Patient Safety

​​​​​​​​​​​​​​Patient Safety Track Sessions Topics​​​​​

See how your peers surpassed challenges using improvement methods. Choose from 175+ sessions to attend, organized through 10 topics that are vital to the improvement of care.

​The Patient Safety topic track is dedicated to reducing harm and preventing mortality across the continuum of care.


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Conference Sessions
Dece​m​ber 10–11​

Safety First: Reducing Serious Safety Events with High Reliability
A14, B14
Five years ago, Hartford HealthCare aimed to advance safety across its system by adopting a model of high reliability to decrease the incidence of patient harm. With leaders on board, the organization has woven high reliability into its operational model and data structures, including tracking harm and serious safety events through dashboards and more than 40 clinical counsels. As a result, Hartford HealthCare has sustained a 70 percent reduction in Serious Safety Events for nearly two years. Presenters will share the best practices to begin and sustain a high-reliability journey, including barriers and how to overcome them. They will discuss how to spread the principles of a high-reliability organization across the continuum of care.
Our Oxygen Mask Comes First: Workforce Safety
A21, B21​
Each day, hundreds of healthcare workers are injured on the job. In 2017, over 224,000 US hospital employees suffered work-related injuries and illnesses over twice the rate for private industry as a whole. Armed with data, stories, and a commitment to improve, 19 health care organizations joined together over the last year to meaningfully and measurably address workforce safety within their organizations.

The session will be a combination of sharing best practices from leading organizations, describing multi-organization learning networks and engaging audience in sharing best practices. The session is intended to give participants specific actionable steps to help their organization accelerate improvements in workforce safety. Specific measurable outcomes including nationally standard metrics established by the Occupational Safety and Health Administration (OSHA).
Getting the Right Diagnosis: Building Cultural Awareness
A24, B24
Diagnostic errors take a toll on patients, families, and providers. We developed an educational video to help providers understand how diagnostic errors occur and avoid errors through improved decision-making, collaboration with patients and teammates, and systems that support timely, accurate, and effectively communicated diagnoses.
Knowledge checks monitor performance and viewers feedback is gathered for continuous improvement. Other complementary initiatives include guides to enhance patient-clinician partnering, online practice of diagnostic skills, and clinical reasoning support systems.

Health Systems Are Merging: What Could Go Wrong?
During health system consolidation, risks to patients arise when clinicians practice in new settings or with new patient populations without sufficient planning. We developed the System Expansion Toolkit to support clinical planning prior to affiliation. It provides guidance on addressing potential safety risks, including differences in infrastructure, responsibilities, and culture, as well as a checklist for establishing council to manage identified risks. Attendees from any discipline will learn about prospective planning and post-merger risk reduction.
Just Culture: The Critical Paradigm Shift
​Just Culture is not a buzzword; it is a paradigm shift. Leaders in High Reliability Organizations use a just approach, creating an environment where staff freely voice concerns. Through the power of stories, we will apply Just Culture to real cases in today's health care environment. This session benefits executives and safety leaders searching for an innovative, successful approach to cultural change and anyone who wants a deeper understanding of Just Culture. We will share our roadmap and lessons learned through implementation at a large, multicenter medical system. Our novel framework has successfully trained >1,300 diverse leaders; 98 percent of them find it useful for their daily work.
A Novel Ambulatory Quality & Safety Infrastructure
Nationally, increasingly complex care and procedures are moving to an ambulatory setting. With these changes, it becomes increasingly important to move from the old model of hospital-based quality programs to system-wide infrastructure to ensure high quality care. We will discuss our experience developing and integrating a system-wide ambulatory quality, safety, and risk infrastructure, including  identifying and mitigating major ambulatory quality and safety hazards, improving outcomes, increasing quality metric scores, and strengthening safety initiative coordination.
Measuring Harm: Tools for Today, Tips for Tomorrow
D06, E06​
This session will discuss our study that assesses the frequency and types of harm in a representative sample of Massachusetts institutions today, covering both inpatients and outpatients. We will share an approach that institutions can use operationally to assess the frequency of harm in an ongoing way, which leverages new harm detection approaches and electronic health records. We will share case examples from our experience developing the framework and tools, as well as advances in methods of assessing harm since the Harvard Medical Practice Study (HMPS) transformed medicine's view of patient safety 30 years ago. We will review the use of consensus panels and electronic surveys to compare different methods of safety measurement, the development of an electronic data collection tool for chart review, and the use of an application for real-time adverse event surveillance with electronic health record data.
1 Year after Diabetes Deprescribing: Our Journey
D09, E09​
For clinicians and quality leaders, we provide a framework for deprescribing diabetes medications in older patients. This framework includes patient case studies and a toolkit for potentially difficult deprescribing conversations. We will share 1-year clinical outcomes of our program, which was associated with a potential survival benefit and a reduction in hypoglycemia while maintaining glucose control. In this session, we will discuss our journey to creating a dedicated deprescribing service with pharmacists and physicians.
Leading Large-Scale Change to Reduce Stillbirth
D12, E12​
Scotland is a small country, with 55,000 births per year, so 274 stillbirths in one year which was the case in 2012 ”was a lot in this context. In response, the Chief medical Officer for Scottish Government gave the Maternity and Children's Quality improvement Collaborative (MCQIC) this aim: Reduce stillbirth by 15 percent by 2015. Using approaches that will be discussed in this session, such as building improvement capacity in the system and focusing on a few to impact many, MCQIC contributed to a 23 percent reduction in stillbirth from 2014, surpassing the goal. Data is submitted to the MCQIC team via run charts where it is aggregated and analyzed. Boards are supported to understand their own data.
Key Factors to Creating a Culture of Safety
D21, E21​
There are proven interventions used to reduce medication-related harm and a growing body of knowledge that supports the application of these changes to produce desired outcomes. However, there are also system-level bottlenecks that prevent the copy and paste approach to implementing interventions from one setting to another.IHI's Africa Hospital Patient Safety Initiative has approached this problem by leveraging several layers of stakeholder engagement and strategically selected interventions to adapt proven frameworks in three countries: Ethiopia, Ghana, and South Africa. Teams were developed at all levels of the system to support implementation, and technology was tested to facilitate real-time coaching and feedback. Additionally, dosing models were tested in each country to identify effective and efficient capability building interventions.
Violence Has No Home in Health Care
D35, E35​

Physical and verbal violence toward health care workers has no place in the healing environment of the hospital; yet, according to the Occupational Safety and Health Administration (OSHA), approximately 75 percent of nearly 25,000 workplace assaults reported annually occur in health care and social service settings.Participants in this session will learn how to build a comprehensive program to decrease workplace violence, applying strategies that will protect their workforce and the community and developing a safety roadmap to enact best practices and innovations. Participants will explore the Connecticut hospital's Safer Hospitals Initiative, which keeps health care organizations safer by stopping violence before it begins. The initiative has identified strategies to create a culture of safety that highlight the principles of high reliability and represent a multifaceted approach for successfully combating violence at all levels of an organization.


​​Pre-Conference Workshops & Excursions
Dece​m​ber 8–9​

Sunday Half-Day Workshop
Sepsis Vigilance: It Takes a Team!
Physician and clinical leaders from Inova Health System recognized a significant opportunity to save lives and improve care in a system that has more than 4000 patients with sepsis annually.

Through this interactive session, you will learn how Inova clinical leaders used improvement science to impact sepsis mortality through early identification of clinical deterioration using early warning score tools and rapid intervention by a multidisciplinary team.

Sunday Half-Day Workshop
Achieving Safety II via Resilience Engineering
Methods, Tools and Frameworks: The intrinsic ability of the healthcare system to adjust its functioning prior to, during, or following changes and disturbances so that it can sustain required operations under both expected and unexpected conditions is resilient behavior fostering Safety II.
This Workshop will focus on the successful transition of Safety II from theoretical constructs to executing Resilience Engineering in a healthcare environment. The audience should be individuals with an understanding of QI methodology and high reliability principles.
Sunday Half-Day Workshop
Communication Framework to Drive Care Improvement​
Patient communication impairment is associated with preventable adverse events and patient and family distress. The Study of Patient-nurse Effectiveness with Assisted Communication Strategies framework supports communication with patients who are unable to speak. We will present the assessment pathway, best practices with tools, an electronic tablet communication application, and an implementation guide. Nurses, physicians, respiratory and rehabilitation therapists, patient advocates, and patient experience coordinators will benefit from case examples, demonstrations, and hands-on practice.
Monday Excursion 
Universal Orlando®: Safety and Reliability​
Go backstage at Universal Orlando® and learn how the stunt team ensures the safety of staff and visitors during high-risk stunts. Learn how the team addresses reliability during hand-offs and staffing changes and how it handles unexpected events. Hear directly from actors and see stunts demonstrated backstage and performed live.
Monday Excursion
Orlando Health System: Delivering Great Care with High Reliability​
Get a behind-the-scenes look at how Orlando Health System has fostered the deep engagement of its clinicians, staff, and patients through a focus on teamwork and results. Participants will visit Orlando Regional Medical Center, a Level 1 trauma center, and Arnold Palmer Medical Center, which includes one of the nation’s largest neonatal intensive care units. Learn how Orlando Health's quality structure helped providers deal with the events of the Pulse Nightclub tragedy.
Monday Half-Day Workshop
A Healthcare-Acquired Condition: Workforce Harm​
The health care workforce experiences high rates of physical and psychological harm, despite adverse consequences for productivity, turnover, morale, and patient outcomes.
This Workshop will introduce a comprehensive, proactive approach, including leadership, hazard identification, risk management, and performance measurement. Faculty will share tools, measures, and lessons learned from health care systems with success in improving workforce safety.
Monday Half-Day Workshop
Doing Diagnostic Error Work: What and How​
Every 9 minutes, someone dies due to a wrong or delayed medical diagnosis. Hear how one health system is using a change package, Improving Diagnosis in Medicine, as a framework for organizational change.
Presenters will share tools, implementation strategies, and examples of learning from diagnostic error, creating reliable diagnostic processes, engaging patients and families, improving cognitive performance, and using teaming for accurate diagnosis. Small group exercises will support plans for change at your home institution.
Monday Full-Day Workshop
Nobody Puts Safety in a Corner: How Culture & Systems Dance Together to Improve Safety​
The Framework for Safe, Reliable and Effective Care describes the interdependencies of culture, systems, leadership, patient partnership and staff engagement and is being used globally by individuals, teams, organizations and systems in service of improved outcomes for patients.
In this Workshop, faculty will describe the Framework and the associated tools including a diagnostic tool that participants can apply to their own work settings. Participants will hear case study examples from organizations using this Framework in practice.
Monday Half-Day Workshop
Successful Practices to Optimize Root Cause Analyses and Actions (RCA2)​​​
This session will explore Root Cause Analyses and Actions (RCA2) through the lens of an organization that has implemented the process within their own system.
This Workshop is intended for anyone who may lead or participate in event analysis and will focus on application of the recommendations and tools presented in RCA2 framework. Participants will walk away with a clear understanding of the Root Cause Analyses and Actions process and practical tools to improve their organizations RCA2.
Monday Half-Day Workshop
Safety at Every Level: A Cultural Transformation
Transforming a complex organization's culture requires a strategic approach. This session will detail our safety journey as Children's National embarked on a cultural transformation to eliminate preventable harm. Between 2014 and 2017, the number of safety event report totals doubled to more than 10,000 submitted annually. Safety culture measurement tools demonstrated positive perceptions of safety improved by 10 percent. Most significantly, the hospital's serious safety event rate decreased by 93 percent. This reduction constitutes the lowest rate in the hospital's history and improvement beyond many industry benchmarks.
Monday Half-Day Workshop
Improving Safety with Routinely Collected Data
Critical gaps exist in the data that enables organisations to identify current and emerging risks to patient safety. Safety failures continue to occur in health services worldwide. In order to combat this, we need to rethink how safety risks are identified. In this session we explore how, with data organisations already collect, risks to patient safety can be identified and care improvements can be directed.
This session will deliver a framework for identifying and analysing non-traditional patient safety data to drive healthcare improvement. The framework encompasses such data as patient feedback, medico-legal claims, sentinel events, reports to government clinical councils, practitioner regulator notifications, care volume, and more to identify and address current and emerging safety risks.