Safety Track

​​​​​​​​​The Safety Track at this year's National Forum focuses on making the health care continuum safer by reducing harm and preventing mortality. Specific topics include:

  • ​Demonstrating strategies in the leadership, learning system, and culture components within the Framework for Safe, Reliable, and Effective Care
  • Co-producing safety with patients and families
  • Understanding how organizations implement a just culture
  • Moving from project-based safety to systems of safety
  • Addressing efforts to mitigate psychological harm of patients, families, and s​taff
Session selection is open. View all Safety​ sessions below or see the full program here. ​You can also view this year's 10 Forum tracks.

Safety Sessions

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Can We Really Learn from the Past?

Can We Really Learn from the Past?

How do we learn from the past? This question faces all countries trying to improve care. Using Scotland as a case study, and a published measurement and monitoring framework which encourages us to “look forward” and integrate learning, we will explore what components you might have in your system and how these can really drive sustainable improvement. Aimed at intermediate and master delegates, this highly interactive session will be stimulating and fun!

After this presentation, you will be able to:

  • Identify key challenges to learning from past events
  • Develop your understanding of approaches to enhance learning
  • Develop a draft “take home” plan to help you implement back at base

Presenters: Brian Robson, MBChB, FRCGP, MPH, DRCOG, IHI / Health Foundation Fellow, Medical Director, Healthcare Improvement Scotland; Craig A. White, MML, PhD, FRCP, Divisional Clinical Lead, Scottish Government; Jo Thomson, BSc (Hons), Scottish Improvement Leader, Senior Programme Manager, Healthcare Improvement Scotland

Engaging Families in I-PASS to Improve Safety

Engaging Families in I-PASS to Improve Safety

Developed by the 2016 John M. Eisenberg Innovation in Patient Safety and Quality national award recipients, Patient and Family Centered I-PASS is an evidence-based program to improve safety through family and interprofessional engagement in hospital communication. Its implementation in seven hospitals was associated with a 38 percent reduction in preventable harms and improved family-nurse engagement. This session will teach families, nurses, physicians, and hospital leaders how to implement Patient and Family Centered I-PASS to improve safety.

After this presentation, you will be able to:

  • Practice using Patient and Family Centered I-PASS elements of health literacy, family activation, and nurse engagement to promote safer hospital communication
  • Brainstorm multimodal communication techniques to enhance the safety of communication during and after family-centered rounds
  • Develop an implementation plan for integrating improvement science methods to adapt Patient and Family Centered I-PASS to your own settings

Presenters: Alisa Khan, MD, MPH, Staff Physician, Boston Children's Hospital; Jennifer Baird, PhD, MPH, MSW, RN, Director, Institute for Nursing and Interprofessional Research, Children's Hospital Los Angeles; Dale Micalizzi, AAS, Founder, Director, Health Educator, The Task Force for Global Health (Justin's HOPE Project); Christopher Landrigan, MD, MPH, Director, Sleep and Patient Safety Program, Brigham and Women's Hospital; Nancy Spector, , Associate Dean of Faculty Development, Executive Director, Executive Leadership in Academic Medicine, Drexel University College of Medicine

The Future of Mortality Review

The Future of Mortality Review

Representatives of an international collaborative of more than 50 hospitals will guide you through the implementation of a safety learning system — not only learning from every death, but also learning from the living. Using a real-time audience response system, participants will: 1) identify opportunities for improvement in care delivered to simulated patient journeys; 2) quantify barriers to implementing a reliable learning system; and 3) prioritize opportunities for improvement. You will walk away with actionable insights.

After this presentation, you will be able to:

  • Implement a learning system that embodies principles of high reliability — specifically, deference to expertise
  • Move beyond the medical model of peer review to a process of interprofessional learning that leads to actionable information and change
  • Define the largest safety problems facing health care today: acts of omission, not commission

Presenters: Jeanne Huddleston, MD, Associate Professor, Mayo Clinic; Annette Pantle, MBBS, MPH, FRACMA, Executive Director, Patient Safety; Hanan Foley, MSN, RN, CPQH, Director, Quality and Safety, MedStar Georgetown University Hospital; Patty Atkins, MS, RN, CPPS, Vice President, Quality and Safety, Sharp HealthCare

Adopting RCA2: See One, Do One, and Take One Home

Adopting RCA2: See One, Do One, and Take One Home

This course will give quality and safety leaders the opportunity to see how our organization has adopted and adapted the NPSF RCA2™ process. Join us as we share examples from our experience. You will participate in simulation exercises to learn how to adopt RCA2 and leave with tools to help you translate this at your institution. This is a hands-on program and designed to be practical, skill-based, and enjoyable.

After this presentation, you will be able to:

  • Recognize the importance of the RCA2 model
  • Learn how to operationalize important RCA2 components, such as immediate post-event action, from huddle to debrief to fact finding
  • Apply the RCA2 investigational model while enhancing efficiency and developing sustainable improvements
  • Use RCA2 data collected to identify trends and opportunities for early intervention, and move to a more proactive approach

Presenters: Brian Cummings, MD, Associate Chief Quality Officer, Massachusetts General Hospital; Jana Deen, RN, JD, Senior Director, Patient Safety, Massachusetts General Hospital; Elizabeth Mort, MD, MPH, Senior Vice President, Quality and Safety, Massachusetts General Hospital; Merranda Logan, MD, MPH, Assistant Chief Quality Officer, Massachusetts General Hospital

Certified Professional in Patient Safety (CPPS) Review Course

Certified Professional in Patient Safety (CPPS) Review Course

This session is being offered to experienced patient safety professionals who plan to take the Certified Professional in Patient Safety (CPPS) exam. This course can help participants prepare for the exam by reviewing domain content areas and test-taking strategies.

After this presentation, you will be able to:

  • Discuss in depth the five patient safety domains, following the exam content outline
  • Discuss patient safety scenario examples like actual exam questions
  • Assess your own level of preparedness for the exam and address additional areas for self-study

Presenters: Janine Carpenter, Director of Programs, IHI; Judy Milne, RN, MSN, CPHQ, CPPS, Patient Safety Officer, Duke University Medical Center; Kenneth Rothfield, MD, MBA, CPE, CPPS, Chief Medical and Quality Officer, Saint Vincent's Medical Center; Dot Snow, MPH, CPPS, Director, National Risk Management and Patient Safety, Kaiser Permanente National Patient Care Services; Karen Garvey, BSN, MPA/HCA, CPHRM, CPPS, Vice President, Parkland Health and Hospital System; Katherine Rowbotham, Project Manager, IHI

Addressing the "Untouchables": The Case of Dr. X

Addressing the "Untouchables": The Case of Dr. X

What do you do with Dr. X, a professional who persistently undermines your safety culture even after he's been made aware that he stands out? Sometimes these individuals seem recalcitrant and "untouchable" for a variety of reasons. Through case-based learning and simulated encounters, we will provide a toolkit for promoting safety culture by addressing Dr. X's behaviors in ways that maximize the probability of success.

After this presentation, you will be able to:

  • Identify the critical infrastructure needed to support sustained accountability for individuals who fail to self-regulate
  • Utilize a toolkit for developing and implementing corrective action plans under authority
  • Develop skills in having conversations with individuals who fail to self-regulate

Presenters: Gerald Hickson, MD, Senior Vice President, Director, Quality, Safety, and Risk Prevention, Vanderbilt University; William Cooper, MD, MPH, Professor and Director, Vanderbilt Center for Patient and Professional Advocacy, Vanderbilt University School of Medicine

Communication and Resolution: The Massachusetts Experience

Communication and Resolution: The Massachusetts Experience

Members of the Massachusetts Alliance for Communication and Resolution (MACRMI) will teach attendees how to implement Communication, Apology, and Resolution (CARe) programs for adverse events in their facilities, discuss results of the three-year pilot study completed in six Massachusetts hospitals, and share practical lessons learned. Attendees will also learn about the value of a multi-stakeholder alliance in supporting and spreading these CARe programs and creating resources to build and sustain programs at low cost.

After this presentation, you will be able to:

  • Understand the merits of a CARe program and the data that supports its implementation
  • Identify the elements necessary for sustaining a successful CARe program and the challenges to be aware of over time

Presenters: Allen Kachalia, MD, JD, Chief Quality Officer and Vice President, Quality and Safety, Brigham and Women's Hospital; Patricia Folcarelli, RN, PhD, Interim Vice President of Health Care Quality, Beth Israel Deaconess Medical Center; Melinda Van Niel, MBA, CPHRM, Project Manager, Beth Israel Deaconess Medical Center; Evan Benjamin, MD, Senior Vice President, Quality and Population Health, Baystate Health

The Army Medicine RESET: Hospitals Do Fly

The Army Medicine RESET: Hospitals Do Fly

The aviation and occupational safety industries provide suitable models for centralized safety oversight with regard to data collection and analysis, accident investigation, and safety messaging. Army Medicine aims to replicate their success by establishing a medical incident investigation capability to study the root causes of adverse patient safety events and spread lessons learned to other hospitals across Army Medicine. In this session, learn about Army Medicine's Root Cause Analysis Event Support and Engagement Team (RESET) and its progress in implementing a patient safety accident investigation program.

After this presentation, you will be able to:

  • Identify how Army Medicine's RESET deploys to study sentinel events in its medical and dental treatment facilities
  • Describe how the Army Medicine RESET contributes to high reliability within the Army Medicine enterprise

Presenter: Stephen Yoest, MD, MHA, Director, USA MEDCOM Quality and Safety Center, US Army Medical Command

Deprescribing: Importing Innovations from Outside the US

Deprescribing: Importing Innovations from Outside the US

Clinical guidelines specify when medications should be started but rarely indicate when or how they should be stopped. An innovation from Ottawa demonstrated a systematic and adaptable process for developing and implementing guidelines for clinicians to discontinue unnecessary or inappropriate medications. Three US-based health systems will share their outcomes, barriers, and successes putting deprescribing into practice. You will advance your learning using their experiences and begin to develop a plan to test the innovation.

After this presentation, you will be able to:

  • Understand the barriers and enablers to implementing deprescribing in primary care and long-term care settings
  • Begin to develop a plan for testing deprescribing in your health system

Presenter: Leslie Pelton, MPA, Director, Innovation, IHI

Balancing Diagnosis Error and Conservative Care

Balancing Diagnosis Error and Conservative Care

Striking a balance between missed or delayed diagnosis vs. over-diagnosis and over-testing requires a new model of appropriate diagnostics. It needs to be based on fundamentals of good diagnosis (careful exam, listening to the patient, understanding test limitations), the precautionary principle, healthy skepticism about testing value and associated harms, and primary medicine/continuity relationships. A new project built on a Massachusetts network for sharing cases and a task force developing principles of conservative diagnosis will be interactively shared.

After this presentation, you will be able to:

  • Identify key issues that contribute to diagnosis error and brainstorm clinical and policy solutions
  • Describe a new, more conservative and appropriate diagnosis paradigm, and contribute to an evolving vision of “10 Key Principles of Conservative Diagnosis”
  • Implement their own sharing and learning network to deal with diagnosis error cases

Presenters: Gordon Schiff, MD, Associate Director, Center for Patient Safety Research and Practice, Brigham and Women's Hospital; Lynn Volk, Associate Director, Partners Healthcare

Improving Access and Surgical Quality in the US Military

Improving Access and Surgical Quality in the US Military

Access to care and surgical quality are strategic priorities for the Military Health Service, ensuring a medically ready force (providers are ready to deploy) and a ready medical force (managing a range of medical issues to keep skills sharp for the battlefield). This session will present how, to accelerate improvements in these areas, 45 military treatment facilities are engaged in a 12-month collaborative, applying improvement methodology and change concepts in a highly competitive and hierarchical environment.

After this presentation, you will be able to:

  • Identify high-level change concepts to improve access to care and surgical quality
  • Apply practical lessons for working collaboratively in a highly competitive and hierarchical environment
  • Describe how access to care and surgical quality contribute to a strategy for becoming a high-reliability organization

Presenters: Joelle Baehrend, MA, Director, IHI; Jennifer Lenoci-Edwards, RN, MPH, Executive Director, Patient Safety, IHI

Using Transparency to Drive Patient Safety

Using Transparency to Drive Patient Safety

The Lucian Leape Institute published a white paper entitled, “Shining a Light: Safer Healthcare through Transparency” in 2015. Transparency was identified as one of the five transforming concepts for improving health care. Attendees of this session will see how one academic medical center has systematically increased transparency over three years to improve patient safety. Specific structures and tools will be described and their implementation discussed. Participants will have the chance to share and hear from others about other effective uses of transparency in patient safety.

After this presentation, you will be able to:

  • Discuss multiple ways to increase transparency in organizations to improve patient safety
  • Understand one medical center’s program for strategically using transparency
  • Discuss three structures that could be implemented to improve the safety event review and systems improvement process

Presenters: Doug Salvador, MD, MPH, Vice President, Medical Affairs, Baystate Medical Center; Mary Beth Collins, RN, BSN, Performance Improvement Coordinator, Baystate Medical Center; Karen Johnson, RN, BSN, Director, Performance Improvement, Baystate Medical Center

Protecting Our Own: Frontline Violence Prevention

Protecting Our Own: Frontline Violence Prevention

Increasing reports of violence directed toward front-line staff led to: development of verbal de-escalation, defensive tactics, documentation tools, and guidelines to improve associate response to verbal aggression; early access to public safety; and reduction in associate injuries related to physical violence. Presenters will provide objectives, development strategy, an implementation plan (including costs), detailed training content, and pilot results.

After this presentation, you will be able to:

  • Describe national trends and financial and human costs of harm associated with violence toward health care personnel
  • Identify measurable outcomes for an associate violence prevention program
  • Develop a plan to implement associate violence prevention training at a health care organization

Presenters: Rachel Zastrow, RN, DNP, CPPS, Director of Patient Safety, Advocate Lutheran General Hospital; Delilah Mendez, Patient Safety Specialist, Advocate Lutheran General Hospital; Monika Bogun-Dzioban, RN, MSN, Clinical Manager, Cardiac Telemetry Unit

Direct Oral Anticoagulants: Best Safety Practices

Direct Oral Anticoagulants: Best Safety Practices

The review of nearly 150 safety events reported to Vizient’s patient safety organization (PSO) revealed process, system, and knowledge deficits that contribute to safety events for patients who have been prescribed the newer direct oral anticoagulants (DOACs). As the use of DOACs is increasing, the health care team has an obligation to reduce the risk of preventable harm. This session will discuss the safety improvement recommendations and interventions aggregated by the Vizient PSO Medication Safety Experts, a multidisciplinary panel from across the nation.

After this presentation, you will be able to:

  • Identify potential risk factors and breakdowns through transitions of care that are contributing factors of reported DOAC safety events
  • Implement leading practices at your organization to improve the reliability of accurate prescribing, and inpatient and outpatient management of DOACs
  • Identify ways to include patients and families in their DOAC safety plan

Presenters: Steve Meisel, PharmD, CPPS, Director, Patient Safety, Fairview Health Services; Jessica Schoenthal, RN, MSN, CPPS, PSO Collaborative Advisor, Vizient; Ellen Flynn, RN, MBA, JD, CPPS, Associate Vice President, Safety Programs, Vizient