NPSF Research Grants Program - NPSF Patient Safety Congress

Office of Inspector General’s series of reports about adverse events in hospitals. Based
on sample cases nationwide, we will review hospital and Medicare responses to
events and discuss implications for hospital and government policy and practice.
Upon completing this session, attendees will be able to:
• Explain hospital responses to adverse events, including the role of incident
reporting systems, investigation practices, and corrective actions
• Investigate Medicare responses to adverse events, including the roles of
the Centers for Medicare and Medicaid Services (CMS), state agencies, and
accrediting organizations
• Investigate the roles and interplay of hospitals and Medicare oversight entities in
identifying, investigating, and addressing adverse events
ShAPiNG thE CuLtuRE
SeSSion 206: Safety and Quality at the Forefront:
transforming Resident Education
1.0 contact hours for physicians
Armand Krikorian, MD, Assistant Professor of Medicine, Associate Residency
Director in the Department of Internal Medicine, Case Western Reserve University
In 2009 the Department of Medicine at University Hospitals Case Medical Center
(UHCMC) identified a need to formalize a structured, standardized curriculum to
teach quality improvement and patient safety. The goal of the unique program is
to equip nursing, pharmacy, risk management, and quality center staff with the
knowledge, attitudes, and skills needed to participate in quality and patient safety
at a large academic medical center. UHCMC has witnessed a culture change related
to quality and patient safety, and a revolution in health care team attitudes,
including physicians, nurses and pharmacists.
Upon completing this session, attendees will be able to:
• Identify techniques for creating a successful interdisciplinary quality and patient
safety program
• Identify measurable impact of implementing a quality and patient safety program
• Design multidisciplinary process improvement projects for the entire health
care team
12:15 PM – 1:45 PM
LEARNiNG & SiMuLAtiON CENtER:
LuNCh, SiMuLAtiONS, EXhiBitS, POStERS
2:00 PM - 3:30 PM | Breakout SeSSionS 301–306
EMBRACiNG thE tEAM
SeSSion 301: Rounding for Results: An innovative
Approach to Family-Centered Rounds
1.5 contact hours for physicians, nurses, healthcare risk management, healthcare
quality and healthcare executives
Martina Keeler, MD, Pediatric Hospitalist, Helen DeVos Children’s Hospital
Jodi Meinke, MSN, RN, CPNP-PC/AC, Pediatric Nurse Practitioner, Helen DeVos
Children’s Hospital
Engagement of families with their health care team – including doctors, nurses,
pharmacists, and care managers – enhances safety, quality, and satisfaction.
To improve rounding effectiveness, pharmacists, dieticians, and care managers
conducted a detailed survey and designed an innovative approach to clinical
rounding that emphasizes communication with patients and families. R2:
Rounding for Results has improved family and team communication and has
ThURSDAY
enhanced overall care and discharge planning. The presentation will describe
methodology and results.
Upon completing this session, attendees will be able to:
• Identify key components of a new family-centered rounding process that
assists the pharmacist, dietician, and care manager in patient care and
discharge processes
• Demonstrate that changing rounds can improve communication and overall
satisfaction between patients and caregivers
• Describe how a well-coordinated rounding process that includes patients and
families enhances the plan of care and improves the timeliness of discharge
ENGiNEERiNG WORkFLOW AND LEvERAGiNG tEChNOLOGY
SeSSion 302: Clinical Alarm Fatigue: Actions by the
healthcare technology Safety institute
1.5 contact hours for physicians, pharmacists 232-999-12-138-L05-P
(activity type- Knowledge), nurses, healthcare risk management, healthcare quality
and healthcare executives
Leah C. Lough, MBA, Executive Vice President, Association for the Advancement of
Medical Instrumentation, Executive Director, AAMI Foundation
Nat Sims, MD, Anesthesiologist and Physician Advisor, Biomedical Engineering,
Massachusetts General Hospital
Andreas Taenzer, MD, FAAP, Anesthesiologist, Dartmouth-Hitchcock Medical Center
Clinical alarm fatigue is a significant patient safety issue. In 2012 the Healthcare
Technology Safety Institute in the AAMI Foundation was established to address
high-priority safety issues involved with health care technology – including
“clinical alarm fatigue.” This presentation will give an overview of the institute;
describe the issues surrounding clinical alarms; discuss the 2012 national summit
that brought to light seven themes surrounding clinical alarms; describe what
some innovative hospitals are doing to successfully address alarms; and note the
summit’s top ten recommendations that can help your facility deal with clinical
alarm fatigue.
Upon completing this session, attendees will be able to:
• Explain why the AAMI Foundation Healthcare Technology Safety Institute was
created by the health care community in 2012 and how it is addressing the top
critical technology issues
• Identify what the nature of the problems really are, why they are important
to patient safety and outcomes, and who is involved in finding the solutions –
particularly surrounding clinical alarms
• Outline the top priorities for addressing issues related to clinical alarms and how
some innovative hospitals are successfully reducing the “noise”
• Describe what the institute is doing to also examine infusion systems and why
the resolution of issues surrounding this technology is key to patient safety
• Explain the impact that the institute could have on shaping the future of
technology safety in your facility
hOt tOPiCS
SeSSion 303: Attention, Awareness, and Reflection:
Prescription for health Professional
Resilience and Quality and Safety in
21st-Century Medicine
1.5 contact hours for physicians, pharmacists 232-999-12-139-L05-P
(activity type- Knowledge), nurses, healthcare risk management, healthcare quality
and healthcare executivess
Patient Safety 365 9 NPSF Annual Patient Safety Congress 2012