The State of Patient Safety: 15 Years Since the IOM Report To Err Is Human EXPERT PANEL Co-Chairs Donald M. Berwick, MD, MPP Emeritus and Senior Fellow Lecturer, Department of Health Care Policy Harvard Medical School Kaveh G. Shojania, MD Director, Centre for Quality Improvement & Patient Safety University of Toronto Editor-in-Chief BMJ Quality & Safety Participants Brian K. Atchinson, Esq. & CEO PIAA David W. Bates, MD, MSc Chief Innovation Officer and Senior Vice Chief, Division of General Internal Medicine Brigham and Women s Hospital Medical Director of Clinical and Quality Analysis Partners HealthCare 1
Alice Bonner, PhD, RN Associate Professor, School of Nursing Faculty Associate, Center for Health Policy Northeastern University Russell P. Branzell, FCHIME, CHCIO CEO and College of Healthcare Information Management Executives (CHIME) Pascale Carayon, PhD Procter & Gamble Bascom Professor in Total Quality, Department of Industrial and Systems Engineering Director of the Center for Quality and Productivity Improvement University of Wisconsin-Madison Mark R. Chassin, MD and CEO The Joint Commission Michael R. Cohen, RPh, MS, ScD (hon), DPS (hon) Institute for Safe Medication Practices Adjunct Associate Professor Temple University Joanne Disch, PhD, RN, FAAN Professor ad Honorem University of Minnesota School of Nursing Immediate Past American Academy of Nursing Board Member Aurora Health Care Chair of Board of Trustees Chamberlain College of Nursing Vice Chair, National Advisory Council Betty Irene Moore School of Nursing Premier QUEST Advisory Board 2
Board of Visitors University of Wisconsin School of Nursing Mary Dixon-Woods, BA, DipStat, MSc, DPhil Professor of Medical Sociology and Wellcome Trust Investigator University of Leicester Visiting Associate Professor Dartmouth College Adjunct Professor Johns Hopkins University Visiting Professor Imperial College Susan Edgman-Levitan, PA Executive Director John D. Stoeckle Center for Primary Care Innovation Massachusetts General Hospital Jane D. Englebright, PhD, RN, CENP, FAAN Chief Nurse Executive Patient Safety Officer Vice Hospital Corporation of America (HCA) Frank Federico Executive Director Chair National Coordinating Council for Medication Error Reporting and Prevention Vice Chair Joint Commission Patient Safety Advisory Group Tejal K. Gandhi, MD, MPH, CPPS and CEO National Patient Safety Foundation 3
Vicki S. Good, MSN, RN, CENP, CPSS System Administrative Director of Clinical Safety CoxHealth Immediate Past American Association of Critical Care Nurses Helen W. Haskell, MA Mothers Against Medical Error Consumers Advancing Patient Safety National Patient Safety Foundation International Society for Rapid Response Systems Robin R. Hemphill, MD, MPH Acting Assistant Deputy Under Secretary for Health, for Quality, Safety, and Value Veterans Health Administration Chief Safety and Risk Awareness Officer VA National Center for Patient Safety Lucian L. Leape, MD Chair NPSF Lucian Leape Institute Adjunct Professor Harvard School of Public Health Stephen E. Muething, MD Vice for Safety Cincinnati Children's Clinical Director Children s Hospitals Solutions for Patient Safety Peter J. Pronovost, MD, PhD, FCCM Senior Vice for Patient Safety & Quality Johns Hopkins Medicine 4
Director Johns Hopkins Armstrong Institute Kathryn (Kathy) Rapala, DNP, JD, RN, CPPS Vice for Clinical Risk Management Aurora Health Mark L. Rosenberg, MD, MPP and CEO The Task Force for Global Health Sanjay Saint, MD, MPH Chief of Medicine VA Ann Arbor Healthcare System George Dock Professor of Medicine University of Michigan Health System Eric J. Thomas MD, MPH Professor of Medicine Associate Dean for Healthcare Quality University of Texas Medical School at Houston Director UT Houston-Memorial Hermann Center for Healthcare Quality and Safety Jed Weissberg, MD, FACP Senior Fellow Institute for Clinical and Economic Review (ICER) Faculty Senior Vice (retired) Kaiser Foundation Health Plan 5