healthcare risk management, and healthcare executives Kerry Dease, RN, BSN, CPHRM, Regional Patient Safety Lead, Kaiser Permanente Robert Stegmoyer, MD, ENT Physician, Kaiser Permanente Recently our focus for simulation training has been on improving the patient care experience in the Ambulatory Surgical Center. We found that by hiring an actor to play the patient/family member in parts of the scenario while using SimMan to rehearse the emergency, we could incorporate a patient and family and still rehearse the emergency using the patient simulators. The actor was a trained observer and an expert in debriefing techniques and has been used by Kaiser in a 3-day intensive communication class for physicians. He could offer the member s viewpoint while also providing feedback to the team on their performance. The entire simulation is videotaped and used in the debriefing. Describe and appreciate how the patient s perspective of the care delivery system can lead to teamwork performance improvement initiatives for a better care experience and improved patient outcomes Explain how teamwork and patient engagement can lead to increased patient satisfaction on Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. Attendees will understand how healthcare team patient communication and service behaviors affect patients experiences and patient outcomes List at least two tools to assist in incorporating the patient s care experience into future simulations in various healthcare settings Shared Decision Making to Promote Accountability between Patients and Providers SESSION 405: Can a Conversation Change an Outcome? The Faces of Medical Error... From Tears to Transparency: The Story of Michael Skolnik 1.5 contact hours for physicians, pharmacists L04-P, nurses (1.8 for Iowa nurses), healthcare risk management, and healthcare executives David Mayer, MD, Co-Executive Director, UIC Institute for Patient Safety Excellence, University of Illinois Medical Center Tim McDonald, MD, JD, Co-Executive Director, UIC Institute for Patient Safety Excellence, University of Illinois Medical Center David Skolnik, Co-Founder and Director, Citizens for Patient Safety Patty Skolnik, Founder and CEO, Citizens for Patient Safety The session will be conducted as a workshop of highly interactive discussion with participants addressing informed consent, informed choice, and shared decision making. The educational film The Faces of Medical Error... From Tears to Transparency: The Story of Michael Skolnik will serve to highlight these important concepts to participants. Through critical analysis and reflection by leading healthcare experts including Harlan Krumholz, Richard Boothman, Peter Angood, and Rosemary Gibson, caregivers will come to appreciate how shared decision making can help change outcomes and save lives. Michael s unfortunate story is a powerful teaching tool that allows caregivers to reflect on and discuss how we can improve our care through true shared decision making. Define characteristics of, and differences between, informed consent and shared decision making Describe how shared decision making is critical to transparent, patientcentered care and how it can improve outcomes while reducing medical liability and overuse of care Endorse the value of having family members or friends present during shared decision making conversations Teamwork and Communication for Enhanced Accountability SESSION 406: Teamwork and Communication for Enhanced Accountability: Emotional Intelligence and Simulation 1.5 contact hours for physicians, pharmacists L04-P, nurses (1.8 for Iowa nurses), healthcare risk management, and healthcare executives Randy Johnson, PhD, Chief Patient Safety Officer, Baptist Health, Associate Professor, Auburn University Judi Miller, RN, MSN, Director, Institute for Patient Safety and Medical Simulation, Baptist Health Most care delivered today is done by teams of people, yet training often remains focused on individual responsibilities leaving practitioners inadequately prepared to enter complex settings (Kohn, Corrigan, and Donaldson, 2000). In this session, we will present the results of current and ongoing research that focuses on team training in a simulated environment and will share our organization s experience in the use of simulation as a vehicle to improve team emotional intelligence (EI) and consequently team decision making. Over 2,000 healthcare professionals and students have been trained using our model consisting of well recognized principles of crew resource management, relational communications, and the Cultivating Patient Safety 13 NPSF Annual Patient Safety Congress 2011

14 Friday importance of regulating emotions of self and others to complete tasks and provide safer patient care. Explain the power of simulation use in improving healthcare communications Express an in-depth understanding of EI and its effects on team-based decision making Define EI measurement and its correlation to safer team decision making 11:30 AM 12:30 PM Breakout Sessions Assuring Accountability and Mindfulness across the Continuum of Care SESSION 501: Increasing the Effectiveness of Hand-off Communication to Reduce Readmissions and Improve the Patient Experience 1.0 contact hours for physicians, pharmacists L04-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Paula Griswold, MS, Executive Director, Massachusetts Coalition for the Prevention of Medical Errors Audrey Compton, MD, MPh, Quality Patient Safety Manager, New York Presbyterian Hospital Klaus Nether, Black Belt, Robust Process Improvement, The Joint Commission Theresa Sievers, RN, MS, Associate Vice President for Performance Improvement, Northeast Hospitals Part I: Joint Commission The Joint Commission s Center for Transforming Healthcare was created to help transform health care into a high-reliability industry. Using robust process improvement methods proven effective in other industries, including Six Sigma, Lean, and Change Management, the center creates sustainable solutions for health care s toughest and most persistent problems, one of which is hand-off communications. This project will be highlighted both on a macro level and by hearing directly from a participating hospital s hands-on experience in changing and raising their hand-off communication performance and quality to consistently excellent levels which have also helped to significantly reduce their bounce backs and readmissions. Describe how the Center for Transforming Healthcare is using robust process improvement to improve health care with a specific focus on the center s hand-off communications project Describe how one participating hospital reduced bounce backs and readmissions through the work of the hand-off communications project Part II: Our current healthcare structure, processes, and financial incentives produce fragmentation of care with significant opportunities to improve the patient experience of care while reducing hospital readmissions. This session will describe a statewide initiative in Massachusetts to address this challenge and promote the creation of accountable care organizations across the state, as well as the specific efforts in one community to create a cross-continuum provider team, identify the critical success factors in improving care, and share the lessons they have learned to date. The session will describe a patient- and family-centered approach that streamlines care processes; assures evidence-based care; and improves patient access, patient education, and communication between and among patients, family members, and healthcare providers. Describe the Massachusetts strategy to promote and support statewide efforts to improve coordination of care across the continuum, with an initial focus on preventing avoidable readmissions and improving the patient s and family s experience of care related to the hospital discharge and follow-up care Identify key transitions in care across the continuum, and strategies to improve the transition process, improve the patient experience and reduce hospital readmissions Building Processes to Drive Personal and Collective Accountability SESSION 502: A NICU Team Approach to Improving the Patient Identification and Breast Milk Administration Process 1.0 contact hours for physicians, pharmacists L04-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Lynn Hemann, RN, BSN, Assistant Nurse Manager, NICU, St. Louis Children s Hospital Debbie Linck, RN, Senior NICU Staff Nurse, St. Louis Children s Hospital Bruce Spurlock, MD, Executive Director, Clinical Acceleration, BEACON Pat Teske, RN, MHA, Implementation Officer, BEACON This session will reveal how a hospital-based safety issue was resolved with a multidisciplinary approach. This resulted in improved outcomes through a process change thereby bringing a significant decrease in errors. The session will also demonstrate how a regional collaborative was able to obtain better outcomes in a shorter period of time than a comparative group. Key levers which contributed to these results will be explored. Distinguish the difference between improvements that resulted from collaborative efforts versus those that resulted from secular trends Question the factors that contribute to improvement Contrast their current improvement efforts with the discussed factors and determine how they can strengthen their own efforts Healthcare Reform and Accountability SESSION 503: Integrated, High-Value Care: What We ve Learned So Far 1.0 contact hours for physicians, pharmacists L04-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Blair G. Childs, Senior Vice President of Public Affairs, Premier Healthcare Alliance This presentation will cover the accountable care (AC) concept, which is included in the recently enacted healthcare reform bill. Specific topics covered in the presentation will be: Medicare requirements and regulations related to becoming an ACO; private sector ACO initiatives; implications for healthcare providers; market developments, trends, and outlook; and examples of leading-edge healthcare systems moving toward accountable care. Outline the details of accountable care organization requirements Explain implications for healthcare providers and communities Outline strategies and work underway by leading health systems Cultivating Patient Safety 14 NPSF Annual Patient Safety Congress 2011

15 FRIday Innovation & Hot Topics SESSION 504: Electronic Health Records and Patient Safety: The New Frontier 1.0 contact hours for physicians, pharmacists L05-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Mukesh Mehta, DPh, MBA, RPh, Vice President, Clinical and Regulatory Solutions, PDR Network Electronic Health Record (EHR) adoption by US providers is exploding, driven by more than $20 billion in federal, state, payer, and hospital incentives. Providers are not only required to purchase EHRs, but to utilize them in accordance with the Meaningful Use guidelines established by the federal government. EHR adoption moves the average provider into an electronic world for the first time, and Meaningful Use of EHRs demands substantial changes to provider workflow. As EHRs create a new frontier for physician patient engagement, fundamental changes to the practice and delivery of health care create new implications for improving patient safety, ensuring regulatory compliance, and reducing gaps in physician knowledge. Describe the forces driving EHR adoption by providers, including existing and near-term adoption rates, and the concept, relevance, and requirements of Meaningful Use Describe the changes in provider workflow created by EHR adoption, including eprescribing, communication of Food and Drug Administration (FDA)-mandated prescription drug information including REMS (Risk Evaluation and Mitigation Strategies), the development of online-based patient safety focused Continuing Medical Education (CME), and others Adopt the knowledge of EHR implementation to improve workflow efficiency, with a primary focus on applying Meaningful Use requirements to ensure that interactive tools for online patient communication are well understood, appropriately adapted, and efficiently applied in daily practice Shared Decision Making to Promote Accountability between Patients and Providers SESSION 505: Patient as Co-Pilot: The Approach to Preference-sensitive Care at Group Health Cooperative 1.0 contact hours for physicians, pharmacists L04-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Matt Handley, MD, Associate Medical Director, Quality and Informatics, Group Health Cooperative Karen Merrikin, JD, Senior Policy Advisor, Group Health Cooperative Group Health has successfully implemented shared decision making across its integrated group practice, and has also extended its use into its physician network. This session will discuss Group Health s experience in using systematic tools and approaches to reduce unintended variation and improve clinical outcomes and patient safety and satisfaction. Implications of shared decision making and how it can be implemented in other health settings will also be discussed. Explain the drivers of variation in preference sensitive care Identify opportunities for improvement in patient-centered outcomes in their own setting Prepare concrete plans for implementing a shared decision making program in their own setting Teamwork and Communication for Enhanced Accountability SESSION 506: Pharmacist s Accountability Medication Management and Improving Continuity of Care through Medication Management 1.0 contact hours for physicians, pharmacists L05-P, nurses (1.2 for Iowa nurses), healthcare risk management, and healthcare executives Mary Andrawis, PharmD, MPH, Director of Clinical Guidelines and Quality Improvement, American Society of Health-System Pharmacists Henri R. Manasse Jr., PhD, ScD, Executive Vice President and CEO, American Society of Health-System Pharmacists This session will explore the pharmacist s role as part of the healthcare team and how the role has evolved in recent decades. The goal of the session is to demonstrate the opportunity to significantly improve patient care and satisfaction, eliminate patient harm, and reduce readmissions and costs. Attendees will be presented with practical implementation tips for ensuring that high-quality medication management services are integrated into every patient s care. Describe three evidence-based results that demonstrate the impact of including pharmacists as part of the healthcare team List the areas of the medication use process that require accountability for safe and effective medication use Explain four best practices that, when implemented, will improve medication safety and optimize patient outcomes 12:30 PM 2:00 PM Learning & Simulation Center: Simulations, Exhibits, Posters, Lunch Visit the NPSF booth and leave your business card for a chance to win a free registration for the 2012 NPSF Congress. Winners will be drawn at 1:00pm on Friday and must be present to win. Join us next year for the 14th Annual NPSF PATIENT SAFETY CONGRESS here at the Gaylord National, Washington, DC May 23 25, 2012 Cultivating Patient Safety 15 NPSF Annual Patient Safety Congress 2011

16 Cultivating Patient Safety 16 NPSF Annual Patient Safety Congress 2011

17 Continuing Education Credit The 2011 NPSF Patient Safety Congress is certified for continuing education credit by the providers listed below. Materials and instructions for submission will be provided at the Congress. This educational conference offers a maximum of: 15.5 contact hours for physicians 15.5 contact hours for pharmacists 15.5 contact hours for nurses in 49 states for nurses in Iowa 15.5 contact hours for professionals in healthcare risk management 15.5 contact hours for healthcare executives PhysicianS: The Doctors Company is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The Doctors Company designates this educational activity for a maximum of 15.5 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activity. PharmacISTS: Inquisit is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. NursES: Inquisit is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. Inquisit is approved by the Iowa Board of Nursing as a provider of continuing education credits. Provider number 333. Inquisit is approved by the Florida Department of Health Board of Nursing as a provider of continuing education credits. Provider number Inquisit is approved by the Board of Registered Nursing State of California as a provider of continuing education credits. Provider number CEP ProfessionalS in Healthcare Risk Management: This program has been approved for contact hours, as listed below, of continuing education credit toward fulfillment of the requirements of ASHRM designations of Fellow (FASHRM) and Distinguished Fellow (DFASHRM) and towards Certified Professional in Healthcare Risk Management (CPHRM) renewal. Patient Safety 101. May 25, contact hours Community Engagement. May 25, contact hours Getting Comfortable: Leadership s Role in Driving Personal, Professional and Organizational Accountability. May 25, contact hours Measurement Bootcamp: Strategies and Tactics for the Real World. May 25, contact hours Main Conference: Cultivating Patient Safety: It s In Our Hands. May 26 27, contact hours Healthcare Executives: Inquisit is authorized to award 15.5 hours of pre-approved category II (non-ache) continuing education credit for this program toward advancement or recertification in the American College of Healthcare Executives. Participants in this program wishing to have the continuing education hours applied toward Category II credit should indicate their attendance when submitting application to the American College of Healthcare Executives for advancement or recertification. Requirements for Credit Full attendance is required at the session to receive CE credits or hours for that session. Partial credit will NOT be awarded. Late arrivals or early departures will preclude awarding CE credits or hours. Attend/participate in the educational activity and review all course materials. Complete the CE declaration form(s) and speaker evaluation(s) after the conference. The link to the conference CE portal will be provided. Cultivating Patient Safety 17 NPSF Annual Patient Safety Congress 2011

18 connected + personalized = elated integrated Actually, it s a pretty simple equation. Your health history and information accessible to your care team instantly and securely. 24 hours a day, 7 days a week. That s integrated care, and it all adds up to a healthier, happier you. Learn more at kp.org/thrive Cultivating Patient Safety 18 NPSF Annual Patient Safety Congress 2011

19 SimulationS at the 2011 NPSF Congress SIMULATION PLENARY HealtHcare Simulation live on Stage Friday 8:00 9:30am MAryLANd BALLrOOM C/d This year, we have expanded our simulation program to include an extraordinary plenary address centered on simulation. Featuring renowned simulation experts, this plenary offers a live experience that demonstrates how healthcare simulation can be used as a hands-on methodology for teaching critical patient safety topics and improving the delivery of health care. The presentation offers a breadth of knowledge for applying simulation techniques and technologies across a broad spectrum of areas within a healthcare organization. The plenary team will display skills for enhancing communication and teamwork education through the use of simulation scenarios, as well as recognizing how simulation and time for debriefing provide important task-training opportunities for clinicians and staff. In addition, attendees will learn how simulation can be effective for training proper disclosure techniques. Plenary Faculty: Jeffrey B. Cooper, Phd, Executive Director, Center for Medical Simulation, Professor of Anaesthesia, Harvard Medical School, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital Lisa Jacobson, Md, Attending Physician, Washington Hospital Center, Medstar Health Connie M. Lopez, rnc-ob, MSN, CNS, CPHrM, National Leader, Simulation-based Education and Training, National Risk Management and Patient Safety, Kaiser Permanente Program Offices Paul Preston, Md, Department of Anesthesia, San Francisco Medical Center, Regional Safety Educator, The Permanente Medical Group Haru Okuda, Md, FACEP, National Medical Director, SimLEARN, Veterans Health Administration robin Wootten, MBA, rn, Executive Director, Society for Simulation in Healthcare Solutions Providers: 3M Armstrong B. Braun B-Line Medical Hill-Rom Hospira Laerdal Medline Ohio Medical Phillips Pocket Nurse Precision Dynamics Smith Medical Turning Technologies general Learning Objectives: At the conclusion of this session, participants will be able to: Describe how simulation can be used as a patient safety tool Describe the breadth of applications of simulation techniques and technologies Develop skills for enhancing communication and teamwork education through the use of simulation scenarios Recognize how simulation and time for debriefing provide important task-training opportunities for clinicians and staff Recognize how simulation can be an effective tool for training clinicians and staff in proper disclosure techniques Wednesday, May 25 6:00 8:00pm Thursday, May 26 12:00 1:45pm 5:30 7:30pm Friday, May 27 12:30 2:00pm Simulations LEARNINg & SIMULATION CENTER EXHIBITION HALL A The 2011 NPSF Patient Safety Congress will once again transform the traditional exhibit hall into the Learning & Simulation Center. Here you will find four stations presenting interactive, engaging simulations depicting realistic healthcare scenarios in the context of patient safety. Using a variety of simulation modalities, these presentations create unparalleled educational opportunities for attendees and are an innovative extension of the NPSF Congress program s commitment to exceptional education. For more details on the Learning & Simulation Center, including a list of solutions providers who supported the program, please consult the booklet NAvIgATINg THE LEArNINg & SIMuLATION CENTEr. Exhibits In addition, the Learning & Simulation Center provides you with access to exhibitors who demonstrate their commitment to safe health care by showcasing their products, systems, and services at the NPSF Congress. Poster Presentations Also in the Learning & Simulation Center you will find the Poster Display, with poster presentations that document innovative research and successful solutions in the field of patient safety. For a complete listing of the posters, please see pages receptions and Lunches Last but not least, the Learning & Simulation Center is the place to gather for evening receptions and lunches. Photo courtesy of The Center for Medical Simulation, Cambridge, MA Cultivating Patient Safety 19 NPSF Annual Patient Safety Congress 2011

20 Now more than ever, hospitals across the country must look closely at their medication management processes. With more patients entering the system and tighter reimbursement regulations, hospitals are forced to find innovative ways to improve patient outcomes, streamline operations, and control costs. Through a balance of national distribution excellence, professional services, and pharmacy automation, AmerisourceBergen is committed to helping hospitals reach and exceed core clinical, operational, and economic goals. To learn more about how AmerisourceBergen can help, contact , solutions@amerisourcebergen.com, or visit The Doctors Company Foundation is a proud sponsor of the Lucian Leape Institute Town Hall Meeting. The Doctors Company Foundation was created in 2008 with the mission to advance and protect the practice of good medicine. The Foundation is committed to supporting patient safety and risk management research that has the potential for reducing patient risk and improving the environment in which all doctors practice. For more information on research grants, please visit A3291_Sponsor_NPSF Program (2).indd 1 4/22/2011 4:54:17 PM Cultivating Patient Safety 20 NPSF Annual Patient Safety Congress 2011

21 2011 NPSF AWARDS The National Patient Safety Foundation is pleased to present the following awards at the 2011 NPSF Patient Safety Congress: National Patient Safety Foundation Chairman s Medal Awarded in recognition of emerging leadership in the patient safety field. Recipient: Robert Connors, MD, President, Helen DeVos Children s Hospital National Patient Safety Foundation Socius Award Given in recognition of work that promotes positive and effective partnering between patients/ families and providers in pursuit of improved patient safety. Recipient: Massachusetts General Hospital and Massachusetts General Physicians Organization, Program to Coordinate Care for High-Risk Medicare Patients National Patient Safety Foundation Stand Up for Patient Safety Management Award Granted to a member hospital of the National Patient Safety Foundation s Stand Up for Patient Safety program in recognition of the successful implementation of an outstanding patient safety initiative that was led by, or created by, mid-level management. Recipient: Franciscan St. Anthony Health - Michigan City, Sentinel Lymph Node Visualization Rates Patient Safety Initiative at America s Public Hospitals Leadership Award Awarded to a participating member of the grant-funded Patient Safety Initiative at America s Public Hospitals, recognizing the successful implementation of an outstanding patient safety program and/or project that was created, implemented, or advanced through participation in this initiative. Recipient: Harborview Medical Center The Doctors Company Foundation Young Physicians Patient Safety Award An award to recognize young physicians for their deep personal insight into the significance of patient safety work, given by The Doctors Company Foundation in partnership with the Lucian Leape Institute at the National Patient Safety Foundation. Recipients: Andrey Ostrovsky, Boston University School of Medicine Noah Rosenberg, University of Massachusetts Medical School Dan Henderson, University of Connecticut School of Medicine, Harvard School of Public Health Christopher Thom, University of Virginia Mengyao Liang, University of Illinois at Chicago Wael Salem, Mayo Medical School Cultivating Patient Safety 21 NPSF Annual Patient Safety Congress 2011

22 Over two years, 157 hospitals have saved 22,164 lives and $2.13 billion. Premier s QUEST collaborative is a voluntary, multiyear collaborative built to help hospitals transition from today s standards to meet tomorrow s requirements for care coordination, greater reductions in costs and evidence-based care. premierinc.com/quest Make the QUEST success story your own. Cultivating Patient Safety 22 NPSF Annual Patient Safety Congress 2011

23 Meet the Experts Agency for Healthcare Research and Quality (AHRQ) Learn about the AHRQ patient safety portfolio and tools to help educate patients and clinicians about healthcare-associated infections, common formats for patient safety event reporting, patient safety culture surveys, safe use of blood thinners, teamwork training materials, AHRQ Web-based resources, and more. In the Learning & Simulation Center EXHIBITION HALL A Wednesday, May 25, 6:00 8:00 pm Common Formats for Skilled Nursing Facility, Patient Safety Organizations (PSOs): Deborah G. Perfetto, PharmD, Health Scientist Administrator, Center for Quality Improvement and Patient Safety (CQuIPS), AHRQ Patient Safety Implementation Funding Opportunities: Eileen M. Hogan, MPA, Project Officer, and Marcy G. Opstal, MPH, Health Scientist Administrator, CQuIPS, AHRQ Safe Use of Blood Thinners Booklet and DVD: Loleta M. Robinson, MD, MBA, Clinical Marketing Manager, Office of Communications and Knowledge Transfer (OCKT), AHRQ Thursday, May 26, 12:00 1:45 pm WebM&M and PSNet: Jennifer Felsher, Public Affairs, OCKT, AHRQ Surveys on Patient Safety Cultures (SOPS): Joann Sorra, PhD, Westat TeamSTEPPS Strategies and Tools to Enhance Performance and Patient Safety: James B. Battles, PhD, Social Science Analyst for Patient Safety, CQuIPS, AHRQ Thursday, May 26, 5:30 7:30 pm AHRQ Comprehensive Unit-based Safety Program (CUSP) to Reduce Central Line Associated Blood Stream Infections (CLABSI): Steve Hines, PhD, Vice President for Research, Health Research and Educational Trust, American Hospital Association AHRQ Patient Safety Portfolio Activities: Jeff Brady, MD, MPH, Captain, US Public Health Service, Patient Safety Portfolio Lead, CQuIPS, AHRQ AHRQ Simulation Funding Opportunities: Kerm Henriksen, PhD, Human Factors Advisor for Patient Safety, CQuIPS, AHRQ 14 th ANNUAL NPSF PATIENT SAFETY CONGRESS May 23 25, 2012 Gaylord National Washington, DC National Patient S 2012 SAVE the DATE Join us again next year Cultivating Patient Safety 23 NPSF Annual Patient Safety Congress 2011

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25 201 1 NPSF Poster Presentations research posters R1 R2 R3 R4 R5 R6 Cincinnati Children s Hospital Medical Center: Use of the Institute for Healthcare Improvement s Global Trigger Tool in an Inpatient Pediatric Setting Emory Neurosurgery: Retrospective Analysis of Hospital Discharges to Assess the Potential Impact of Unrecognized Abnormal Laboratory Test Results on Patient Safety Harvard Combined Orthopedic Surgery Residency Program: Hazardous Attitudes in Surgeons Harvard Combined Orthopedic Surgery Residency Program: Combating Fatigue in Graduate Medical Education John Muir Health: It s a Long Wait to Extubate! Decreasing Ventilator Length of Stay through Partnership with a TeleICU Team and Implementation of a Cross- Campus Weaning Protocol Lifespan Rhode Island Hospital: Translating an Evidence-Based Practice Protocol for Nurses Shift Hand Offs R7 R8 R9 R10 R11 R12 R13 Lincoln Medical and Mental Health Center: Fast Track Lung Cancer Intervention Study Massachusetts College of Pharmacy and Health Sciences: Enhancing Institution- Specific High Alert Medication Knowledge among Pharmacy, Nursing and Medical Staff Mount Sinai Medical Center: Missed Step NAPCRG (North American Primary Care Research Group); EGPRN (European General Practice Research Network): Effectiveness of Different Strategies Used for Type 2 Diabetes National Board of Osteopathic Medical Examiners: Evaluation of a Patient Risk Assessment Tool to Promote a Culture of Patient Safety: A Pilot Study Ohio State University Medical Center: Preventing Wrong Site, Procedure and Person Events Using Common Cause Analysis Safety Institute, Premier Healthcare Alliance: Stop Syringe Reuse and Unsafe Injection Practices R14 R15 R16 R17 R18 R19 SonoSite Inc.: The Clinical and Economic Advantage of Ultrasound Guidance among Patients Undergoing Thoracentesis SonoSite Inc.: The Clinical and Economic Advantage of Ultrasound Guidance among Patients Undergoing Paracentesis St. Joseph: Preventing Medication Administration Interruptions Promotes a Culture of Patient Safety Women and Children s Hospital of Buffalo, Kaleida Health: Teamwork Training Is Associated with Decreased Ventilator Days and Length of Stay in a Pediatric Critical Care Unit Beth Israel Medical Center: A Multidisciplinary, Collaborative Approach to Decreasing Obstetrical Morbidity University HealthSystem Consortium: Physician Event Reporting in the UHC Patient Safety Net solutions posters S1 S2 S3 S4 S5 S6 S7 Clinical Services Group, HCA: Using an Automated Electronic Tracker to Identify Symptomatic Patients and Prevent the Spread of Infections and Emerging Multidrug-Resistant Organisms Baltimore VA Medical Center: Helping Ensure that Patients Are Ready for Surgery A Novel Process for Supplying Preoperative Instructions Baptist Memorial Hospital Memphis: Improving Glucose Control in ICU Baptist Health South Florida: Communication Tools Improving Patient Safety by Engaging the Patient and Family in Care Baptist Health South Florida: Forever Changed Patient Safety Shared Learning Changhua Christian Hospital: Introduction of Rapid Response Teams to a League of 8 Hospitals in Taiwan Children s Hospitals and Clinics of Minnesota: Reduction of Nosocomial Infections in the NICU S8 S9 S10 S11 S12 S13 S14 S15 S16 Coney Island Hospital: Use of Crisis Prevention Team in Psychiatric Units to Calm Agitated Patients Leads to a Reduction in the Use of Restraints and Seclusion thereby Resulting in Fewer Injuries and Enhancing Patient Safety Dialog Medical: Leveraging the Meaningful Use Objectives Fitting Patient Safety into the Hospital s EHR Strategy Doctors Hospital of Manteca: Use of a Virtual CHF Clinic to Avoid Readmissions Tenet Healthcare and Doctors Hospital of Manteca: VTE Prophylaxis Drexel University College of Medicine and St. Christopher s Hospital for Children: The Patient Safety Conference A Catalyst for Culture Change Fairview Ridges Hospital: Ensuring Patient Safety during Care Model Redesign Hackensack University Medical Center: CorrectInject System: Reducing Epidural- Intravenous Misconnections HCA: Invasive Tubes and Lines Preventing Connection and Access Errors in a Large Healthcare System HCA: Falls Prevention Initiative The Pharmacist Role in Preventing Falls S17 S18 S19 S20 S21 S22 S23 S24 S25 HCA: Medication Safety Reducing Harm Related to Meperidine Events Henry Ford Hospital: Decreasing Vent Days in the Medical ICU Henry Ford Health System: Shattering the Fallacy of Perfect Human Performance to Motivate Behavior Change Can an Educational Intervention Influence Perception of Safety, Promote Engagement in Error Prevention Strategies, and Enhance an Organizational Culture of Safety? Henry Ford Health System: Defying Gravity Can We Reduce Inpatient Falls and Hospital-Acquired Pressure Ulcers? Hospital of the University of Pennsylvania: Redesigning Patient Safety Walkrounds Institute for Clinical Systems Improvement: Reducing Harmful Radiation by Using Decision Support to Order Diagnostic Imaging Scans Kenner Army Health Clinic: Medication Reconciliation Getting the List to the Patient in Ambulatory Care Kent Hospital: Role of Data Collection in Changing Culture Lehigh Valley Health Network: Catch a Near Miss and Prevent a Harmful Error Cultivating Patient Safety 25 NPSF Annual Patient Safety Congress 2011

26 Members of the Lucian Leape Institute Lucian Leape institute at the national patient safety foundation FourthAnnual Forum&Gala thursday, september 22, 2011 omni parker house & the state Room, Boston Special Dinner Speaker Atul Gawande, MD, MPH Best-Selling Author and Surgeon Join us for this extraordinary afternoon and evening event. in a unique and collegial setting designed to encourage sharing of perspectives, the LLi forum & Gala provides a remarkable opportunity for you to meet and connect with national patient safety thought leaders and peers from across health care and to signal your support for the institute s mission. afternoon session: an interactive discussion will be led by Lucian Leape institute members, who will offer insights into their work and seek attendee reaction and input. evening program: the networking reception and dinner at the state Room, overlooking Boston s skyline and harbor, promises to be an impactful experience. We are most honored to announce our dinner speaker, atul Gawande, Md, Mph, general and endocrine surgeon, Brigham & Women s hospital, and author of the new york times bestsellers the checklist Manifesto: how to Get things Right and complications: a surgeon s notes on an imperfect science. Register now at Lucian L. Leape, MD chair, Lucian Leape institute adjunct professor of health policy harvard school of public health Diane C. Pinakiewicz, MBA president, Lucian Leape institute president, national patient safety foundation ~ Carolyn M. Clancy, MD director agency for healthcare Research and Quality James B. Conway, MS adjunct faculty harvard school of public health Susan Edgman-Levitan, PA executive director John d. stoeckle center for primary care innovation, Massachusetts General hospital James A. Guest president, consumers union Gary S. Kaplan, MD, FACMPE chairman and ceo Virginia Mason Medical center Julianne M. Morath, RN, MS chief Quality and safety officer Vanderbilt Medical center Dennis S. O Leary, MD president emeritus the Joint commission Paul O'Neill former chairman and ceo, alcoa 72nd secretary of the us treasury David M. Lawrence, MD LLi Member emeritus chairman and ceo (retired) Kaiser foundation health plan inc. and Kaiser foundation hospitals Pamela A. Thompson, MS, RN, FAAN LLi Member ex-officio immediate past chair, npsf Board of directors ceo, american organization of nurse executives to learn more about the work of the Lucian Leape institute, visit for details on sponsorship opportunities, contact david coletta at or dcoletta@npsf.org. Cultivating Patient Safety 26 NPSF Annual Patient Safety Congress 2011

27 posters S26 S27 S28 S29 S30 S31 S32 S33 S34 S35 S36 S37 S38 S39 S40 Lehigh Valley Health Network: Dashboards Drive Direction Lehigh Valley Health Network: It s Time to Teach Back An Interprofessional Approach to Enhance Learning and Reduce Readmissions Lincoln Medical and Mental Health Center: Radiation Dose Reduction for CT Examinations Lincoln Medical and Mental Health Center: Successful Implementation of an Interdisciplinary DVT Prevention Program Utilizing an Electronic Risk Assessment, Clinical Decision and Monitoring Tool Massachusetts General Hospital: Automated, Mandatory Quality Assurance Data Capture in Anesthesia A Secure Electronic System to Capture Quality Assurance Information Linked to an Automated Anesthesia Record Massachusetts General Hospital: Universal Protocol: Watching It Happen Was That a Rolling Stop or a Hard Stop Time-Out? Mayo Clinic: Adverse Event Communication Memorial Sloan-Kettering Cancer Center: A Human Factors Approach to the Redesign of Clinical Reminder Signage Memorial Sloan-Kettering Cancer Center: Enhancing Medication Safety Using Computerized Provider Order Entry (CPOE) Metropolitan Hospital Center: Utilizing the TeamSTEPPS Approach to Improve Patient Care and Safety Metropolitan Hospital: Assault/Violence Prevention and Management on Inpatient Psychiatry Units Metropolitan Hospital: Quiet Zone Miami Children s Hospital: Leveraging Crew Resource Management (CRM) in Driving an Error-Free Culture Miami Children s Hospital: Positive Changes Preventing Catheter Blood Stream Infection Using Lean Methodology Morgan Stanley Children s Hospital of New York, NY Presbyterian Hospital: Transforming Care at the Bedside through a Leadership, Physician and Staff Partnership S41 S42 S43 S44 S45 S46 S47 S48 S49 S50 S51 S52 S53 S54 National Health Foundation: Patient Safety First... A Partnership for Health New York City Health and Hospitals Corporation: Empowering and Engaging Smart People to Work Together and Communicate to Prevent Errors and Commit to Patient Safety Omaha VA Medical Center: Engaging Physicians in Patient Safety: An Innovative Approach to Teaching Quality Improvement and Patient Safety Pascal Metrics Inc.: Utilizing Global Trigger Data Designing AHS Quality Improvement Collaboratives Saint Francis Hospital: Saint Francis Hospital Fall Prevention Protocol: A Successful Implementation of Evidence-Based Nursing Practice Shore Health System: Code White Rapid Response to Hemorrhage St. Anthony s North Hospital: Team Care Handoff Refocusing Care to Make Patient Safety Our Priority Stony Brook Long Island Children s Hospital: Moving beyond the ICU: Preventing Central-Line Infections in Pediatric Hematology Oncology Stony Brook University Hospital: Patient Safety A 24/7 State of Mind Tawam Hospital: What We Did and What We Learned Counts Tawam Hospital (in affiliation with Johns Hopkins Medicine): Establishing Culture of Safety A Middle East Hospital Experience The Hospital for Sick Children: Engaging Staff in Quality and Safety The Hospital for Sick Children: Improving Nursing Shift-to-Shift Handoff in Pediatric Critical Care Mount Sinai School of Medicine: A Team Model for Floor Intubations Impact on Recognition of Critical Events during Intubation S55 S56 S57 S58 S59 S60 S61 S62 S63 S64 S65 S66 S67 University of Texas M. D. Anderson Cancer Center: Making Patient Care Safer and Enhancing Clinical Evaluation by Providing Video Streaming of Speech Pathology Tests to the Electronic Medical Record System University of Louisville: Medication Optimization The Last 100 Feet University of Texas M. D. Anderson Cancer Center: Using Failure Mode Effects Analysis (FMEA) to Reduce Patient Harm Associated with the Prescribing of Opioids at the University of Texas M. D. Anderson Cancer Center University of Medicine and Dentistry, New Jersey/ New Jersey Medical School: Empowering Patients as a Safety Strategy University of Michigan Health System: Hospital Billing Records Can Increase Event Reporting and Improve Patient Safety Veterans Health Administration: Safety Improvement EHR Display Virginia Mason Medical Center: Standardized RN Handoffs for Reliable Care Virginia Mason Medical Center: Identification and Management of Delirium in Critical Care Westat: The AHRQ Health Care Innovations Exchange A Resource for Patient Safety Improvement Woodhull North Brooklyn Health Network: The Impact of TeamSTEPPS Methodologies on Patient Care in the Emergency Room Utilizing Strategies of Communication and Team Work to Improve Patient Care Catholic Healthcare West: Retained Surgical Items Taking Sponges to Zero! Beth Israel Medical Center: A Multicenter, Multidisciplinary Collaborative Project to Design a Portable Care Map and Culturally Sensitive Patient Education Material for the Morbidly Obese Parturient University HealthSystem Consortium: An Analysis of Blood Transfusion Related Events in the UHC Patient Safety Net Cultivating Patient Safety 27 NPSF Annual Patient Safety Congress 2011

28 201 1 NPSF Congress Supporters PLATINUM SILVER SIMULATION PLENARY RESEARCH & SOLUTIONS POSTERS FRIEND MEDIA SUPPORTERS DONOR American Organization of Nurse Executives Cultivating Patient Safety 28 NPSF Annual Patient Safety Congress 2011

29 SUPPORTERS GOLD LLI TOWN HALL PLENARY LEARNING & SIMULATION CENTER BRONZE FRIEND Cultivating Patient Safety 29 NPSF Annual Patient Safety Congress 2011

30 201 1 NPSF Congress Supporters The National Patient Safety Foundation offers sincere thanks to these organizations, whose generous support of the 2011 Patient Safety Congress demonstrates their steadfast commitment to the goal of safer health care for all. PLATINUM McKesson 5995 Windward Parkway Alpharetta, GA McKesson is a healthcare services and information technology company committed to better health: of patients, our customers, and the nation s healthcare system. Working with organizations across the industry, we bring a unique vantage point to help our customers improve care quality, adapt to changes of health reform, and sustain business operations. GOLD Hospital Corporation of America HCA Holdings Inc. One Park Plaza Nashville, TN (615) At its founding in 1968, Nashville-based HCA was one of the nation s first hospital companies. Today, we are the nation s leading provider of healthcare services, a company comprised of locally managed facilities that includes about 164 hospitals and 106 freestanding surgery centers in 20 states and Great Britain and employing approximately 183,000 people. HCA is committed to the care and improvement of human life and strives to deliver high-quality, cost-effective healthcare in the communities we serve. Ventana 1910 E. Innovation Park Drive Tucson, Arizona Ventana Medical Systems Inc., a member of the Roche Group, is a world leader and innovator of tissuebased diagnostic solutions. Passionately pursuing our mission, to improve the lives of cancer patients, the people of Ventana discover, develop, and deliver medical diagnostic systems and slide-based cancer tests that are shaping the future of health care. We also offer premier workflow solutions designed to improve laboratory efficiency and preserve patient safety. Lexington Insurance Company 100 Summer Street Boston, MA Lexington Insurance Company, a Chartis Company, is America s leading surplus lines insurer. Chartis is the marketing name for the worldwide property-casualty and general insurance operations of Chartis Inc. Lexington is a recognized market leader in underwriting wide-ranging healthcare risks, providing cutting-edge risk management, and exceptional claims service. SILVER AmerisourceBergen 1300 Morris Drive, Suite 100 Chesterbrook, PA AmerisourceBergen is one of the world s largest pharmaceutical services companies servicing healthcare providers in the pharmaceutical supply channel. The company provides drug distribution and related pharmacy automation and professional service solutions designed to reduce costs, increase efficiency, and improve patient outcomes. PatientSafe Solutions 5375 Mira Sorrento Place, Suite 500 San Diego, CA PatientSafe Solutions develops innovative handheld technology that helps hospitals prevent medical errors, improve quality, and reduce costs by enabling nurses to efficiently coordinate care, manage clinical workflows, communicate with care team members and document patient information in real-time. Meet PatientTouch, the industry s first smart device designed specifically for patient care. Premier Healthcare Alliance 2320 Cascade Pointe Blvd. Charlotte, NC Premier is a performance improvement alliance of more than 2,500 hospitals and 73,000-plus other healthcare sites leading the transformation to highquality, cost-effective care. Owned by hospitals and health systems, Premier maintains the nation s most comprehensive repository of clinical, financial, and outcomes information and operates a leading healthcare purchasing network. Sanofi-Aventis 55 Corporate Drive Bridgewater, NJ Sanofi-Aventis US, based in Bridgewater, NJ, and employing 13,000 people across the country, is part of a leading global pharmaceutical company that discovers, develops, produces, and markets innovative therapies that enhance people s lives. Our extensive research and development efforts are focused on healthcare challenges in cardiology, oncology, and internal medicine, as well as metabolic diseases, central nervous system disorders, and vaccines. LLI TOWN HALL PLENARY The Doctors Company Foundation 185 Greenwood Road Napa, CA The Doctors Company Foundation supports patient safety research, forums, and pilot programs; patient safety education programs; and medical liability research. Our mission is to reduce patient risk and improve the environment in which doctors and all healthcare providers practice. LEARNING & SIMULATION CENTER Kaiser Permanente 1800 Harrison Street, 24th floor Oakland, CA Kaiser Permanente is committed to helping shape the future of health care. We are recognized as one of America s leading healthcare providers and not-forprofit health plans. Founded in 1945, our mission is to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve. SIMULATION PLENARY Society for Simulation in Healthcare 5353 Wayzata Blvd., Suite 207 Minneapolis, MN The Society for Simulation in Healthcare (SSH) represents the rapidly growing group of educators and researchers who utilize a variety of simulation techniques for education, testing, and research in healthcare. We are a broad-based, multidisciplinary, multispecialty, international society with ties to all medical specialties, nursing, allied health paramedical personnel, and industry. RESEARCH & SOLUTIONS POSTERS Laerdal Medical 167 Myers Corners Rd. Wappingers Falls, NY 877-LAERDAL ( ) Laerdal Medical is a world leader in providing healthcare solutions. True to its mission of helping save lives, Laerdal products and services include: Advanced Simulation, Self Directed Learning, Airway/ Immobilization. Over the last 50 years, Laerdal s Resusci Anne and other CPR training manikins have trained over 250 million people worldwide in cardiopulmonary resuscitation. BRONZE Hospira 275 North Field Drive Lake Forest, IL Hospira is a global specialty pharmaceutical and medication delivery company dedicated to Advancing Wellness. As the world leader in specialty generic injectable pharmaceuticals, Hospira offers one of the broadest offerings of generic acute-care and oncology injectables, and infusion therapy and medication management solutions. Hospira s products help improve the safety, cost, and productivity of patient care. Cultivating Patient Safety 30 NPSF Annual Patient Safety Congress 2011

31 3M Healthcare 3M Center St. Paul, MN M-HELPS We provide innovative products and solutions for medical, oral care, health information management, drug delivery, and food safety, throughout the world. We leverage 3M technology, world-class manufacturing and global reach to provide trusted products that help promote health and improve the quality, cost, and outcomes of care. WellPoint Inc. 120 Monument Circle Indianapolis, IN WellPoint works to simplify the connection between health, care, and value. We help to improve the health of our communities, deliver better care to members, and provide greater value to our customers and shareholders. WellPoint is the nation s largest health benefits company in terms of medical enrollment. MedicAlert Foundation 2323 Colorado Avenue Turlock, CA MedicAlert Foundation pioneered the use of medical IDs and services to relay vital medical information to emergency responders on behalf of its members so they receive faster and safer treatment. Today, MedicAlert provides the functionality of an e-health information exchange through an innovative combination of a unique patient identifier linked to a PHR and a live 24/7 emergency response service. MedicAlert services are available around the world through a network of international nonprofit affiliated organizations licensed by the Foundation. National Association of Chain Drug Stores Foundation 413 North Lee Street Alexandria, VA The National Association of Chain Drug Stores (NACDS) Foundation is a 501(c)(3) non-profit charitable organization that serves as the education, research and charitable affiliate of NACDS. The NACDS Foundation seeks to improve the health and wellness of the people in America by utilizing education, research, and charitable involvement to help people improve their health and quality of life through an understanding of the importance of medication therapy and taking medications appropriately. FRIEND American Hospital Association 325 Seventh Street, NW Suite 700 Washington, DC The American Hospital Association (AHA) is the national organization that represents and serves all types of hospitals, health care networks, and their patients and communities. Close to 5,000 hospitals, healthcare systems, networks, other providers of care, and 37,000 individual members come together to form the AHA. CNA 333 S. Wabash Avenue Chicago, IL A proven leader in providing comprehensive insurance coverages to the healthcare industry, CNA offers a full range of insurance products for healthcare providers and organizations. National Association of Public Hospitals and Health Systems 1301 Pennsylvania Avenue, NW, Suite 950 Washington, DC NAPH represents America s safety net hospitals and health systems, with an emphasis on protecting safety net financing. NAPH members provide high-quality health services for all patients, including the uninsured and underinsured, regardless of ability to pay. They provide essential community-wide services such as primary care and trauma care and train many of America s healthcare providers. Cerner Corporation 2800 Rockcreek Parkway Kansas City, MO Cerner is a leading global supplier of healthcare information technology (HIT) solutions, healthcare devices, and related services that optimize clinical and financial outcomes. Cerner offers a broad range of services including implementation and training, remote hosting, healthcare data analysis, transaction processing for physician practices, and employer health plan third party administration services. Blue Cross Blue Shield Association 225 North Michigan Avenue Chicago, IL The Blue Cross and Blue Shield Association is a national federation of 39 independent, community-based and locally operated Blue Cross and Blue Shield companies that collectively provide healthcare coverage for nearly 98 million members one in three Americans. Foundation for Informed Medical Decision Making 40 Court Street, Suite 300 Boston, MA The Foundation for Informed Medical Decision Making is a non-profit organization leading the way for shared decision making and decision quality since We work to advance medical research, health care policy, and clinical models to ensure patients have complete and unbiased information to make sound medical decisions. Michigan Hospital Association 6215 W. St. Joseph Highway Lansing, MI The Michigan Health & Hospital Association (MHA) is the statewide leader representing all of the 143 community hospitals in Michigan. Established in 1919, the MHA represents the interests of its member hospitals SUPPORTERS and health systems in both the legislative and regulatory arenas on key issues and supports their efforts to provide quality, cost-effective, and accessible care. Novartis Diagnostics Novartis Diagnostics Inc Horton Street Emeryville, CA Novartis Diagnostics is the global leader in blood safety. Our portfolio of nucleic-acid testing products allow for earlier detection of HIV, Hepatitis, and West Nile viruses in donated blood. We are also creating diagnostics to detect, prevent, and predict disease in the areas of infectious disease, prenatal health, and transfusion medicine. Saint Louis University, Center for Aviation Safety Research 3450 Lindell Boulevard St. Louis, MO The goal of the Center for Aviation Safety Research (CASR) at Saint Louis University is to serve as the central resource for practitioners, researchers, and consultants to develop sustainable safety initiatives across air transportation, healthcare, and other highconsequence industries. MEDIA SUPPORTERS Modern Healthcare 360 N. Michigan Avenue Chicago, IL ModernHealthcare.com Modern Healthcare is the industry s leading source of healthcare business news, research, and information. We report on important healthcare events and trends, as they happen, through our weekly print magazine, websites, e-newsletters, and mobile products. Our readers use that information to make informed business decisions and lead their organizations to success. Patient Safety & Quality Healthcare 5506 Roswell Street, Suite 220 Marietta, GA Patient Safety & Quality Healthcare (PSQH) is a respected source of research, news, and practical tools for improving the safety and quality of healthcare. Readers of PSQH include clinical practitioners and directors, hospital executives, patient safety officers, risk managers, quality directors, IT professionals, engineers, business leaders, policy makers, and educators, among others. This diverse community of professionals also supplies the feature articles, research, case studies, and opinions published in PSQH. PSQH offers a print and digital bi-monthly magazine, and a monthly enewsletter. Cultivating Patient Safety 31 NPSF Annual Patient Safety Congress 2011

32 Exhibitors in the Learning & Simulation Center EXHIBITION HALL A Hours: Wednesday, May 25, 6:00 8:00pm Thursday, May 26, 12:00 1:45pm, 5:30 7:30pm Friday, May 27, 12:30 2:00pm NPSF Corporate Council Members at the Learning & Simulation Center AmerisourceBergen Hospira Laerdal Medical /315 McKesson Ohio Medical Corporation Pascal Metrics Inc Posey SonoSite Exhibitors 3D-ETC, LLC Agency for Healthcare Research and Quality (AHRQ) AliMed American Academy of Family Physicians American College of Surgeons AmerisourceBergen Booz Allen Hamilton Datix Department of Defense Patient Safety Program Dialog Medical Digital Designed Solutions Inc EarlySense ECRI Institute Education Management Solutions Inc EndurID Gaumard Scientific GE Healthcare Hospira HyGreen Inc Institute for Healthcare Improvement International Nursing Association for Clinical Simulation and Learning isys Global Solutions Krames StayWell Laerdal Medical /315 Lippincott Williams & Wilkins, Wolters Kluwer Health Masimo McKesson MedicAlert Foundation Medivance National Patient Safety Foundation NCC Nestlé Nutrition Nuance Communications Ohio Medical Corporation Pascal Metrics Inc PatientSafe Solutions /618 Patient Safety & Quality Healthcare (PSQH) PDR Network PharMEDium Services Inc Posey PRC Premier Healthcare Alliance Principle Business Enterprises Inc. 407 Quantros Inc RF Surgical Systems Inc, MedSun. 408 RL Solutions Safer Healthcare Social & Scientific Systems Inc Society for Simulation in Healthcare Software Testing Solutions SonoSite Standard Register /518 SurgiCount Medical The Doctors Company University HealthSystem Consortium University of Florida University of Illinois at Chicago Patient Safety Leadership Program Ventana Medical Systems /602 Vision Safety Solutions Cultivating Patient Safety 32 NPSF Annual Patient Safety Congress 2011

33 201 1 NPSF Congress Exhibitors The National Patient Safety Foundation expresses appreciation to these companies and organizations for their support of this educational activity. 3-D ETC, LLC Centerpoint Parkway, Suite 103 Pontiac, MI Immersive 3-D training technology allows patient care staff to experience the results of positive or negative choices in key processes such as hand hygiene, medication accuracy, and communication. Specific skills-training allows rapid understanding and use of proven techniques to eliminate distractions while regaining and maintaining focus. Custom program development available. Agency for Healthcare Research and Quality (AHRQ) Gaither Road Rockville, MD The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans. Within the Department of Health and Human Services, AHRQ supports research to improve the quality of health care and promote evidence-based decisions. AliMed High Street Dedham, MA, AliMed is a manufacturer and master distributor of a wide range of medical products including patient safety, patient mobility, fall prevention, durable medical equipment, and products for orthotic and orthopedic use, bariatric care, and bariatric retrofit for facilities plus operating room and radiology items. American Academy of Family Physicians Tomahawk Creek Parkway Leawood, KS ALSO (Advanced Life Support in Obstetrics) is multidisciplinary, evidence-based advanced clinical training in the management of obstetric emergencies. CareTeam OB is a comprehensive patient safety program for healthcare facilities that provides obstetrical teams with an evidence-based, multidisciplinary approach to improving quality, safety, and communications in treating obstetric emergencies. American College of Surgeons N. Saint Clair Street Chicago, IL The American College of Surgeons National Surgical Quality Improvement Program is the first nationally validated, outcomesbased program to measure and improve the quality of surgical care. ACS NSQIP utilizes risk-adjusted surgical outcomes, which allows for valid benchmarking amongst all participating hospitals. Participation in NSQIP empowers hospitals to improve efficiency and reduce costs by avoiding surgical complications. AmerisourceBergen 301 Silver Supporter 1300 Morris Drive, Suite 100 Chesterbrook, PA AmerisourceBergen is one of the world s largest pharmaceutical services companies servicing healthcare providers in the pharmaceutical supply channel. The company provides drug distribution and related pharmacy automation and professional service solutions designed to reduce costs, increase efficiency, and improve patient outcomes. Booz Allen Hamilton Greensboro Drive Hamilton Building McLean, VA Booz Allen s patient safety capabilities include training, education, and collaboration activities, including the use of simulation in training. Our team organizes and supports delivery of TeamSTEPPS, including site-assessment and ongoing coaching; and designed and delivers a 3-day Basic Patient Safety Manager Course for the DoD Patient Safety Program. Datix Boundary Street London E2 7JQ +44 (0) Datix is a patient safety and risk management software application that enables users to spot trends as incidents/adverse events occur and reduce future harm by prioritizing risks and putting in place corrective actions. Datix has been proven by frontline healthcare staff for over 20 years and is in use in hospitals, clinics, and health authorities worldwide. Department of Defense Patient Safety Program Leesburg Pike, Suite 810 Falls Church, VA The Patient Safety Program focuses on creating a culture of safety and quality by providing products, services, and training to build trust, transparency, teamwork, and communication within the Military Health System (MHS). The exhibit showcases recent initiatives around improving systems, processes, and teamwork within the MHS. Dialog Medical Perimeter Park Drive Atlanta, GA Dialog Medical s imedconsent application enhances the education, discussion, and documentation associated with the informed consent process. Trusted by 195 hospitals, this novel solution is integral to efforts to enhance patient safety. Use of the imedconsent application reduces risks, standardizes communication, ensures compliance, lowers costs, and increases patient satisfaction. Digital Designed Solutions Inc Wilkerson Road Rock Hill, SC Digital Designed Solutions is a manufacturer of printed, magnetic dry erase boards. Our boards are used as patient information room boards and tracking boards for surgeries, ERs, ICUs, and at nurses stations. Our boards are heat transfer printed and are meant for intense use. EarlySense Washington Street, Suite 204 Dedham, MA EarlySense is bringing to market an innovative contact-free patient supervision technology. EarlySense s continuous early sensing capabilities and patient management tools empower the medical staff in the unmonitored units to improve clinical outcomes and reduce pressure ulcers and patient falls by measuring key parameters through a sensor placed underneath the patient s mattress. The continuous patient supervision device that follows and documents patient s vital signs and movement allows nursing staff to proactively reduce adverse events. EarlySense was founded in 2004 and is headquartered in Massachusetts. ECRI Institute Butler Pike Plymouth Meeting, PA ECRI Institute is an independent nonprofit with more than 40 years of experience researching the best approaches to improving patient care. Our unbiased, evidence-based research, information, and advice help you address patient safety, quality, and risk management challenges. Education Management Solutions Inc Creamery Way, Suite 100 Exton, PA Enhance patient care outcomes through simulation skill building and team training with EMS turnkey simulation management solution. Video record simulated sessions, simultaneously capture data from multiple simulators, debrief and evaluate, generate scores and reports, and manage data in a central location. EndurID Merrill Industrial Drive Unit 4 Hampton, NH Endur ID Designs, manufactures, and markets wristbands and systems for the identification of patients. Endur ID is focused on patient safety and bringing critical information to bedside. All Endur ID wristbands are designed to be printed in color using standard laser printers and include photos, colorcoded alerts, and barcodes. Gaumard Scientific SW 136 Street Miami, FL Gaumard provides innovative simulators for emergency care, nursing, OB/GYN, and surgery worldwide as part of our global commitment to healthcare education. In 2004, Gaumard introduced the first of its growing family of tetherless simulators, which now includes two HALs, NOELLE, Susie, two Pediatrics, and two Newborn simulators. GE Healthcare 805 N16 W22419 Watertown Road Waukesha, WI GE Healthcare s Nursing Library of Online Education is designed to help nurses stay current with best practices, be more effective and confident. Learn how the Nursing Library can help improve patient outcomes and satisfaction and lower facility costs with proven care strategies. Cultivating Patient Safety 33 NPSF Annual Patient Safety Congress 2011

34 EXHIBITORS Hospira 611 Bronze Supporter 275 North Field Drive Lake Forest, IL Hospira is a global specialty pharmaceutical and medication delivery company dedicated to Advancing Wellness. As the world leader in specialty generic injectable pharmaceuticals, Hospira offers one of the broadest offerings of generic acute-care and oncology injectables, and infusion therapy and medication management solutions. Hospira s products help improve the safety, cost, and productivity of patient care. HyGreen Inc SW 47th Avenue, Suite 100 Gainesville, FL HyGreen Inc. improves lives by safeguarding health through technology. The HyGreen Hand Hygiene Reminding and Recording System reminds healthcare workers to wash their hands and records all hand hygiene data, providing tools to reduce infections, improve hand hygiene rates, and incentivize good hand hygiene behavior. Institute for Healthcare Improvement University Road, 7th Floor Cambridge, MA The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action. International Nursing Association for Clinical Simulation and Learning Rousseau Road Windham, ME The International Nursing Association for Clinical Simulation and Learning (INACSL) is an organization devoted to promoting and providing for the development and advancement of clinical simulation and learning resource centers. Membership benefits include: active listserv, website, bimonthly online professional journal, and an annual conference. isys Global Solutions W. 950 N., Suite 100 Centerville, UT isys offers an advanced video capture and management system that enables medical facilities to inexpensively and expertly film, access, edit, catalog, and securely store their medical lectures, training sessions, simulations, grand rounds, administrative meetings, and other HR and technical events. Filming and sharing key video training assets drastically increases staff effectiveness and improves patient care. Krames StayWell Township Line Road Yardley, PA Krames StayWell (a MediMedia company) is the nation s largest provider of patient education, consumer health information, and population health management communications. Integrating print, interactive, and mobile communications, Krames StayWell is proud to offer solutions that touch more than 80 million healthcare consumers every year, delivering measurable results for our clients. Laerdal Medical 314/315 Research & Solutions Posters Supporter 167 Myers Corners Rd. Wappingers Falls, NY 877-LAERDAL ( ) Laerdal Medical is a world leader in providing healthcare solutions. True to its mission of helping save lives, Laerdal products and services include: Advanced Simulation, Self Directed Learning, Airway/ Immobilization. Over the last 50 years, Laerdal s Resusci Anne and other CPR training manikins have trained over 250 million people worldwide in cardiopulmonary resuscitation. Lippincott Williams & Wilkins Wolters Kluwer Health Market Street Philadelphia, PA Lippincott Williams & Wilkins offers comprehensive clinical reference and training resources for hospitals, long-term care facilities, home health agencies, and other institutions that need to ensure staff knowledge and competency. When you need quality information from a trusted source in an easy to use format, LWW exceeds expectations. Masimo Parker Irvine, CA Masimo is a global medical technology company responsible for the invention of award-winning noninvasive technologies, medical devices, and sensors that are revolutionizing patient monitoring, including Masimo SET, Masimo Rainbow SET Pulse CO-Oximetry, Meet PatientTouch TM PatientTouch. The world s first smart device designed for patient care. Handheld technology that helps hospitals prevent medical errors, improve quality and reduce costs by enabling nurses to efficiently coordinate care, manage clinical workflows, communicate with care team members and document patient information in real-time. See PatientTouch at booth 617/618. Cultivating Patient Safety 34 NPSF Annual Patient Safety Congress 2011

35 EXHIBITORS noninvasive and continuous hemoglobin (SpHb ), acoustic respiration rate (RRa ), Masimo Patient SafetyNet, and SEDLine (EEGbased) Brain Function Monitors. McKesson 209 Platinum Supporter 5995 Windward Parkway Alpharetta, GA McKesson is a healthcare services and information technology company committed to better health of patients, our customers, and the nation s healthcare system. Working with organizations across the industry, we bring a unique vantage point to help our customers improve care quality, adapt to changes of health reform, and sustain business operations. MedicAlert Foundation 712 Bronze Supporter 2323 Colorado Avenue Turlock, CA MedicAlert Foundation pioneered the use of medical IDs and services to relay vital medical information to emergency responders on behalf of its members so they receive faster and safer treatment. Today, MedicAlert provides the functionality of an e-health information exchange through an innovative combination of a unique patient identifier linked to a PHR and a live 24/7 emergency response service. MedicAlert services are available around the world through a network of international nonprofit affiliated organizations licensed by the Foundation. Medivance South Taylor Avenue, Suite 200 Louisville, CO The Arctic Sun by Medivance is the Targeted Temperature Management system of choice in top hospitals around the world. The noninvasive technology rapidly achieves target temperature and maintains prescribed temperature with precision. Normothermia and hypothermia protocols can be preprogrammed in the device to ensure safe and consistent delivery of therapy. National Patient Safety Foundation Summer Street, Sixth Floor Boston, MA The National Patient Safety Foundation has been pursuing one mission since its founding in 1997 to improve the safety of care provided to patients. As a central voice for patient safety, NPSF is committed to a collaborative, inclusive, multi-stakeholder approach in all that it does. NPSF is an independent, not-for-profit 501(c)(3) organization. NCC E. Ontario Street, Suite 1700 Chicago, IL NCC is a not-for-profit organization providing obstetric, gynecologic, and neonatal credentialing for nurses, physicians, and other licensed health care professionals. Nestlé Nutrition Vreeland Road Florham Park, NJ Nestlé HealthCare Nutrition offers nutritional solutions including delivery systems designed for patient safety for people with specific needs related to illnesses, disease states, or the special challenges of different life stages. Nestlé HealthCare Nutrition is part of Nestlé Health Science S.A., a wholly owned subsidiary of Nestlé S.A. Nuance Communications Wayside Road Burlington, MA At Nuance, we re the people who make voice work. We design and deliver intuitive technologies that help people live and work more intelligently. We provide the tools to inform, to connect, and to empower people to be more productive and creative. We give people more than just control over their communications. We give them command of their lives. Ohio Medical Corporation Lakeside Drive Gurnee, IL Ohio Medical offers the broadest selection of vacuum regulators in the industry including our Patient Safety feature Push-To-Set product line. Our vacuum regulators are specially designed for a variety of clinical applications including airway, gastric, and surgical suctioning as well as chest drainage. Ohio Medical has been providing suction products to healthcare facilities worldwide for over 45 years. Our vacuum regulators continue to be the preferred choice for maximum performance, high quality, and minimum maintenance. Pascal Metrics Inc Thomas Jefferson Street NW, Suite 420 East Washington, DC Acknowledged as a leading innovator and advisor in patient safety and quality analytics, Pascal Metrics brings together data science, clinical experience, and technology to help healthcare clients improve patient safety and quality in high-risk environments. Headquartered in Washington, DC, Pascal Metrics is dedicated to making patients safer globally and serves clients in North America, Europe, the Middle East, and Asia. PatientSafe Solutions 617/618 Silver Supporter 5375 Mira Sorrento Place, Suite 500 San Diego, CA PatientSafe Solutions develops innovative handheld technology that helps hospitals prevent medical errors, improve quality, and reduce costs by enabling nurses to efficiently coordinate care, manage clinical workflows, communicate with care team members and document patient information in real-time. Meet PatientTouch, the industry s first smart device designed specifically for patient care. Patient Safety & Quality Healthcare (PSQH) 506 Media Supporter 506 Roswell Street, Suite 220 Marietta, GA Patient Safety & Quality Healthcare (PSQH) is a respected source of research, news, and practical tools for improving the safety and quality of healthcare. Readers of PSQH include clinical practitioners and directors, hospital executives, patient safety officers, risk managers, quality directors, IT professionals, engineers, business leaders, policy makers, and educators, among others. This diverse community of professionals also supplies the feature articles, research, case studies, and opinions published in PSQH. PSQH offers a print and digital bi-monthly magazine, and a monthly enewsletter. PDR Network Paragon Drive Montvale, NJ PDR Network is the leading distributor of drug labeling information, product safety Alerts, and REMS programs and includes the Physicians Desk Reference (PDR ), the most highly trusted and commonly used drug information reference available in the US, PDR.net, mobilepdr, and the new adverse drug and device event reporting system, RxEvent.org. PharMEDium Services, Inc North Field Drive, Suite 350 Lake Forest, IL PharMEDium is the national leading outsourced pharmacy provider, rigorously ensuring the accuracy and sterility of all your customized IV and epidural preparations. PharMEDium is a nationwide network of state-licensed and federally registered pharmacy outsourced compounding centers, providing trusted solutions to more than 2,000 hospitals throughout the United States. Posey Peck Road Arcadia, CA Since 1937, the Posey Company has been manufacturing quality healthcare and safety products for fall management, bed safety, wound care, and seating and positioning to hospitals, nursing homes, and home care patients. All Posey products have a 100% satisfaction guarantee and are available for a no-risk trial. PRC P Street Omaha, NE For 31 years, PRC has been the nation s leading market and customer research firm dedicated solely to the healthcare industry. PRC has helped over 2,000 hospitals and healthcare organizations with their survey needs, including patient loyalty, HCAHPS, and the Patient Safety Assessments. Premier Healthcare Alliance 603 Silver Supporter 2320 Cascade Pointe Blvd. Charlotte, NC Premier is a performance improvement alliance of more than 2,500 hospitals and 73,000-plus other healthcare sites leading the transformation to high-quality, cost-effective care. Owned by hospitals and health systems, Premier maintains the nation s most comprehensive repository of clinical, financial, and outcomes information and operates a leading healthcare purchasing network. Principle Business Enterprises Inc. 407 Pine Lake Industrial Park Dunbridge, OH Principle Business Enterprises Inc. (PBE) is the premier provider of footwear solutions to the acute and long-term care marketplace. Our emphasis is on fall management and the reduction of medical errors through color-coding patients to specific conditions. Our goal is to reduce the incidence of falls by providing the highest quality products available combined with powerful educational tools and a Falls Management Program CD. We offer a full range of sizes from infant through bariatric in terrycloth, hardsole, and foam footwear. We also offer a full range of sizes in red, yellow, and purple for patient coding. Quantros Inc North McCarthy Blvd., Suite 200 Milipitas, CA Quantros is a leading software and services provider for the healthcare industry in the area of safety and quality improvement. With applications for pharmacovigilance, infection surveillance, and clinical quality and performance improvement, Quantros offers a comprehensive view of your clinical landscape. Today more than 2,300 healthcare facilities use Quantros solutions to improve clinical performance and provide a safe, high-quality environment of care. Cultivating Patient Safety 35 NPSF Annual Patient Safety Congress 2011

36 #1CHOICE THE INDUSTRY S Thank you for making Modern Healthcare the #1 source of news and information for the healthcare industry. We re proud to receive these awards from our peers in 2010, but more importantly, we re honored to be your #1 choice for healthcare news and information. American Society of Business Publication Editors (National) Gold Award Special Supplement: 100 Top Hospitals Silver Award Government Coverage: Still Under Wraps Bronze Award News Section: The Week in Healthcare Bronze Award Overall Headline Writing American Society of Business Publication Editors (Midwest-South Regional) Gold Award Feature Series: Safety Crusaders Gold Award News Analysis/Investigative: Making Them Pay Gold Award Opening Spread/Computer Generated: Under Closer Inspection Gold Award Organization Profile: A Fresh Approach Gold Award Original Research: Let the Spending Begin Silver Award Feature Series: Productivity Matters Silver Award News Analysis/Investigative: A Stimulating Conversation American Society of Healthcare Publication Editors Gold Award Profile: A Fresh Approach Silver Award Feature Article: Trauma to the System Silver Award Feature Article Series: Productivity Matters Silver Award News Section: The Week in Healthcare Silver Award Single News Article: United, Yes; United, No Silver Award Special Report/Section: M&A: An Upside to a Down Market Trade, Association and Business Publications International Gold Award Single News Article: United Yes; United, No Bronze Award Cover Photo: Trauma to the System Bronze Award News Section: The Week in Healthcare Honorable Mention Regular Department: Outliers Honorable Mention Single Issue National Institute for Health Care Management NIHCM Print Journalism Award Best Article/Trade Publications: Trauma to the System Society of Professional Journalists Sigma Delta Chi Award for Excellence in Journalism Informational Graphics: By the Numbers Modern Physician American Society of Business Publication Editors Gold Award E-Newsletter/General Excellence Daily Dose American Business Media Jesse H. Neal National Business Journalism Award Finalist Best Newsletter ModernHealthcare.com American Society of Business Publication Editors Gold Award Web News Section Visit ModernHealthcare.com/subscribe for a special celebratory discount! Cultivating Patient Safety 36 NPSF Annual Patient Safety Congress 2011

37 EXHIBITORS RF Surgical Systems Inc th Avenue SE Bellevue, WA RF Assure and RF Surgical Detection Systems bring innovation, simplicity, confidence and compliance to hospitals by providing an easy to use, accurate system for detecting and preventing retained surgical sponges. Using the RF Surgical Detection System is simply a smarter way to operate. RL Solutions Peter Street, Suite 300 Toronto, ON Canada M5V 2G RL Solutions designs innovative healthcare software for patient feedback, incident reporting and risk management, infection surveillance, and claims management. At RL Solutions, nurturing long-lasting relationships with our clients is what we do best. We have over 800 clients, including healthcare networks, hospitals, long-term care facilities, and more. RL Solutions is a global company with offices in Canada, the United States, Australia, and the United Kingdom. Safer Healthcare Race Street, Suite 200 Denver, CO Safer Healthcare is the leading provider for hospital process improvement and human factors education and training. By using a combination of healthcare-centric Crew Resource Management and Perfect Patient Care programs, Safer Healthcare connects integrated tools for improving patient safety in high-risk areas to efficiencies in scheduling, patient flow, and financial benefits. Social & Scientific Systems Inc., MedSun Georgia Avenue, 12th Floor Silver Spring, MD The FDA Medical Product Safety Program (MedSun) involves a network of 350 hospitals and additional healthcare facilities that report through the secure, on-line system that has been designed for submission of reports about adverse events and potential for harm with medical devices or human cells and tissues. Society for Simulation in Healthcare 417 Simulation Plenary Supporter 5353 Wayzata Blvd., Suite 207 Minneapolis, MN The Society for Simulation in Healthcare (SSH) represents the rapidly growing group of educators and researchers who utilize a variety of simulation techniques for education, testing, and research in healthcare. We are a broad-based, multidisciplinary, multispecialty, international society with ties to all medical specialties, nursing, allied health paramedical personnel, and industry. Software Testing Solutions 303 PO Box Tucson, AZ Software Testing Solutions (STS) is dedicated to transforming healthcare IT quality for the benefit of patients and healthcare professionals. STS s innovative RATIO automated testing and documentation solutions for hospital software systems deliver exhaustive testing quickly and efficiently, saving time and money while reducing risk, increasing patient safety, and ensuring regulatory compliance. SonoSite th Drive SE Bothell, WA SonoSite is the world leader and specialist in hand-carried and mounted ultrasound. Through its expertise in ASIC design, SonoSite is able to offer imaging performance typically found in costly ultrasound machines weighing more than 300 pounds in a system that is approximately the size and weight of a laptop computer. Standard Register 517/ Albany Street Dayton, OH Standard Register Healthcare helps you enhance patient safety and improves the quality of care with innovative solutions to establish positive patient identification, share information among caregivers, educate staff, and more effectively engage patients in their care. SurgiCount Medical Venture, Suite 350 Irvine, CA SurgiCount prevents the retention of sponges from occurring by scanning sponges and towels before and after a surgical procedure, guaranteeing customers an accurate count. Studies show that 90% of sponge retention occurred because of an incorrect count. We have been used in over 1.4 million procedures with no false correct counts. The Doctors Company Greenwood Road Napa, CA The Doctors Company is fiercely committed to advancing, protecting, and rewarding the practice of good medicine. With nearly 55,000 members and $4 billion in assets, we are the nation s largest insurer of physician and surgeon medical liability and a national leader in patient safety. University HealthSystem Consortium Spring Road, Suite 700 Oak Brook, IL The University HealthSystem Consortium (UHC) Patient Safety Net is a Web-based, real-time reporting tool used by scores of Academic Medical Centers. UHC was among the first 10 Patient Safety Organizations listed by the Agency for Healthcare Research and Quality (AHRQ) in Contact PSNInfor@uhdc.edu to schedule a demonstration. University of Florida Hough Hall Box Gainesville, FL Earn your Master of Science in Management with a concentration in Health Care Risk Management Online through the nationally accredited University of Florida. This 30-credit degree combines courses from the top-ranked Warrington College of Business with industry expertise from the College of Pharmacy. Apply today! University of Illinois at Chicago Patient Safety Leadership Program S. Halsted, Suite 225 Chicago, IL , Option 2 Improve patient care. Reduce medical error. Created by the top-ranked Institute for Patient Safety Excellence and the College of Medicine at University of Illinois at Chicago, the Patient Safety Leadership master s degree and certificate give individuals and organizations a direct path to developing a culture of patient safety in their organizations. Ventana Medical Systems 601/602 Gold Supporter 1910 E. Innovation Park Drive Tucson, Arizona Ventana Medical Systems Inc., a member of the Roche Group, is a world leader and innovator of tissue-based diagnostic solutions. Passionately pursuing our mission, to improve the lives of cancer patients, the people of Ventana discover, develop, and deliver medical diagnostic systems and slide-based cancer tests that are shaping the future of health care. We also offer premier workflow solutions designed to improve laboratory efficiency and preserve patient safety. Vision Safety Solutions Riverfront Blvd. #301 Elmwood Park, NJ Vision Safety Solutions (VSS) powered by VTID (Vision Tracking and Identification), provides a system of leading-edge technology for healthcare professionals that improves hand hygiene compliance. VSS offers state of the art services that combine monitoring, identification of noncompliant events, and real-time feedback to improve patient safety. Cultivating Patient Safety 37 NPSF Annual Patient Safety Congress 2011

38 DISCLOSURE STATEMENTS In accordance with the policies on disclosure of the Accreditation Council for Continuing Medical Education (ACCME), Accreditation Council for Pharmacy Education (ACPE), the American Nurses Credentialing Center s Commission on Accreditation (ANCC), the Iowa Board of Nursing, the Florida Department of Health Board of Nursing, the Board of Registered Nursing State of California and the American Society for Healthcare Risk Management (ASHRM), presenters for this conference have been asked and are expected to identify whether they do or do not have any real or apparent conflict(s) of interest or other relationships related to the content of their presentation(s). THE FOLLOWING INFORMATION WAS DISCLOSED: Tiffany Christensen would like to disclose that she serves as a consultant for Project Compassion in Chapel Hill, NC. Jeffrey Cooper, PhD, would like to disclose that he is the Executive Director of the Center for Medical Simulation, a non-profit educational organization with interests related to his presentation. Kerry Dease, RN, BSN, CPHRM, would like to disclose that her organization purchased and received training for their simulators (trade name SimMan) through Laerdal Corporation. No other relationship exists to promote Laerdal in any way. Alicia Knight, RN, would like to disclose that she receives research support from the Foundation for Informed Medical Decision Making (non-commercial) and training support from Mercy Clinics Inc., as they offer Physician Office Health Coach training in collaboration with the Advisory Board Company. Del Konopka, RN, MS, would like to disclose that she receives research support from the Foundation for Informed Medical Decision Making (non-commercial) and training support from Mercy Clinics Inc., as they offer Physician Office Health Coach training in collaboration with the Advisory Board Company. Mukesh Mehta, DPh, MBA, RPh, would like to disclose that he is an employee of PDR Network LLC and executive director of PDR Secure. Karen Merrikin, JD, would like to disclose that she has a relationship with Health Dialog as their vendor for shared decision making aids. Judi Miller, RN, MSN, would like to disclose that she receives support from Raytheon Professional Services LLC. Art Papier, MD, would like to disclose that he is a shareholder of Logical Images Inc. Karen Sepucha, PhD, would like to disclose that she receives research support from the Foundation for Informed Medical Decision Making. Bryan Sexton, PhD, would like to disclose that he is a consultant for Pascal Metrics. NO SIGNIFICANT FINANCIAL RELATIONSHIP REPORTED BY PRESENTER: Jason Adelman, MD, MS Mary Andrawis, PharmD, MPH Peter Angood, MD FAS, FCCM Laura Appel Sean Berenholtz Doug Bonacum, MBA, BS Richard Boothman, AB, JD Helen Burstin, MD, MPH Darrell Skip Campbell, MD Hans P. Cassagnol, MD, FACOG Franchesca Charney, RN, BS, MSHA Blair G. Childs Audrey Compton, MD, MPh Carolyn Corvi Jeffrey S. Desmond, MD Kimberly W. Erlandson, RN, MPH Frank Federico, RPh Nancy E. Foster Cathie Furman, RN, MHA Ruthie Goldberg, MHA Suzanne Graham, RN PhD Paula Griswold Steve Grossbart, PhD Matt Handley, MD Amy Helwig, MD Lynn Hemann, RN, BSN William Hendee, PhD Gerald Hickson, MD Judy Ho, MSN, RN, ACNS-BC, CPHQ Barbara Hodne, DO Steve Horner, MBA, RN Claire Horton, MD Charlotte Huber, RN, MSN Lisa Jacobson, MD Randy Johnson, PhD Michael Kanter, MD John Kemp, MD Linda Kenney Jason Launders, MSc Annie LeBlanc, PhD Debbie Linck, RN Michele Lizzi, RN, BSN Connie Lopez, RNC-OB, MSN, CNS Henri R. Manasse, Jr., PhD, ScD Harry O. Mateer, MD David Mayer, MD Tim McDonald, MD, JD Karen Miguel, RN, BSN, MM-H John Morley, MD Lawrence Morrissey, MD Elizabeth Mort, MD, MPH Ben Moulton, JD, MPH Stephen Muething, MD Klaus Nether Roger Nierenberg Haru Okuda, MD, FACEP Mary Oldenkamp, RN Jessica Persons, MSN, RN, BC Paul Preston, MD Urmimala Sarkar, MD, MPH Geri Schimmel, RN, BSN, MS, LHRM Carol Shaffer, RN, PhD, CIP Manisha Shah, MBA, RT Nilay D. Shah, PhD Jo Shapiro, MD Robert Sheridan, RTR, Kathleen Shostek, RN, ARM, BBA Theresa Sievers, RN, MS Leigh Simmons, MD David Skolnik Patricia Skolnik, MSW Bruce Spurlock, MD Robert Stegmoyer, MD Pat Teske, RN, MHA Symme W. Trachtenberg, MSW, LSW Sam Watson Rob Welch, MD Derek Wheeler, MD Linda Williams, RN, MSI Robin Wootten, Ph(c), MBA, RN Heather Wurster, RN, MPH Barbara J. Youngberg, JD, MSW, BSN, Yvonne Zawodny, RN, LHRM, CPHRM DISCLAIMER STATEMENT The information presented at this conference represents the views and opinions of the individual presenters, and does not constitute the opinion or endorsement of, or promotion by, The Doctors Company, Inquisit, or the National Patient Safety Foundation. Reasonable efforts have been taken intending for educational subject matter to be presented in a balanced, unbiased fashion and in compliance with accreditation/regulatory requirements. However, each program attendee must always use his/her own personal and professional judgment when considering further application of this information, particularly as it may relate to patient diagnosis or treatment decisions including, without limitations, FDA-approved uses and any off label uses. Cultivating Patient Safety 38 NPSF Annual Patient Safety Congress 2011

39 201 1 congress faculty Jason Adelman, MD, MS Jason Adelman is the Patient Safety Officer at Montefiore Medical Center in The Bronx, New York, where he oversees the patient safety program for this 1500-bed acute care hospital and 30 ambulatory sites across the borough. He is an assistant professor of medicine at the Albert Einstein College of Medicine. His research focuses on the use of information technology in preventing medical errors. Dr. Adelman has led projects related to patient errors in CIS systems, clinical decision support for safe medication use, and barcoding for the medication administration. He is a member of the American Hospital Association and the National Patient Safety Foundation Patient Safety Leadership Fellowship and is a Senior Fellow of the Health Research and Educational Trust (HRET). Mary A. Andrawis, PharmD, MPH Mary Andrawis is an advocate and educator in quality improvement, public policy, pharmacy, and leadership. She is currently Director of Clinical Guidelines and Quality Improvement for the American Society of Health-System Pharmacists. She also serves as adjunct professor for the Virginia Commonwealth University and University of Maryland Schools of Pharmacy and has presented to national audiences including quality improvement organizations and the Society of Human Resources Management. At ASHP, Dr. Andrawis oversees development of ASHP therapeutic guidance documents and serves as an advocate on clinical quality improvement initiatives with various public and private sector organizations. She also reviews proposed standards, guidelines, regulations, and initiatives of various public and private sector organizations and provides guidance to ASHP members and external stakeholder organizations to promote the safe and effective use of medications. Peter Angood, MD, FRC S(C), FACS, FCCM Peter Angood is Medical Director of the GE Patient Safety Organization for GE Healthcare Performance Solutions. In recent years, as a consultant, he provided senior executive healthcare expertise for small, medium, and large healthcare organizations across a variety of focus areas; he completed a 2-year engagement with the National Quality Forum (NQF) as Senior Advisor for Patient Safety; and he provided technical expertise on projects related to the National Priorities Partnership s goal of improving the safety of America s healthcare system. Previously, Dr. Angood was the Chief Patient Safety Officer and a Vice President for The Joint Commission. He helped lead early development of the World Health Organization s Collaborating Center for Patient Safety Solutions and continues to work with the WHO Alliance for Patient Safety initiative. Laura Appel Laura Appel is Vice President for Federal Policy and Advocacy for the Michigan Health and Hospital Association. She works at the federal level to represent the interests of Michigan hospitals and health systems in both the legislative and regulatory arenas on key issues, including patient safety and quality and health reform. Prior to coming to the MHA, Ms. Appel was the staff director for the democratic policy staff for the Michigan House of Representatives. She also spent 12 years as a legislative policy analyst and did regulatory work for the Michigan Insurance Bureau (now OFIR). Sean M. Berenholtz, MD, MHS, FCCM Sean Berenholtz is Associate Professor in the Johns Hopkins University School of Medicine (Departments of Anesthesiology/ Critical Care Medicine and Surgery) and the Bloomberg School of Public Health (Department of Health Policy and Management). Dr. Berenholtz was co-investigator for a successful statewide collaborative to improve teamwork and communication, and reduce hospital-acquired infections in more than 100 Michigan ICUs. He currently serves as a co-investigator on an AHRQ-funded project ON THE CUSP: STOP BSI to disseminate the successful Michigan program, aiming to improve safety culture and eliminate central line associated blood stream infections in 50 states. Doug Bonacum, MBA, BS Doug Bonacum, Vice President of Safety Management at Kaiser Permanente, has been with that organization since He was previously Environmental, Health and Safety Manager for two large manufacturing facilities of Tyco/North American Printed Circuits in Connecticut. Prior to that, his experience included eight years active duty in the US Submarine Force where he was responsible for weapons and ship s safety as well as nuclear power plant operations. In addition to his degrees, Mr. Bonacum holds a Certificate in Healthcare Management from the University of San Francisco, and is a Certified Safety Professional (CSP) and a Certified Professional in Healthcare Risk Management (CPHRM). Richard Boothman, AB, JD Rick Boothman is Chief Risk Officer for the University of Michigan Health System. He defended malpractice lawsuits for 22 years before he implemented a principled, pro-active approach to the University of Michigan s claims. His work found broad acclaim, with NPR s Weekend Edition and All Things Considered, and numerous newspaper and magazine stories featuring the program. He testified before the United States Senate in 2006 and published details of the University of Michigan s response to patient injuries and claims in Annals of Internal Medicine. Helen Burstin, MD, MPH Helen Burstin is the Senior Vice President for Performance Measures of the National Quality Forum, a private, not-for-profit membership organization established to develop and implement a national strategy for healthcare quality measurement and reporting. Dr. Burstin joined NQF in 2007 and is responsible for the NQF consensus development process and projects related to performance measures and practices. A board certified general internist, Dr. Burstin is a volunteer physician at La Clínica del Pueblo, a federally qualified Latino health center in Washington, DC. Darrell Skip Campbell, MD Skip Campbell is Chief Medical Officer of the University of Michigan Medical School. He has worked with Blue Cross Blue Shield of Michigan to develop a surgical quality improvement program in 34 Michigan hospitals and has been active in the American College of Surgeons National Surgical Quality Improvement Program. Dr. Campbell won the Michigan Hospital Association s Patient Safety and Quality Leadership Award in 2005 and was the recipient of the 2007 John M. Eisenberg Award for Patient Safety and Quality. He participates in the National Quality Forum s National Voluntary Consensus Standards for Patient Safety project and is chairperson of the Technical Advisory Panel for this project focusing on Healthcare-Associated Infections. Hans P. Cassagnol, MD, FACOG Hans Cassagnol is Director of Obstetrics and Gynecology, Chairman of Performance Improvement, and Chairman of the Ethics Committee for Geisinger Northeast in Wilkes-Barre, PA. Dr. Cassagnol graduated from the University of Connecticut medical school in 1998 and completed residency at Flushing Hospital Medical Center. He has worked at Geisinger since Franchesca Charney, RN, BS, MSHA, CPHRM, CPHQ, CPSO, FASHRM Fran Charney is the Director of Educational Programs for the Pennsylvania Patient Safety Authority in Harrisburg, PA. Her participation in the Color of Safety Initiative along with several other Pennsylvania hospitals won a Hospital and Healthsystem Association of Pennsylvania (HAP) Innovation Award and Patient Safety Achievement Award. Fran also serves as faculty for the patient safety curriculum for ASHRM, and she was accepted into the HRET Patient Safety Leadership Fellowship. She has served as President of the Central PA Association of Health Care Risk Management (CPAHRM), sits on the Council on Patient Advocacy for the Pennsylvania Medical Society, Patient Safety Advisory Group and Committee for Quality and Care Management for HAP. Blair G. Childs Blair Childs is Senior Vice President of Public Affairs for Premier Healthcare Alliance, leading the Advocacy, Communications and Conferences units and serving on the company s executive team. He works with the Congress, White House, and other policymakers involved in health policy. Childs has been at the center of policy issues for over two decades, playing a leading role on issues impacting devices, pharmaceuticals, insurers, and hospitals. He has held senior management positions in professional, trade, and advocacy associations and a Fortune 50 company. Tiffany Christensen Tiffany Christensen was born with cystic fibrosis and has received two life-saving double lung transplants. Today she is Chief Executive Officer of Sick Girl Speaks, as well as a national public speaker and author of two books about patient advocacy/safety, and she serves on the Duke Patient Advocacy Council. Christensen focuses on end of life issues, advocacy, and patient safety strategies. In her presentations she incorporates her life experience with her training as a Respecting Choices Instructor and as a TeamSTEPPS Master Trainer. Audrey Compton, MD, MPh Audrey Compton is a Quality Patient Safety Manager at New York Presbyterian Hospital. She has undergone training as a Black Belt and a TeamSTEPPS Master Trainer, and in the Patient Safety Officer Executive Training Program at the Institute for Healthcare Improvement. She directs her efforts to improving quality and safety of patient care using data-driven methods to improve processes and communications protocols. Dr. Compton is also attending physician at New York-Presbyterian Hospital/ Columbia University Medical Center and an assistant professor in clinical medicine at Columbia University College of Physicians and Surgeons. Jeffrey B. Cooper, PhD Jeffrey Cooper is the founder and Executive Director of the Center for Medical Simulation, which is dedicated to the use of simulation in health care as a means to improve the process of education and training and to avoid risk to patients. He is also Professor of Anaesthesia at Harvard Medical School and Massachusetts General Hospital. Dr. Cooper did landmark research in medical errors in the 1970s, is a co-founder of the Anesthesia Patient Safety Foundation (APSF), and has been on the Board of Governors of the National Patient Safety Foundation and founded its Research Program, which he chaired for seven years. He has been awarded the 2003 John M. Eisenberg Award for Lifetime Achievement in Patient Safety from the National Quality Forum and the Joint Commission on Accreditation of Healthcare Organizations and the 2004 Lifetime Achievement Award from the American Academy of Clinical Engineering. The Department of Anesthesia and Critical Care of MGH recently established the Jeffrey B. Cooper Patient Safety award in his honor. Carolyn Corvi Until her retirement, Carolyn Corvi held leadership positions with Boeing over a 34-year period. As Vice President General Manager of Airplane Programs, Boeing Commercial Airplanes, she was responsible for leading Commercial Airplanes fully integrated production system. As Boeing s lean leader and a student of the Toyota Production System, she spearheaded Boeing s lean cultural transformation. Corvi was the 2006 recipient of the Eli Whitney Productivity Award granted by the Society of Manufacturing Engineers for distinguished accomplishments in improved production capabilities. For her contributions to both Boeing and the aerospace industry, she received the 2001 Women in Aerospace Leadership award. Since 2002 she has served on the board of Virginia Mason Medical Center, where she is presently Chair of the Virginia Mason Health and Virginia Mason Medical Center Boards, and serves on the Quality Oversight Committee and the Executive Compensation Committee. Kerry Dease, RN, BSN, CPHRM Kerry Dease is the Regional Patient Safety Lead in the Risk Management Department of Kasier Permanente, Ohio Region. She works with contracted hospitals in the region to implement simulation training in the perinatal setting and has implemented simulation training in an ambulatory surgery center at Kaiser Permanente. She also has experience working within the region to implement and spread Human Factors training, SBAR communication, and a Just culture. She has 25 years experience as a registered nurse in various healthcare settings. Cultivating Patient Safety 39 NPSF Annual Patient Safety Congress 2011

40 FACULTY Heather Dekan Heather Dekan is a second-year pharmacy student at the University of Minnesota College of Pharmacy. As an Executive Board Chair for CLARION, she serves a supporting role in all of CLARION s activities including A Night in the ER, the Annual Case Competition, and networking events. She is also an active member of the Minnesota Pharmacy Student Alliance and serves as the AWARxE Coordinator helping to educate middle school youth on the dangers of misusing and abusing prescription and over the counter medications. Jeffrey S. Desmond, MD Jeffrey Desmond is a Clinical Assistant Professor and the Service Chief for Adult Emergency in the University of Michigan Health System. Dr. Desmond has led a variety of process improvement and information technology initiatives within the emergency department, as well as implementation of a peer review process for the department. His research interests focus on the application of operations management principles to health care and specifically emergency department operations in order to improve patient care. Dr. Desmond is the developer and co-leader of the University of Michigan Graduate Medical Education Scholarship Program Administrative Track. Scott Ellner, DO, MPH Scott Ellner is the Director of Surgical Quality at Saint Francis Hospital and Medical Center in Hartford, Connecticut. Dr. Ellner is an acute care and trauma surgeon who is completing the Patient Safety Leadership Fellowship with the National Patient Safety Foundation and the American Hospital Association. At Saint Francis, he uses evidenced-based outcomes data to drive performance improvement and enhance surgical safety in his organization s operating rooms. He is an Assistant Professor of Surgery at the University of Connecticut Medical School and is currently developing a core curriculum for medical students focused on operating room patient safety. Kimberly W. Erlandson, RN, MPH, CPHQ Kim Erlandson is Quality Management Coordinator at University of Iowa Hospitals and Clinics. She has over 15 years experience in safety and quality management. Currently Kim coordinates the patient safety program and facilitates a variety of projects. She trains staff on performance improvement methodologies and tools and has done numerous local, state, and national presentations on quality and safety topics. She is certified through the Iowa Quality Center in Black Belt Six Sigma and is a Certified Professional in Healthcare Quality. Frank Federico, RPh Frank Federico is Executive Director, Strategic Partners, and safety faculty at the Institute for Healthcare Improvement. His areas of focus include patient safety, application of reliability principles in health care, preventing surgical complications, and the Idealized Design of Perinatal Care Model. He has worked with IHI since 1996, including as co-chair of a number of Patient Safety Collaboratives and presently as faculty for the Patient Safety Officer Training Program. Previously, Mr. Federico was with the Risk Management Foundation (RMF) of the Harvard Affiliated Institutions, where he, along with a team of nurse surveyors, developed a compendium of effective practices to reduce risk and harm in the office setting. During a term as Director of Pharmacy at Children s Hospital, Boston, he co-chaired a quality improvement team charged with revamping the medication system and chaired the Adverse Drug Event Committee. Brandon Ferlas Brandon Ferlas is a fourth-year pharmacy student at the University of Minnesota College of Pharmacy. As CLARION s Case Competition Chair, he worked to coordinate the skills and efforts of the CLARION executive board in presenting the 7th annual CLARION Local and National Case Competitions as well as various networking and interprofessional events throughout the year. Mr. Ferlas is also an active member of the Minnesota Pharmacy Student Alliance and Pharmacy Leadership Society, student liaison to the Minnesota Society of Health-System Pharmacists, and works as a pharmacy intern within the HealthEast Care System. Nancy E. Foster Nancy Foster is Vice President for Quality and Patient Safety Policy at the American Hospital Association. She is the AHA s point person for the Hospital Quality Alliance, their representative to the National Quality Forum, and their liaison to the Joint Commission s Board. She also serves as co-chair of the Patient Safety Coordination Center Advisory Committee at the Agency for Healthcare Research and Quality (AHRQ). She provides advice to hospitals and public policy makers on opportunities to improve patient safety and quality, including regulatory standards. Prior to joining the AHA, Ms. Foster was Coordinator for Quality Activities at AHRQ. Her roles there included principal staff person for the Federal Quality Interagency Coordination Task Forceand lead in the development of the patient safety research agenda for AHRQ. Cathie Furman, RN, MHA Cathie Furman is Senior Vice President for Quality and Compliance at the Virginia Mason Health System. She developed and oversees all aspects of VM s Strategic Quality Plan and their patient safety program and serves as corporate compliance officer for the organization. Furman created, implemented, and oversees the Patient Safety Alert process; leads the strategic initiative to provide transparent quality performance measurement; is a certified leader in the Virginia Mason Production System, a management method based on manufacturing principles that seeks to continually improve how work is done; and serves on the Puget Sound Health Alliance Board. She speaks frequently about the critical success factors of a patient safety program and how to implement management methods that improve patient safety. Ruthie Goldberg, MHA Ruthie Goldberg is Group Leader for Kaiser Permanente s Southern California Clinical Operations department. In this role, she helps oversee the outpatient quality of care for KPSC s 3.3 million members. Her work has significantly impacted quality performance in Southern California, including cancer screening and centralized outreach. After completing a 2-year Administrative Fellowship with KPSC, Goldberg joined Southern California Permanente Medical Group (SCPMG) as a project manager in Suzanne Graham, RN, PhD Suzanne Graham is Executive Director of Patient Safety for Kaiser Permanente, California Regions. She has served in multiple roles within Kaiser Permanente at the medical center, regional, and national levels. Suzanne is a graduate of the University of North Carolina Kenan-Flager Business School Kaiser Permanente Advanced Leadership Program and the AHA Health Forum Patient Safety Leadership Fellowship Program and has completed the IHI Patient Safety Officer Executive training program. She is a member of several national patient safety groups including the Joint Commission National Patient Safety Goal Advisory Board. In 2006 Dr. Graham received the first National Patient Safety Foundation Chairman s Medal in recognition of leadership in patient Safety. Paula Griswold, MS Paula Griswold is the Executive Director of the Massachusetts Coalition for the Prevention of Medical Errors, a statewide publicprivate partnership established to improve patient safety and reduce medical errors. The Coalition includes state and federal government officials, consumer organizations, and professional associations representing hospitals, physicians, nurses, and long-term care institutions, professional liability organizations, researchers, health plans, and purchasers. In partnership with its member organizations, the Coalition has conducted several statewide improvement collaboratives, including hospital collaboratives on reconciling medications, communicating critical test results, and preventing hospital-acquired infections, and is now working to reduce readmissions and to implement patient safety programs with primary care practices. Stephen R. Grossbart, PhD Stephen Grossbart is Senior Vice President and Chief Quality Officer at Catholic Health Partners, Cincinnati, OH, and oversees Catholic Health Partners Patient Safety and Clinical Transformation department. His team focuses on developing and leading Catholic Health Partners system-wide efforts for clinical quality, medication and patient safety, process redesign, performance measurement, nursing excellence, chronic and palliative care, and home care services. Dr. Grossbart has served on committees of the National Quality Forum, including the group that developed the initial set of National Voluntary Consensus Standards for Hospital Care. He has worked in healthcare since 1996, primarily in the area of quality and process improvement analytics. Matt Handley, MD Matt Handley is Associate Medical Director, Quality and Informatics, for Group Health Cooperative, one of the nation s largest consumer-governed health care systems. Dr. Handley is responsible for quality improvement, patient safety, and clinical information technology, working to create an infrastructure that supports the highest levels of organizational performance. Saundra Hartmann Saundra Hartmann is completing her Doctor of Pharmacy degree at the University of Minnesota College of Pharmacy. She is Coordinating Chair of CLARION. Ms. Hartmann is committed to enhancing her education through experiences outside of the classroom. She enjoys extra-curricular activities that allow her to engage the community, and values the opportunity to learn and interact with students of other health professional programs within the University of Minnesota s Academic Health Center. Amy Helwig, MD, MS Amy Helwig currently serves as a Medical Officer in the US Department of Health and Human Services, Agency for Healthcare Research and Quality, Center for Quality Improvement and Patient Safety. As the lead physician on the team charged with implementing the Patient Safety and Quality Improvement Act, she is a specialist in the development of Patient Safety Organizations and the national reporting structure for patient safety events. Additionally, Dr. Helwig brings her family medicine practice experience to AHRQ s involvement in adverse event trigger development for electronic health records, patient safety culture, clinical team dynamics, and medical errors research. Lynn Hemann, RN, BSN Lynn Hemann is an Assistant Nurse Manager in the Neonatal Intensive Care Unit at St. Louis Children s Hospital. In her 25 years at this hospital, she has worked a variety of roles within this unit including staff nurse and unit charge nurse. She led the construction of a 40-bed addition to the NICU and has since been acting in the role of Assistant Nurse Manager. William R. Hendee, PhD William Hendee currently holds the title of Distinguished Professor of Radiology, Radiation Oncology, Biophysics, and Institute for Health and Society, at the Medical College of Wisconsin. He is also Professor in Bioengineering at Marquette University, Adjunct Professor of Electrical Engineering at the University of Wisconsin- Milwaukee, Clinical Professor of Radiology at the University of New Mexico, and Adjunct Professor of Radiology at the University of Colorado. Dr. Hendee is currently Chair of the American Board of Radiology Foundation and President and CEO of the Commission on the Accreditation of Medical Physics Graduate Programs. He is past president of the American Association of Physicists in Medicine, the Society of Nuclear Medicine, the American Institute of Medical and Biological Engineering, the World Congress on Medical Physics and Biomedical Engineering and past vice president of the National Patient Safety Foundation. Jason Hickok, MBA, RN Jason Hickok joined the Hospital Corporation of America in 2003 and is now Assistant Vice President leading their Patient Safety and Infection Prevention initiatives. He provided direct oversight for the development and deployment of HCA s MRSA initiative, which is an ongoing effort aimed at eradicating MRSA from HCA-affiliated facilities. Due to the successful deployment of this initiative, HCA is now part of a public private research study with the Centers for Disease Control, Harvard Pilgrim, and the Agency for Healthcare Research and Quality evaluating the most effective and efficient way to eradicate transmission of MRSA. Hickok is an active Fellow in the AHA-NPSF Patient Safety Leadership Fellowship. Gerald Hickson, MD Gerald Hickson is the Joseph C. Ross Chair in Medical Education and Administration, Associate Dean for Clinical Affairs, Director of the Center for Patient and Professional Advocacy, and Director of Clinical Risk and Loss Prevention at Vanderbilt University Medical Center. Dr. Hickson s research has focused on why families choose to file suit, why certain physicians attract a disproportionate share of claims, and how to identify and intervene with high-risk Cultivating Patient Safety 40 NPSF Annual Patient Safety Congress 2011

41 physicians. His work has resulted in over 40 peer reviewed articles and chapters, as well as the development of the PARS peer-review system. Dr. Hickson has served as Chairman of the National Patient Safety Foundation Board of Governors and is currently a member of the Board of Directors. He has received numerous awards for excellence in research and teaching. Judy Ho, MSN, RN, ACNS-BC, CPHQ Judy Ho is Education Specialist at St. Luke s Episcopal Hospital. Her work focuses on the graduate nurses residency program and nursing peer review (NPR). As chair of the NPR committee, she works with staff nurses, nurse managers, and nurse executives in aligning the nurses practice to be in accordance with the Board of Nursing and thus promote patient safety. She co-chairs the Medication Safety Team and is a member of the Patient Safety Committee. Prior to this, Judy had served as a staff nurse, quality coordinator, and clinical nurse specialist. Barbara Hodne, DO, FAAFP Barbara Hodne is Medical Director for the House of Mercy Clinic, Family Medicine of Urbandale, Iowa, and is in family practice there. Stephen Horner, MBA, RN Steve Horner is Vice President, Clinical Analytics, Clinical Services Group, for the Hospital Corporation of America (HCA). He is responsible for public reporting, pay for performance reporting, patient and physician engagement surveys, outcomes measurement, and clinical analytics and reporting for HCA, Inc. Mr. Horner serves as HCA s representative to the National Quality Forum where he has served on several steering committees and on the Quality Committee and Board of Governors of the Federation of American Hospitals, and he was instrumental in the formation of the Joint Commission/CMS Hospital Vendor Workgroup. He is also on the Faculty of Tennessee State University in the College of Health Sciences. Claire Horton, MD Claire Horton is Associate Medical Director for at San Francisco General Hospital and Assistant Professor of Medicine at the University of California at San Francisco. She coordinates all quality improvement efforts of the clinic and leads an ambulatory Quality Improvement curriculum for residents at San Francisco General Hospital. Her work has included the expansion of chronic disease registries; introduction of panel management systems; and the introduction of new patient safety systems, such as ambulatory morbidity and mortality, and abnormal lab review. She plays a guiding role in San Francisco General s Healthy San Francisco Innovations projects, and is working to redesign the General Medicine Clinic s patient care into team-based models. Charlotte Huber, RN, MSN Charlotte Huber is a Patient Safety Analyst/Consultant for ECRI Institute and the project manager of multiple clients for the ECRI Institute Patient Safety Organization. She analyzes reports of near misses, serious events, and other confidential communication to identify patterns, trends, and potential system issues impacting patient safety. Ms. Huber has over 30 years of healthcare experience, including patient safety program development with the primary focus on prevention to maximize patient safety and facilitate practice change. She is a certified TeamSTEPPS provider; is actively involved in ASHRM at the national and the Pennsylvania chapter levels; is a member of Sigma Theta Tau International, American Society of Professionals in Patient Safety (NPSF); and has served on the Nursing Leadership Congress Steering Committee. Bethany Hyde Bethany Hyde is a recent graduate of the University of Minnesota Master in Healthcare Administration program. As a member of CLARION, she coordinated several events to increase interprofessionalism among health sciences students at the University of Minnesota. She will be starting an administrative fellowship at North Memorial Health Care in Robbinsdale, MN, this summer. Lisa Jacobson, MD Lisa Jacobson is Attending Physician at Washington Hospital Center, Medstar Health. Residency trained in Emergency Medicine at the Mount Sinai School of Medicine Emergency Medicine Residency, Dr. Jacobson is faculty for the Emergency Medicine Residency Program at Georgetown University School of Medicine. Randy Johnson, PhD Randy Johnson is Chief Patient Safety Officer at Baptist Health and Associate Professor at Auburn University. He teamed with Baptist Health in 2005 to develop Synergistic Medical and Resource Team (SMART) Training. His background and research interests include patient safety, communications, Crew Resource Management (CRM), and human factors. He serves as the Chief Patient Safety Officer for Baptist Health where he oversees safety and quality programs for Baptist Medical Center South, Baptist Medical Center East, and Prattville Baptist Hospital. Michael Kanter, MD Michael Kanter has been Medical Director of Quality and Clinical Analysis for the Southern California Permanente Medical Group (SCPMG) since January He is responsible for quality improvement, utilization management, technology assessment, clinical practice guideline development, population care management, member health education, continuing and graduate medical education, and clinical research activities for the Southern California Region of Kaiser Permanente, which serves 3.3 million members. Dr. Kanter joined SCPMG in John Kemp, MD John Kemp is currently Professor of Pathology, Vice Chair for Clinical Affairs, and Director of Clinical Laboratories at the University of Iowa Hospitals and Clinics. He supervises the Quality Assurance team in the Department of Pathology and participates in a number of projects aimed at enhancing quality and safety at UIHC. In collaboration with several other colleagues, he has explored the utility of barcode scanning technology in improving transfusion safety. Linda Kenney Linda Kenney is Executive Director of Medically Induced Trauma Support Services. For more than ten years, she has been at the forefront of the national patient safety movement, offering her expertise to such organizations as the American Hospital Association, the Agency for Healthcare Research and Quality, the American Society of Healthcare Risk Management, the Institute for Healthcare Improvement, and Consumers Advancing Patient Safety. Ms. Kenney currently serves on the Board of Directors for both Planetree and the National Patient Safety Foundation, as Chair of the NPSF Patient and Family Advisory Committee, and as a member of the Joint Commission Patient and Family Advisory Committee. Ms. Kenney was the first consumer participant selected for the prestigious AHA-HRET Patient Safety Leadership Fellowship, which she completed in In 2006, she received the NPSF Socius Award, a national honor bestowed in recognition of Effective Partnering in Pursuit of Patient Safety. Alicia Knight, RN Alicia Knight is a Transition of Care Health Coach in the Quality Department of Family Medicine of Urbandale, Iowa. She manages the disease registry, works with shared decision aids and patient education, and handles pay for performance and medicare physician quality reporting. She is dedicated to pursuing excellence in areas such as quality improvement, self management of chronic illnesses, coordination of care, and management of disease registry and coumadin therapy. Del Konopka, RN, MS Del Konopka is the Education Coordinator on the Quality Team for Mercy Clinics, Inc. (of Catholic Health Initiatives) in Des Moines, IA. There she is the project coordinator for the Mercy Clinics Primary Care Site in the Foundation for Informed Medical Decision Making proof of concept study. She also coordinates other projects and training for the health coaches, provides resources for patient and staff education and patient advisory councils, and writes funding proposals for grants. Previously, she was the clinical study coordinator for an NIH-funded research project at Iowa State University, with a focus on immune response in the aged as influenced by exercise. Jason Launders, MSc Jason Launders is Senior Project Officer at ECRI Institute. He has been working in diagnostic imaging since 1993, and for the last 12 years in ECRI Institute s Health Devices program. He is primarily responsible for evaluating diagnostic imaging. In addition to evaluation, he has conducted accident investigations and safety Faculty reviews in radiology, and he provides technical expertise to a wide range of ECRI Institute departments. Annie LeBlanc, PhD Annie LeBlanc is an Epidemiologist and Health Services Researcher Postdoctoral Fellow at the Knowledge and Evaluation Research Unit in the Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic. She is the recipient of a postdoctoral scholarship in knowledge translation from the Canadian Institute of Health Research. Her research focuses on knowledge generation, synthesis, and its translation into practice through the design, implementation, and evaluation of patient-centered interventions. Her main work is centered around quantitative modeling of the complex interaction of providers and patients in shared decision making in primary care. Debbie Linck, RN Debbie Linck is a Senior Staff Nurse at St. Louis Children s Hospital, Neonatal Intensive Care Unit (NICU). She is an original member and the co-chair of the staff nurse based NICU PICC (peripherally inserted central catheter) team. She has published an article related to the development and impact of this team in the NICU. She is an active member of the hospital s Clinical Practice Council, the NICU s Safe Medication Practice committee, Blood Stream Infection Committee, and Quality and Safety Council. She has just started a newly created position of Central Line Management Nurse in the unit. Michele Lizzi, RN, BSN Michele Lizzi is the Care Coordinator Counselor for the Department of Pediatrics at the Children s Hospital of Philadelphia. She has dedicated her career to pediatric nursing in the Philadelphia area and has been at Children s Hospital for the past 15 years. She also leads the hospital s Care Binder program and is a Clinical Educator in the Nurse Residency Program. Connie M. Lopez, RNC-OB, MSN, CNS, CPHRM Connie Lopez is the National Leader of Simulation-based Education and Training, in National Risk Management and Patient Safety, at Kaiser Permanente s Program Offices in Oakland, California. Ms. Lopez is now leading the National Kaiser Permanente (KP) Healthcare Simulation Collaborative, initiated to organize efforts to provide all eight KP regions with robust simulation programs in a variety of areas in order to reduce adverse events. She has seven years experience researching and implementing simulation in the clinical setting. She has been asked to present various simulation-based programs and topics at numerous nursing and international conferences over the past four years and is currently evaluating several standardized simulation-based programs that will be linked to clinical outcomes. Henri R. Manasse Jr., PhD, ScD Henri R. Manasse Jr. has been Executive Vice President-Designate, Executive Vice President and Chief Executive Officer of the American Society of Health-System Pharmacists (ASHP) since He presently serves as a Senior Policy Fellow with the Center on Drugs and Public Policy, University of Maryland. He has adjunct professor appointments at the University of Iowa, the University of Illinois, and the University of Maryland, and most recently was appointed Visiting Professor at the Peking Union Medical College Hospital in Beijing, China. Dr. Manasse has previously chaired the Board of Directors of the National Patient Safety Foundation. He also represents ASHP at the National Quality Forum, where he co-chaired the Safe Practices Steering Committee and presently serves on the Advisory Committee for Executive Leadership. He chaired the Sentinel Event Alert Advisory Group at The Joint Commission, and he serves Joint Commission International as a member of the Steering Committee on Patient Safety. He served on the Drug Safety and Risk Management Advisory Committee of the United States Food and Drug Administration for three years. Harry O. Mateer, MD Harry O. Mateer Jr. is Director of Obstetrics at Geisinger Medical Center, Danville, PA. He is also an associate physician in the department of obstetrics and gynecology at GMC. He is a graduate of Jefferson Medical College and completed his residency in obstetrics and gynecology at the Reading Hospital and Medical Center, Reading, PA. Cultivating Patient Safety 41 NPSF Annual Patient Safety Congress 2011

42 Faculty David Mayer, MD David Mayer is Vice Chair for Quality and Co-Executive Director of the UIC Institute for Patient Safety Excellence, University of Illinois Medical Center. He is a member of the National Quality Forum patient safety advisory board, a consultant to the New South Wales National Commission addressing safety and quality, and has participated in a Lucian Leape Institute patient safety roundtable. He is co-producer of the award winning patient safety educational film series The Faces of Medical Error... From Tears to Transparency. He was awarded the 2010 Sprague Patient Safety Award by the Institute of Medicine in Chicago. Timothy McDonald, MD, JD Tim McDonald is Co-Executive Director of the UIC Institute for Patient Safety Excellence, University of Illinois Medical Center. As a physician-attorney, he has been involved in patient safety efforts at the University of Illinois Medical Center for the past decade. He serves as the Executive Sponsor for the Medical Center s Universal Protocol Task Force, where his focus has been on the principled approach to patient harm with an emphasis on the robust reporting of patient safety events, near misses, and unsafe conditions, and including a commitment to communicate within the health care team and with patients and families throughout the therapeutic relationship. It also involves a promise to investigate and create systems improvement following harm or near miss events. His work also includesthe establishment of teaching methodologies for all levels and professions in health care. Mukesh Mehta, DPh, MBA, RPh Mukesh Mehta is the Vice President for Clinical and Regulatory Solutions for PDR Network LLC and Executive Director of PDR Secure, a patient safety organization. A pharmacist by education, he has over 20 years of experience at Thomson Reuters Healthcare and Science, where he held several senior regulatory, clinical, and new-product development positions. He has been selected by the European Medicines Agency (EMA) to be a member of a High Level Advisory Group for Eudrapharm. He is a member of PhRMA/HL7 SPL Task Force and a recipient of the FDA s Commissioner s Special Citation for his contribution toward the SPL implementation. Karen Merrikin, JD Karen Merrikin is Senior Policy Advisor to the Group Health Cooperative and Director of its Health Reform Initiative. She leads a cross-functional team that is working to successfully prepare Group Health to meet the challenges and opportunities of federal health reform. She has also served as Group Health s Executive Director, Public Policy, and Associate General Counsel. Ms. Merrikin also serves as a liaison to national, state, and local coalitions and organizations that aim to promote affordable, quality health care, including Washington State s shared decision making collaborative. Karen Miguel, RN, BSN, MM-H Karen Miguel is the Patient Safety Officer in the Imaging Department at Massachusetts General Hospital. Her focus research encompasses advancing patient safety through the adoption of Team Training dynamics. Ms. Miguel has established and manages a team program across six interventional specialties with more than 300 interventional staff members. She has authored a chapter on the subject of team training and has published in the Journal of Neurointerventional Surgery. Ms. Miguel is certified as a Patient Safety Officer through the Institute for Healthcare Improvement and has completed the Harvard University Quality Colloquium Patient Safety certification program. Judi Miller, RN, MSN Judi Miller is Director of the Institute for Patient Safety and Medical Simulation at Baptist Health and has served as Director of Organizational Development for Baptist Health since 2003.She participated in the creation and development of the Institute for Patient Safety and Medical Simulation and has served as director since its inception. Judi has consulted with numerous organizations and community business leaders regarding the design, implementation, and integration of simulation in education and training. She lends her extensive knowledge to area universities and has served as adjunct faculty at Auburn University and South University. Kathryn Mitchell, MBA Kathryn Mitchell is Manager, Patient Safety, for the Hospital Corporation of America. She provides leadership for a wide array of quality and patient safety projects as a member of HCA s Clinical Services Group in Nashville, TN. Her responsibilities include management of HCA s Patient Safety Improvement Program event and close-call reporting database which receives over 200,000 event and close-call reports each year. Ms. Mitchell is responsible for analyzing and aggregating events reported to PSIP and communicating findings so that they are used to make patients safer. John Morley, MD John Morley joined the New York State Department of Health as Medical Director for the Office of Health Systems Management in Previously he served as Vice President for Medical Affairs and Medical Director at Albany Medical Center Hospital. His clinical background includes board certification in anesthesiology, internal medicine, pulmonary and critical care medicine. Dr. Morley s primary interests concern patient safety and quality improvement in the areas of adverse event reporting, wrong sided/sited surgery, and just culture. Lawrence Morrissey, MD Larry Morrissey is a general pediatrician and the Medical Director of Quality Improvement for Stillwater Medical Group. SMG is a non-profit organization with a community board and is dedicated to serving its community by providing primary and specialty care. SMG has been working on implementation of shared decision making since 2006, and strives to be patient-centered in order to provide the highest quality care to their community. Elizabeth Mort, MD, MPH Elizabeth Mort is a practicing general internist who holds the administrative titles of Vice President of Quality and Safety at Massachusetts General Hospital as well as Associate Chief Medical Officer for the MGH. Since 2003, Dr. Mort has served as Team Leader of the Partners HealthCare s Uniform High Quality team. In 2010 she assumed the role of chair of the Partners Community HealthCare Performance Oversight Committee, the body responsible for network-wide performance of quality, service, and cost. Dr. Mort has served on a number of national committees involved in developing quality measures. Farzad Mostashari, MD, ScM Farzad Mostashari serves as National Coordinator for Health Information Technology at the US Department of Health and Human Services. Previously, he served at the New York City Department of Health and Mental Hygiene as Assistant Commissioner for the Primary Care Information Project, where he facilitated the adoption of prevention-oriented health information technology by over 1,500 providers in underserved communities. Dr. Mostashari also led the Centers for Disease Control and Prevention (CDC) funded NYC Center of Excellence in Public Health Informatics and an Agency for Healthcare Research and Quality funded project focused on quality measurement at the point of care. Prior to this he established the Bureau of Epidemiology Services at the NYC Department of Health. He was one of the lead investigators in the outbreaks of West Nile Virus and anthrax in New York City, and among the first developers of real-time electronic disease surveillance systems nationwide. Benjamin Moulton JD, MPH Ben Moulton is Senior Legal Advisor for the Foundation for Informed Medical Decision Making. He has had an extensive career in healthcare law, serving clients in both the private and public sectors. Previously he served as legal counsel to George Washington Medical Center, which involved providing legal advice to an academic medical center, a teaching hospital, medical school, and affiliated physicians. Prior to joining the Foundation, he served for over 15 years as Executive Director of the American Society of Law, Medicine and Ethics. He holds a teaching appointment as an adjunct professor at the Harvard School of Public Health where he teaches a course on health law in clinical practice in the Department of Health Policy and Management. Stephen Muething, MD Stephen Muething is a pediatrician and Associate Professor at the University of Cincinnati and Cincinnati Children s Hospital Medical Center. He is also the Assistant Vice President of Patient Safety for the hospital. He has led efforts to reduce serious safety events and to implement a strategic plan to develop a culture of high reliability. Dr. Muething is a leader of state-wide collaborative efforts and a multi-instrumental collaborative focused on patient safety and has served as an expert on national panels. He teaches extensively on quality improvement and safety and serves as a mentor to faculty on these areas. He has also led work to improve acute care systems, focusing on evidence-based care patient flow and patient- and family-centered care. Klaus Nether Klaus Nether is a Black Belt specializing in robust process improvement for The Joint Commission and serving on the Joint Commission Center for Transforming Healthcare. Mr. Nether supports activities that establish and sustain a robust process improvement culture using Lean Six Sigma, Change Acceleration Process (CAP), and other performance improvement methodologies. His experience includes manager of Olson Clinical Laboratories at Northwestern Memorial Hospital in Chicago, where he was responsible for six departments including Microbiology and Diagnostic Molecular Biology. He received Six Sigma training from GE Healthcare and Black Belt certification from Villanova University. He is certified by the American Society for Clinical Pathology Board of Registry as a medical technologist and as a specialist in virology. Roger Nierenberg Roger Nierenberg, creator of The Music Paradigm, has led presentations with more than eighty different orchestras throughout North and South America, Europe, Asia, and Oceania. Employing the powerful metaphor of a symphony orchestra to illustrate the complexities and nuances of dynamic organizations, conductor Nierenberg challenges leaders and teams to explore how we work together, how the management of organizational relationships can spell success or failure, and how we each individually can look beyond the constraints of conventional thinking. For 14 years Nierenberg directed the Jacksonville Symphony Orchestra in Florida, where he established a special reputation for his highly successful collaborations with many of today s outstanding soloists and composers. For 23 years he was Music Director of the Stamford Symphony Orchestra in Connecticut. Haru Okuda, MD, FACEP Haru Okuda is the National Medical Director for the Veterans Health Administration s Simulation Learning Education and Research Network (SimLEARN) Program. Previously, he was the director of the Institute for Medical Simulation and Advanced Learning for the New York City Health and Hospitals Corporation and held a position as Associate Professor of Clinical Emergency Medicine at the Mount Sinai School of Medicine. Dr. Okuda is Vice Chair of the Simulation Academy for the Society for Academic Emergency Medicine and Co-Chair of Simwars for the International Meeting on Simulation in Healthcare. Mary Oldenkamp, RN Mary Oldenkamp is Senior Director for Performance Improvement at the Veterans Health Administration Upper Midwest where she assists in the development and management of the Patient Safety Inititive for VHA Upper Midwest members. This work is focused on improving patient safety culture for over 37 healthcare teams, specifically: helping the unit manager to create an environment where frontline staff own the leadership of changing the culture and ultimately improving the care provided. Ms. Oldenkamp has been engaged in health care for over 30 years and has extensive experience in development of clinical care process design and use of various performance improvement methodologies. Art Papier, MD Art Papier is Associate Professor of Dermatology and Medical Informatics at the University of Rochester College of Medicine. His research focuses on point of care reference systems for physicians, and Internet-based medical information for patients. He is particularly interested in the topic of diagnostic errors in medicine and decision support systems, with a focus on the integration of point of care diagnostic decision support with the electronic health record. Dr. Papier was the principal investigator on a 5-year NIAMS/NIH grant to develop a comprehensive dermatology lexicon. Jessica Persons, MSN, RN, BC Jessica Persons is Clinical Educator in Nursing Informatics at St. Luke s Episcopal Hospital, a teritiary teaching hospital in Texas Cultivating Patient Safety 42 NPSF Annual Patient Safety Congress 2011

43 Medical Center. She develops and facilitates informatics training programs for staff nurses as well as other clinical staff. Her clinical experience includes certification in medical/surgical nursing, staff nurse on a medical/surgical-telemetry floor and charge nurse assisting with training and education. Paul Preston, MD Paul Preston is a Staff Anesthesiologist at the San Francisco Kaiser Permanente Medical Center and a Physician Safety Educator for the Permanente Medical Group. He has been active for 11 years with simulation training in anesthesia, obstetrics, emergency departments, and other hospital environments, and has taught extensively on error and human factors in the perinatal, operating room, and general medical areas. Dr. Preston is also an Improvement Advisor for the Institute for Healthcare Improvement working with surgical team communications. Urmimala Sarkar, MD, MPH Urmimala Sarkar is Assistant Professor at the University of California, San Francisco, in the Division of General Internal Medicine at San Francisco General Hospital. She attends on medical wards, and she maintains a primary care clinic at San Francisco General Hospital. Dr. Sarkar s research focuses on patient safety in ambulatory care, especially for vulnerable chronic disease populations. Her interests include the role of communication in safety as well as health information technology interventions. Geri Schimmel, RN, BSN, MS, LHRM Geri Schimmel is Director of the Baptist Health Patient Safety Partnership, an entity of Baptist Health South Florida. She has coordinated the patient safety campaign at Baptist Health since its launch in 2003, including the creation and maintenance of the Patient Safety Champions program. Ms. Schimmel has 20 years of clinical nursing experience, and she has also served as a nursing faculty member, and has worked as a corporate educational consultant coordinating hospital/health system in-service programs. She frequently speaks at national seminars on patient safety/risk management, including the Versant RN residency program. Karen Sepucha, PhD Karen Sepucha is Director of the Health Decision Sciences Center at Massachusetts General Hospital and is Assistant Professor in Medicine at Harvard Medical School. Her research and clinical interests involve developing and implementing tools and methods to improve the quality of significant medical decisions made by patients and clinicians. Her recent research has focused on the development of survey instruments to measure the quality of decisions. Dr. Sepucha has been active in local, national, and international efforts to promote shared decision making and improve decision quality. J. Bryan Sexton, PhD Bryan Sexton is a psychologist member of the Department of Psychiatry at Duke University Hospital, and he is the Director of the Patient Safety Center for the Duke University Health System. He has studied teamwork and safety practices in high-risk environments such as the commercial aviation cockpit, the operating room, and the intensive care unit under funding from NASA, the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, the Swiss National Science Foundation, and the Gottlieb Daimler and Karl Benz Foundation. His research instruments have been used around the world in over 2500 hospitals in 20 countries. He is dedicated to finding practical ways of getting busy caregivers to do the right thing, by making it the easy thing to do. You are better off changing the situation, than trying to change human nature. Carol Shaffer, RN, PhD, CIP, Carol Shaffer is Research Coordinator at Reston Hospital Center. She has worked in the nursing profession for more than 40 years as a clinician, educator, and researcher. After retiring as a professor in 2002, she focused her attention on developing a hospital-based clinical research program for bedside staff nurses. She also lends her expertise to the collection and interpretation of quality data. Manisha Shah, MBA, RT Manisha Shah is Vice President of Programs at the National Patient Safety Foundation, where she oversees the development of patient safety programs, leading cross-functional teams to create solutions for diverse issues, including operations improvement, patient safety, and team building, as well as cost savings, waste elimination, and process management. She also directs the day-to-day operations of the American Society for Professionals in Patient Safety. Previously, as part of the Hospital Corporation of America Patient Safety team, she was the vision and drive behind HCA s emar and Bar Coding initiative, and she served as mentor, coach, and consultant for the division leadership and the hospital electronic medication administration record (emar) coordinators at all 170 HCA hospitals. Ms. Shah is an appointee of the Barcoding advisory committee initiated by the Terra Firma project and represents NPSF on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). Nilay D. Shah, PhD Nilay Shah is Senior Associate Consultant, Division of Health Care Policy and Research, Department of Health Sciences Research, at the Mayo Clinic, and is Assistant Professor of Health Services Research at the Mayo Clinic College of Medicine. Dr. Shah is Co-Director of the Knowledge Translation Research Unit, Center for Translational Science Activities of the Mayo Clinic. Dr. Shah s research focuses on evaluating alternative models of chronic disease care delivery, medication adherence in chronic disease, policy implications of shared decision making, and disparities in care. Other areas of ongoing research include optimizing treatment decisions in diabetes, decision analytic modeling of diagnostic strategies across a spectrum of diseases, and evaluating the evidence base for quality measurement. He has published widely and received numerous grants in support of his work. Jo Shapiro, MD Jo Shapiro serves as Chief, Division of Otolaryngology, in the Department of Surgery at Brigham and Women s Hospital. She is Associate Professor of Otology and Laryngology at Harvard Medical School. In October 2008, she became the director of the new Center for Professionalism and Peer Support at BWH. She has had multiple educational leadership roles including: Senior Associate Director of Graduate Medical Education for Partners HealthCare, Founding Scholar of the Academy at Harvard Medical School, Director of the Otolaryngology Clerkship for HMS, and President of the Society of University Otolaryngologists as well as Chair of the Committee on Faculty Development. She was recently named as a finalist for the Schwartz Center Compassionate Caregiver Award. Robert Sheridan, RTR Robert Sheridan has a dual role at Massachusetts General Hospital as Director of Interventional Radiology and Director of the Radiology Consulting Group. Mr. Sheridan is responsible for the day-to-day operations and strategic management of Interventional Radiology, performing over 15,000 procedures annually. As Director of the Radiology Consulting Group, Mr. Sheridan brings over 15 years of healthcare experience and a strong clinical background to the role, with a focus on leadership development, patient safety, charge capture, competency based training, inventory management, and operational efficiency. Kathleen Shostek, RN, ARM, BBA, FASHRM, CPHRM Kathleen Shostek is Senior Risk Management Analyst at ECRI Institute. She consults on a broad range of risk management and patient safety topics; she is currently leading a project for a risk retention group involving a team-based assessment of insured hospitals imaging services. As program manager for a collaborative of radiology providers, she oversees a program focused on improving patient safety and preventing harm related to radiation dose in computed tomography. Prior to joining ECRI Institute in 2002, Ms. Shostek served as risk management director for a large physician group, as a risk consultant for a malpractice insurer, and an ambulatory surgery nurse manager. She serves on the American Society for Healthcare Risk Management s governing board. Theresa Sievers, RN, MS Terry Sievers is the Associate Vice President for Performance Improvement at Northeast Hospitals, a health system that includes three community hospitals with over 300 inpatient acute care and behavioral health beds and an ambulatory surgical and medical care center. Her responsibilities include quality management, coordination of physician peer review and quality-related credentialing data, infection prevention and control, patient relations and service excellence, compliance with accreditation and regulatory agencies, public reporting of quality measures Faculty and patient experience data, pay for performance measures and submission of data, and reports to voluntary agencies such as the Institute for Healthcare Improvement and Leapfrog. Leigh Simmons, MD Leigh Simmons is a general internist at Massachusetts General Hospital and a Physician Fellow at the John D. Stoeckle Center for Primary Care Innovation. Her research and clinical interests include enhancing patient engagement in care and studying the implementation of tools and methods to improve the quality of decisions made by patients and clinicians in the primary care and specialty care settings. Dr. Simmons co-chairs an initiative to implement shared decision making and video decision aids into routine care at 14 primary care practices at MGH. David M. Skolnik David Skolnik is Co-Founder and Director of Citizens for Patient Safety. Mr. Skolnik was successful in business for most of his career. When his son Michael was injured by a failed medical system, David and his wife, Patty, became totally involved as Michael s advocates until Michael s death, after suffering for 32 months. David left Corporate America to join his wife in their quest to improve the quality and safety of health care by empowering consumers with the tools they need to navigate the system. They promised Michael,who loved the medical field, to leave it better than he found it. Patricia Skolnik Patty Skolnik is CEO of Citizens for Patient Safety, a non-profit organization that believes that patients must be participants in their own health care and partner with their healthcare professionals. Patty teaches Patient Advocacy, a course sponsored by hospitals interested in educating the community around them. CPS has had two laws passed on transparency in health care. Patty has been named one of CNN s Intriguing People and was invited to the White House to discuss health care in She is the winner of the MITTS Award, the CPSC Patient Safety Leadership Award, and the Transparent Health Award. Bruce Spurlock, MD Bruce Spurlock is the Executive Director for Clinical Acceleration at BEACON, the Bay Area Patient Safety Collaborative, and is responsible for clinical leadership, creative design, strategic planning, clinical content, and scientific support. Dr. Spurlock is also the Chair of the California Hospitals Assessment and Reporting Taskforce (CHART) Steering Committee and an Adjunct Associate Professor with Stanford University. As President and CEO of Convergence Health Consulting, Dr. Spurlock works with physicians and health care executives to create results-oriented clinical management programs. He is recognized as a leader in California quality initiatives, change management, performance improvement, physician relations, medical staff issues, and patient safety. Robert Stegmoyer, MD Robert Stegmoyer is a Kaiser Permanente Ear-Nose-Throat Physician in the Ohio region. His special interests include simulation in health care, communication skills training with physicians, quality, and patient safety. He is board certified in Otolaryngology. Pat Teske, RN, MHA Pat Teske serves as the Implementation Officer for BEACON, the Bay Area Patient Safety Collaborative, where she designed and implemented the Avoid Readmissions through Collaboration learning community. She has over two decades of quality improvement experience at the individual hospital, regional, and system levels. For the past eight years she has also been an independent consultant working with various organizations on licensure, accreditation, and quality improvement projects, as well as statewide and regional collaboratives. Symme W. Trachtenberg, MSW, LSW Symme Trachtenberg is the Director of Community Education for The Children s Hospital of Philadelphia, a Clinical Associate in Pediatrics at the University of Pennsylvania School of Medicine, and a part-time Professor of Social Work at the University of Pennsylvania School of Social Policy and Practice. She co-leads the Community Resources for Families database project and provides the community outreach for the Care Binder program. For 10 years, she was the Director of Social Work for Children s Seashore House. Mrs. Trachtenberg has focused her career on the needs Cultivating Patient Safety 43 NPSF Annual Patient Safety Congress 2011

44 FACULTY of children, youth, and young adults with neuro-developmental disabilities and their families. Sam Watson Sam Watson is Senior Vice President for Patient Safety and Quality of the Michigan Health and Hospital Association, and Executive Director of the MHA Keystone Center for Patient Safety and Quality. The Center conducts statewide patient safety collaboratives in the areas of intensive care, surgery, emergency departments, obstetrics, and rehospitalization prevention. Mr. Watson is a Senior Fellow with the Health Research and Educational Trust and serves on the board of the Michigan Hospice and Palliative Care Organization, the National Quality Forum s Patient Safety Advisory Committee, and other committees including the Michigan Department of Community Health s Steering Committee on Health Care Associated Infections Rob Welch, MD Rob Welch is Vice President for Clinical Affairs at VHA Upper Midwest, where he analyzes and delivers results for the Agency for Healthcare Research and Quality Surveys on Patient Safety Culture (SOPS), striving to identify high-leverage, effective opportunities for improving safety culture and organizational performance. He also is an instructor at the University of Minnesota School of Public Health teaching interdisciplinary teamwork in the MHA program. Dr. Welch spent 28 years at Ridgeview Medical Center in various roles, including Medical Director of Emergency Services, Vice President, Clinical Effectiveness, and Chief Operating Officer. His interests are in clinical performance improvement and patient safety, with a systems perspective. Derek Wheeler, MD, FAAP, FCCP, FCCM Derek Wheeler is Clinical Director of the Division of Critical Care Medicine at Cincinnati Children s Hospital Medical Center and is Associate Professor of Clinical Pediatrics at the University of Cincinnati College of Medicine. He serves as Associate Director of Safety at the Medical Center and Chair of Inpatient Clinical Systems Improvement. His clinical and research interests include the early recognition of clinical deterioration and shock, rapid response systems and high-reliability organizations theory. Dr. Wheeler is the leader of the hospital-wide efforts to eliminate central line associated bloodstream infections, ventilatorassociated respiratory infections, and catheter-associated urinary tract infections. Linda Williams, RN, MSI Linda Williams is Program Specialist and Cybrarian at the VA National Center for Patient Safety. She has over 10 years with the Center for Patient Safety, serving initially as computer specialist, now in program operations with a focus on development and implementation of patient safety curriculum for physicians. She teaches human factors engineering at faculty development workshops and is Co-Director of the VA Patient Safety Fellowship program. She also is involved in the practical application of usability principles to medical devices and software. Her MSI degree from the University of Michigan School of Information was tailored to medical informatics with emphasis in human computer interaction. Robin Wootten, MBA, RN Robin Wootten is Executive Director of the Society for Simulation in Healthcare, an international professional association which has over 2700 multidisciplinary, multispecialty healthcare professional members from over 40 countries. Ms. Wootten is a nurse with 25 years of clinical and administrative healthcare experience. She began the simulation program at the University of Missouri School of Medicine in 2006, conducting training for individuals, students, residents, departments, hospital staff, and national programs. Heather Wurster, RN, MPH Heather Wurster is Executive Director of Medical Affairs in the Office of Clinical Affairs of the University of Michigan Health System; she joined UMHS 29 years ago as a nurse in cardiology. She helps lead planning and policy development related to clinical quality, and functions principally as an interpreter of hospital bylaws and medical staff policies for administrative staff, medical staff, and external agencies and groups. Her responsibilities range from coordinating peer review committee due process hearings to ensuring compliance with accreditation, regulatory, and licensing standards. Barbara J. Youngberg, JD, MSW, BSN, FASHR M Barbara Youngberg is Visiting Professor of Law, and Academic Director for On-Line Legal Education, at Loyola University of Chicago, Beazley Institute for Health Law and Policy, and a professor at Concord Kaplan University School of Law. Previously, she served as vice president of insurance, risk quality, and legal services for the University Health System Consortium. Ms Youngberg has over 25 years experience helping major health systems and other complex healthcare organizations with risk management, patient safety, and legal and regulatory compliance. She has authored numerous articles and textbooks on quality management and patient safety. Yvonne D Angelo Zawodny, RN, LHRM, CPHRM Yvonne Zawodny is Corporate Assistant Vice President of Risk Management/Patient Safety for Baptist Health South Florida. Ms. Zawodny has been with Baptist Health South Florida since 1976, beginning her career as a registered nurse and becoming risk manager in She is a member of FSHRMPS, ASHRM, AHA, RIMS and SFHA. She volunteers as a mentor in the Women of Tomorrow program and is a frequent guest speaker at symposiums and seminars regarding risk management, claims management, and patient safety. Get on the map in M Health Care proudly supports the mission and work of the National Patient Safety Foundation 2011 Patient Safety Awareness Week Celebrations Patient Safety awareness week March 4 10, 2012 WellPoint eighth page Proud to support the 13th Annual NPSF Patient Safety Congress wellpoint.com 02201VAMENWLP 4/11 Registered Trademark, WellPoint, Inc WellPoint, Inc. All Rights Reserved. Cultivating Patient Safety 44 NPSF Annual Patient Safety Congress 2011

45 Commitment to Saving Lives...Improving Care In 1956, MedicAlert Foundation pioneered the use of medical IDs and services to relay vital medical information to emergency responders on behalf of its members so they receive faster and safer treatment. Today, MedicAlert provides the functionality of an e-health information exchange through an innovative combination of a unique patient identifier linked to a PHR and a live 24/7 emergency response service. Written by healthcare professionals, Patient Safety & Quality Healthcare is a respected source of research, news and practical tools and opinions for improving the safety & quality of healthcare. MedicAlert services improve care coordination for patients with chronic conditions and enhances patient safety through tools like Implant Connect and the Difficult Airway Registry. MedicAlert provides a nationwide site to store and access advance directives so the information is always available to providers and families in medical emergencies. Our unique combination of services provides our members and their families another layer of defense against adverse events and helps enhance patient safety ID.ALERT MedicAlert Foundation is a 501(c)(3) nonprofit organization All rights reserved. MedicAlert is a U.S. registered trademark and service mark. Please visit for: News Trends Industry Blogs Digital Versions Updated Calendar Information Sponsorships Subscriptions Resource Center Advertising Information and much more! For more information contact Kelly Millwood / kelly@lionhrtpub.com NPSF Research Grants Program Promoting Research in Patient Safety The National Patient Safety Foundation congratulates the 2011 NPSF Research Grant recipients: NPSF Board Research Grant James Gray, MD, Beth Israel Deaconess Medical Center, Boston Trigger Events as a Burst-like Phenomena: Understanding the Role of Care Team Structure and Designing Solutions Supported in part by generous contributions from NPSF Board members The Hospira Research Grant Emily Patterson, PhD, Ohio State University Medical Center Patient Handoffs: The Impact of a Fresh Perspective on Patient Mortality in Critical Care Settings Funded through the generosity of Hospira, Inc. Since 1998, the NPSF Research Grants Program has provided funding to 36 investigators seeking to contribute to the growing body of knowledge about patient safety and safe care practices. For more information, visit the NPSF booth in the Learning & Simulation Center here at Congress, or go to CENTER FOR AVIATION SAFETY RESEARCH 2012 Safety Across High-Consequence Industries Conference March Where Patient Safety Meets Flight Safety. A forum for researchers and practitioners from aviation, healthcare and other highconsequence fields. s a i n t l o u i s u n i versity parks.slu.edu/faculty-research/casr STAY INFORMED. GET CONNECTED. GROW PROFESSIONALLY. Exclusive NPSF Offer! Save 33% when you join the Society for Simulation in Healthcare Today! Visit our booth in the exhibit hall to receive this exclusive offer. Society for Simulation in Healthcare SSH Cultivating Patient Safety 45 NPSF Annual Patient Safety Congress 2011

46 NPSF Proudly Recognizes Members of our Corporate Council for their Commitment to Patient Safety CORPORATE COUNCIL National Patient Safety Foundation National Patient Safety Foundation 268 Summer Street, Sixth Floor. Boston, MA fax To learn more about the NPSF Corporate Council and the many benefits of participation, please visit NPSF at booth #401 here at Congress or contact David Coletta at or

47 NPSF Board of Directors Richard E. Anderson, MD, FACP Chairman & CEO The Doctors Company Charles G. Benda, PhD, CPCU, ARM Secretary Senior Vice President & COO Global Loss Prevention Doug Bonacum, BS, MBA Vice Chair Vice President, Safety Management Kaiser Permanente Jennifer Daley, MD, FACP Executive Vice President & COO University of Massachusetts Memorial Medical Center Susan Edgman-Levitan, PA Executive Director John D. Stoeckle Center for Primary Care Innovation Massachusetts General Hospital Gerald B. Hickson, MD Joseph C. Ross Chair in Medical Education & Administration Associate Dean for Clinical Affairs Director, Center for Patient & Professional Advocacy Vanderbilt University Medical Center William F. Jessee, MD, FACMPE, FACPM, FACPE Treasurer President & CEO Medical Group Management Association Gary S. Kaplan, MD, FACMPE Chair Chairman & CEO Virginia Mason Medical Center Linda K. Kenney President & Executive Director Medically Induced Trauma Support Services Gregg S. Meyer, MD, MSc Ex-Officio Member Chair, NPSF Board of Governors Senior Vice President for Quality and Patient Safety Massachusetts General Hospital Dennis S. O Leary, MD President Emeritus The Joint Commission David R. Page, MHA President & CEO (retired) Fairview Health Systems Jonathan Perlin, MD, PhD, MSHA, FACP, FACMI CMO & President, Clinical Services Hospital Corporation of America Diane C. Pinakiewicz, MBA Ex-Officio Member President National Patient Safety Foundation Pamela A. Thompson, MS, RN, FAAN Immediate Past Chair CEO American Organization of Nurse Executives Barbara J. Youngberg, JD, MSW, BSN, FASHRM Visiting Professor of Law Beazley Institute for Health Law and Policy Loyola University Chicago School of Law NPSF Board of Governors Gordon L. Alexander Jr., MD President & CEO Children's Hospital of Central California Peter B. Angood, MD, FACS, FCCM Medical Director, GE Patient Safety Organization James P. Bagian, MD, PE Director Center for Health Engineering University of Michigan Barbara M. Balik, RN, EdD Principal CommonFire Healthcare Consulting Ann Scott Blouin, PhD, MSN, MBA, RN Executive Vice President, Accreditation & Certification Operations The Joint Commission Richard C. Boothman, AB, JD Chief Risk Officer University of Michigan Health System Albert Bothe Jr., MD Executive Vice President & Chief Quality Officer Geisinger Health System Rebecca R. Burkholder, JD Director of Health Policy National Consumers League John R. Combes, MD President & COO Center for Healthcare Governance American Hospital Association Jeffrey B. Cooper, PhD Executive Director Center for Medical Simulation Professor of Anaesthesia Harvard Medical School Department of Anesthesia, Critical Care & Pain Medicine Massachusetts General Hospital Toni Cordell Literacy Advocate Ilene Corina Patient Safety Consultant Founder & President PULSE of NY Sharon Dunn, MAS, BSN, RN Vice President, Corporate Innovation Walgreen Company Jane Englebright, PhD, RN Chief Nursing Officer Hospital Corporation of America Timothy T. Flaherty, MD Past Chair, NPSF Board of Governors Past Chair, Board of Trustees American Medical Association Tejal K. Gandhi, MD, MPH Director, Patient Safety Partners HealthCare Paul A. Gluck, MD Associate Clinical Professor OB/GYN Fellow, Center for Patient Safety University of Miami Miller School of Medicine Maulik S. Joshi, DrPH President Health Research & Educational Trust Senior Vice President of Research American Hospital Association Carol A. Ley, MD, MPH Director, Occupational Medicine 3M Health Care Business Kathryn McDonagh, RN, MS, PhD Vice President, Executive Relations Hospira Gregg S. Meyer, MD, MSc Chair Senior Vice President for Quality and Patient Safety Massachusetts General Hospital J. Lloyd Michener, MD Professor & Chair Department of Community & Family Medicine Duke University School of Medicine Director, Duke Center for Community Research Durham Veterans Medical Center Suzanne G. Mintz, MS President & CEO National Family Caregivers Association Julianne M. Morath, RN, MS Chief Quality & Safety Officer Vanderbilt University Medical Center Mary Beth Navarra-Sirio, RN, MBA Vice President, Patient Safety Officer McKesson Corporation Donald J. Palmisano, MD, JD President Intrepid Resources Mary A. Pittman, DrPH President & CEO Public Health Institute Kathryn Rapala, DNP, JD, RN Director, Clinical Risk Management Aurora Health Care Richard G. Roberts, MD, JD, FAAFP, FCLM Professor of Family Medicine University of Wisconsin Medical School Pauline F. Robitaille, RN, MSN, CNOR Director, Operating Room Brigham & Women's Hospital Susan E. Sheridan, MIM, MBA President Consumers Advancing Patient Safety Barry Silbaugh, MD, MS, FACPE Vice Chair CEO American College of Physician Executives Robert M. Wachter, MD Associate Chair Department of Medicine University of California San Francisco Saul N. Weingart, MD, PhD Vice President for Patient Safety Dana-Farber Cancer Institute Josie R. Williams, MD, MMM Director, Quality & Patient Safety Initiatives, Rural & Community Health Institute Texas A&M University Assistant Professor of Internal & Family Medicine Texas A&M University System Health Sciences Center Cultivating Patient Safety 47 NPSF Annual Patient Safety Congress 2011

48 Mark your calendar: Professional learning series at the national Patient safety foundation Continuing education Credits available for an Unlimited number of attendees* Physicians nurses Physician assistants Pharmacists Register today at Medical simulation 101: fundamental strategies for advancing Your Patient safety agenda JUne 15, :00am eastern Quality, safety and reliability: engaging Physicians and influencing Culture Change JUlY 27, :00pm eastern Jeffrey B. Cooper, PhD Executive Director, Center for Medical Simulation, Prof. of Anesthesia, Harvard Medical School, Dept. of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital Haru okuda, MD National Medical Director, Simulation Learning Education and Research Network (SimLEARN), Veterans Health Administration gordon alexander Jr., MD President and CEO Children s Hospital Central California Barry silbaugh, MD, Ms, facpe Chief Executive Officer, American College of Physician Executives Members of the American Society of Professionals in Patient Safety (ASPPS) receive a registration discount Stand Up for Patient Safety members receive complimentary access to all Professional Learning Series webcasts * Non-Members: $199 per connection, multiple attendees encouraged per connection Berkshire Direct / Miller Printing proudly support the National Patient Safety Foundation From design concept to production, printing, binding, mailing and fulfillment - your complete source for marketing services! marketing design web print mail fulfillment 173 Water Street, Ste. 7 Williamstown, MA (ph) (fax) miller printing a division of berkshire direct 173 Water Street, Ste. 7 Williamstown, MA (ph) (fax) Cultivating Patient Safety 48 NPSF Annual Patient Safety Congress 2011

49 General Information Americans with Disabilities Act (ADA) If you feel you need services or auxiliary aids in order to fully participate in this continuing education activity, please contact NPSF Management at the Congress Registration Desk. Electronic Devices As a courtesy to meeting attendees, NPSF requests that all electronic devices be turned off during educational sessions. If you must use your cell phone, we request that you step outside the meeting room so as not to disturb other attendees. Gaylord National Hotel & Convention Center 201 Waterfront Street National Harbor, Maryland Phone: Parking: $5.00 for first hour $12.00 for 0 3 hours self parking $19.00 per day self parking/overnight* $17.00 for 0 3 hours valet parking $28.00 per day valet parking/overnight* For more information, please call *All rates are subject to change without notice. Please call ahead to confirm pricing. Registration You may pick up your registration packet and badge at the NPSF Congress Registration Desk during the following hours: Tuesday, May 24, 4:00 6:00pm Wednesday, May 25, 7:00am 5:00pm Thursday, May 26, 7:00am 6:00pm Friday, May 27, 7:00 10:00am Opening Reception Wednesday, May 25, 6:00 8:00pm In the NPSF Congress Learning & Simulation Center Connect with Congress attendees and meet new colleagues at the Opening Reception in the Learning & Simulation Center. Badges The official badge and badge holder must be worn for admission to sessions, exhibits, and other conference activities. We thank you in advance for your cooperation. Dress Business casual attire is appropriate for all Congress events. Meeting rooms are usually kept cool, so light jackets or layers are recommended inside the Congress sessions. Internet Access Wireless and high-speed Internet access are available in guest sleeping rooms. Please note that wired and wireless Internet access in the Convention Center and meeting areas is not included. NPSF Congress Press Room The press room, Chesapeake K, is available to credentialed and registered press. The room is available for media to conduct interviews, write articles, and network with NPSF spokespeople. Press releases and other information from NPSF will also be available. Use of the room will be limited to registered press. Solicitations Solicitations for orders by unauthorized persons are strictly prohibited. Sales and promotional activities are restricted to exhibitors and must take place at their own exhibit areas. Shuttle Service The Gaylord National offers an exclusive, express shuttle to and from Reagan National Airport. Operates 6:00am 8:00pm. Departs every 20 minutes from Gaylord National s front door to Reagan National Airport, and every 20 minutes from the Reagan National Airport baggage claim. Reservations are recommended, but tickets also will be available from the SuperShuttle desk, located on the lower level of the airport, near baggage claim. $18 one way; $32 per person, round trip; $78 for exclusive van service, booked in advance. Local Reservations: hr Reservations: IKON Business Center Hours For last-minute changes or projects, the business center, on the main floor of the Convention Center, is open from 7:00am 9:00pm every day. Relâche Fitness Center The 24-hour fitness center has the most sophisticated fitness equipment available, including cardio equipment outfitted with personal televisions. Access to the fitness center is complimentary (included in Resort Fee) for hotel guests. Emergencies In case of an emergency during the NPSF Congress, please dial 333 from any house phone to reach the security department. You can always ask NPSF or Gaylord staff for help. Lost and Found Congress Lost and Found will be located at the NPSF Congress Registration Desk. Any items not claimed by the end of each day will be turned in to the Gaylord Lost and Found department. Cultivating Patient Safety 49 NPSF Annual Patient Safety Congress 2011

50 Stand Up for Patient Safety It Begins with a Single Decision The Stand Up for Patient Safety program delivers evidence-based tools and resources that allow your organization to meet current patient safety goals and engage executive leadership, clinicians, frontline staff, patients, families, and the broader community in advancing patient safety. Join over 600 hospitals, health systems, and ambulatory facilities nationwide in a shared commitment to providing safe health care. Core BenefitS of MeMBerSHiP Choose from Hospital-based or Ambulatory Programs AMBULATORY For more information about membership or to join the Stand Up for Patient Safety program, visit or contact us at StandUp@npsf.org cccomprehensivecresourcecguidecwithceducationalcmodules,ccustomizablec templates,cbrochures,candcdvds ccunlimitedcaccessctocacvirtualcpatientcsafetyccommunity cccomplimentarycregistrationctocthecprofessionalclearningcseriescatcnpsfc cc CME,cCEU,candcACPEcaccreditedcmonthlycwebcastscpresentedcbycindustrycleaders ccready-to-usecpatientcsafetycawarenesscweekctoolkitcandcresourcesc ccregistrationcdiscountcforcallcstaffctocthecnpsfcpatientcsafetyccongress ccexclusiveceducationcandcnetworkingcopportunities cccustomizablecprojectcplans,cpresentations,candcmarketingcmaterialcdesignedctoc promotecyourcorganization sccommitmentctocpatientcsafety ccsubscriptionsctocnpsfcpublications,cincluding Current Awareness Literaturec AlertcandcFocus on Patient Safety Newsletter Lexington Insurance Company is proud to support the 13th Annual NPSF Patient Safety Congress Lexington Insurance Company, a Chartis company, is the leading U.S.-based surplus lines insurer. Chartis is the marketing name for the worldwide property-casualty and general insurance operations of Chartis Inc. For additional information, please visit All products are written by insurance company subsidiaries or affiliates of Chartis Inc. Coverage may not be available in all jurisdictions and is subject to actual policy language. Non-insurance products and services may be provided by independent third parties. Surplus lines insurers do not generally participate in state guaranty funds and insureds are therefore not protected by such funds. Cultivating Patient Safety 50 NPSF Annual Patient Safety Congress 2011

51 The worst place to be mistaken for someone else is in the pathology lab. Misidentification of results in the anatomic pathology lab can have devastating consequences for patients and the people who treat them. Put your lab on a SaferPath. Take the first step at booth 601. Brought to you by Ventana, mission-driven to improve the lives of all patients afflicted with cancer, and a proud supporter of the National Patient Safety Foundation. Support the National Patient Safety Foundation. Cultivating Patient Safety 51 NPSF Annual Patient Safety Congress 2011

52 COMMIT TO PATIENT SAFETY [full-page ad to come] Join Us Today >>> The fi rst and only individual membership program for the patient safety fi eld. Register for membership today at the NPSF Information Desk in the registration lobby or the NPSF Booth in the Learning & Simulation Center. Individual membership is the newest addition to the NPSF portfolio, which includes continuing education credits through the Professional Learning Series, the NPSF Annual Patient SafetyCongress, and other high-value programs. American Society of Professionals in Patient Safety 268 Summer Street, Sixth Floor Boston, MA Membership Services: