Day One April 29,2008
8:00 – 8:30 am
Opening/Welcome from Conference Chairs
Peter Angood, MD
Vice President and Chief Patient Safety Officer
The Joint Commission & Co-Director, Joint Commission International Center for Patient Safety (confirmed)
Lena M. Napolitano MD, FACS, FCCP, FCCM
Professor of Surgery
Division Chief, Acute Care Surgery Trauma, Burn, Critical Care, Emergency Surgery
Associate Chair of Surgery for Critical Care
Department of SurgeryDirector, Surgical Critical Care
University of Michigan Health System
Vice ChairCouncil of Surgical and Perioperative Safety(confirmed)
8:30 – 10:00 am
Keynote- The State and Direction of Perioperative Safety Culture and Safety…or If-Then
Work with Stephen Harden to see what would happen:
IF you created… a better environment for your physicians to practice medicine, THEN you would gain improved physician satisfaction
a better work environment for your nurses and staff, THEN you would gain improved employee satisfaction, less nurse turnover, lower replacement and “agency” costs fewer undetected and uncorrected errors by your care givers THEN you would gain improved patient satisfaction leading to improved market share and safer and better quality care for your patients and thus fewer malpractice claims
Stephen Harden
President, Lifewings Partners, LLC (confirmed)
10:00 – 10:30 am
Break
10:30 – 12:00 pm
Plenary – Communication with Perioperative Services: Culture of Communication
Donald Moorman, MD, FACS
Vice Chair, Clinical Affairs
Israel Beth Deaconess Hospital, Boston MA (confirmed)
12:00 – 1:00 pm
Lunch
Afternoon – Tracks
1:00 – 2:00 pm
Universal Protocol
The Pennsylvania Safety Reporting System : Correct Site Surgery
Turning Wrong Site Surgery into Correct Site Surgery depends on many factors and Dr Clarke will share the work and findings of the Pennsylvania Patient Safety Reporting System that seek to reduce wrong site surgery. Based on retrospective and contemporary comparisons of near-miss to actual events, their goal is to develop and implement a data collection tool for wrong site surgery events that addresses the salient points as well as effective guidelines to reduce this persistent problem.
John Clarke, MD
Clinical Director, Pennsylvania Safety Reporting System (confirmed)
Infection Control – Hot Topics in Perioperative Care Surgical Site Infections
Surgical site infections can be a serious sequelae of the more than 27 million surgical procedures performed in the United States each year and may be initiated during the pre-operative, intra-operative, or post -operative phases of treatment. Surgical site infections can increase a patient's hospital stay by 4 or more days affecting patient outcome as well as influencing treatment cost. Eliminating infections is a major goal for all those involved in perioperative services and requires a preventive mindset, ongoing vigilance and teamwork. Learn how the University of Chicago Hospitals has addressed the issue of surgical site infections as they share their efforts, successes and lessons learned.
Sylvia Garcia-Houchins, MBA, CIC
Director, Infection Control Program
University of Chicago Medical Center (confirmed)
Interdisciplinary Care
Disruptive Behavior
Disruptive behavior on the part of surgical staff has negative effect on the team. Team members themselves perceive disruptive behavior as contributing to adverse events, medical errors, patient safety/mortality, as well as impacting patient quality of care and patient satisfaction. The tool shared will guide you in identifying, assessing and reducing such behaviors.
Alan Rosenstein, MD, MBA
Vice President & Medical Director, VHA, Inc
Michelle O’Daniel, MHA, MSG Director, Member Relations
VHA, West Coast(confirmed)
2:05 – 3:05 pm
In Patient Setting
Patient Identification
Site Marking
Time Out
This presentation will focus on the findings from two national surveys. The first survey was an evaluation of the effect of the AORN Correct Site Surgery Tool Kit on implementation of the The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. The second survey was designed to identify the number of wrong site surgery incidents occurring during the six-year period from January 1, 2000 to July 31, 2006. Evidence based strategies to prevent wrong site surgery will be identified.
Deborah Farina Mulloy, PhD (c ) MSN, RN, CNOR
Center for Qualty & Safety
Massachusetts General Hospital Partners Health Care(confirmed)
Sterilization/Flash
This session will identify the practices recommended by the new CDC sterilization guidelines; review the recommendations for prevention of cross transmission from medical/surgical devices contaminated with prions and emerging pathogens (avian influenza, norovirus, C. difficile); and describe the surgical services role in ensuring appropriate reprocessing of reusable medical devices (e.g., surgical instruments, endoscopes, endocavitary probes.
William A. Rutala, Ph.D., MPH
Professor of Medicine
Director, Statewide Infection Control Program
UNC
"Creating a Culture of Mutual Respect: Successes and Challenges"
In 2004 the Maimonides Medical Center Medical Staff endorsed a “Code of Mutual Respect” that requires respectful behavior and attention paid to the causes of frustration that often lead to poor behavior. The Code is being imbedded in the MMC culture using these key components: nurse/physician leadership, mediated conversations, skills building, and the tracking of systems issues. Dr. Feldman will share the program components and report on the challenges of transforming a culture.
David Feldman, MD, MBA., CPE., FACS.
Vice-President, Perioperative Services
Vice-Chairman, Department of Surgery
Maimonides Medical Center Brooklyn NY(confirmed)
3:05-4:05 pm
Ambulatory Surgery
Patient Identification
Site Marking
Time Out
Clint Chain, RN, BSN
Director of Quality
United Surgical Partners International (confirmed)
Patient Safety and Processing/Reprocessing of Medical Devices
Devices are classified according to how they are reprocessed and repackaged and the answers to these five questions will be shared during this hour with Dr Dagi: Should single use components or devices be reused? What are the FDA requirements? May hospitals reprocess instruments and in doing so do hospitals assume the role of manufacturers? And, what must be done in order to avoid complications from reprocessing of disposable, partially disposable and reusable devices?
T. Forcht Dagi, MD, FACS, FCCM
Harvard/MIT Program in Health Sciences & TechnologyVice Chair, Committee on Perioperative Care
American College of Surgeons(confirmed)
Use of Surgical Clinical Pathways as a Method of Iinterdisciplinary Care and Outcomes Improvement
The concept of a team-based approach to surgery is critical in highly complex, multi-team surgical procedures. Clinical Pathways have been proven to improve the care of patients during their hospital course, resulting in better outcomes and shorter length of stay. This session will highlight how to apply the same principles to create Intraoperative Critical Pathways which enhance decision-making, increases team effectiveness, assess competency and improve resource management in the operating room.
Charlotte Gugliemli, RN, BSN, MSN CNOR
Education/Staff developmenmt
Beth Israel Deaconess Boston MA(confirmed)
Donald Moorman, MD, FACS
Vice Chair, Clinical Affairs
Israel Beth Deaconess Hospital, Boston MA (confirmed)
4:10 – 4:45 pm
Moderator Lead Panel Discussion
Day Two April 30, 2008
8:00 – 8:15 am
Update/Announcements
8:15 – 9:15 am
Sentinel Events in Perioperative Care – What Safety Lessons Have We Learned?
Among the most recent Sentinel Events statistics reported by The Joint Commission, wrong site surgery and op/post op complications remain at the top of the list claiming 13 % and nearly 12% respectively. Further down the list but still surgically related are retention of foreign bodies (2%), anesthesia (1.8%) and fires (1.5%). Lessons learned serve to develop and implement preventive approaches and Dr Leonard will take you through the safety lessons learned from sentinel events in perioperative are and share prevention strategies.
Michael Leonard, MD, Colorado Permanente
9:15 – 10:15 am
Apology and Disclosure for Surgical Misadventures
10:15 – 10:45
Break
10:45 – 11:45 am
Tracks
Misadventures in the OR Anesthesia Awareness: Is It Real?
The incidence and implications of unintended awareness during anesthesia are reviewed and the perspectives of patients and staff are explored. Relevant research into methods to reduce the incidence of awareness with recall is examined.
Kenneth Plitt CRNA, MBA
Emerald City Anesthesia A
AssociatesMill Creek, WA
Surgical Fires: Minimizing the Fire Triangle Connection
Fire, an inherent risk in the OR, poses a real hazard to patient and healthcare worker safe and thus, fire prevention and safety during surgical procedures is a continuing concern for all members of the patient care team. Although no centralized database exist on surgical fires, it is estimated that approximately 100 surgical fires occur each year in the United States, resulting in roughly 20 serious patient injuries, including one to two deaths annually. Fires occur when an ignition source, a fuel source and an oxidizer come together: the fire triangle. A multidisciplinary approach to developing policies and procedures to reduce fire risk and this presentation highlights how to implement a fire prevention program to reduce the risk of surgical fires within your Perioperative services division.
Paula Graling, RN, MSN, CNOR, CNS
Clinical Nurse Specialist, Perioperative Services
Inova Fairfax Hospital
NoThing Left Behind: Tools for the Prevention of Retained Surgical Items
In the last three years, multiple forces joined together to make hospital administrators and risk managers, surgeons and perioperative care nurses take action and address the persistent problem of retained surgical items (RSI). The surgical patient safety project “NoThing Left Behind” seeks to make RSI a true “never happen” event through implementation of an evidence-based, multi-stakeholder OR policy; refinement and dissemination of OR best practices and processes of care for surgeons, nurses and radiologists; and evaluation and application of new technological adjuncts to count and/or detect surgical items.
Verna C Gibbs, MD
Attending Surgeon, SF
VAMC, San Francisco CA
Professor of Surgery, UCSF, San Francisco, CA
Director, “NoThing Left Behind”
12:00-1:00 pm
Lunch
1:15 – 2:15 pm
Tracks
Medication Safety Issues
Medication Safety in the OR
The perioperative environment remains a high-risk area due to the complexity of the work and the rapid pace. Medication errors in the perioperative area can occur via omission, unauthorized or wrong drug, improper dose/quantity or wrong time. Through this presentation you will examine methods used to prevent errors and learn how to achieve and maintain medication safety in the OR by expanding the role of pharmacy department in the OR process.
Andrew Donnelly, Pharm D, MBA
Director of Pharmacy
Medical Center
University of Illinois, Chicago
Perioperative Patient Education Patient Literacy and Comprehension
Assessing patients’ literacy skills is an important step in being able to provide optimum care and has even greater implications when related to surgery with issues such as understanding procedures, providing informed consent and post operative care. Dr Wolf will highlight current methods to assess patient literacy and to ensure comprehension and share materials designed to accomplish both tasks.
Michael S Wolf, PhD, MPH
Assistant Professor, Center for Healthcare Studies, Northwestern University
Feinberg School of Medicine
Impaired Worker
An impaired worker poses a threat to self and others, and has serious repercussions in the surgical world. A personal shared story frames the problem and the steps toward recovery.
Thomas Krizick, MD, FACS
2:25-3:25 pm
Preparation and Dispensing in the OR
Options: 1. Pharmacy Services Or 2.Preparing and Labeling
Peggy Bickham, PharmD
Assistant Director, Specialty & Support Services
University of Illinois Medical Center at Chicago
Cultural Comprehension
Health care practitioners literally have to understand where their patients “are coming from” – the beliefs, values, and cultural mores and traditions that influence how healthcare information is shared and received. Surgical success ranging from pre-operative instructions through recovery and post-op depends on recognizing and understanding cultural differences and at the sametime, finding workable solutions that yield good surgical outcomes with respect for culture.
Suzanne Salimbene, PhD
PresidentInterface International
Airway Obstruction
P. Allan Klock, M.D.Vice-Chair for Clinical Affairs
Dept. Anesthesia and Critical Care
University of Chicago Hospitals
3:35-4:35 pm
Medication Reconciliation Across Perioperative Services
Medication reconciliation across perioperative services (pre-operative area, operating room, and post-anesthesia care unit) is a vital component of safe outcomes for surgical patients. Patient medication information is gleaned from multiple, and diverse sources and keys to successful management include coordination and good communication among all involved in order to achieve a comprehensive medication list upon which to make decisions. You will have the opportunity to learn how one system has succeeded in setting up a successful reconciliation process.
Tammy Williams, RN, MSN
Nursing Administration
University Medical Center
Lubbock, Texas
Patient/Family Post Op Teaching: Prescription for Success
Each patient defines their own concept of family and the patient and their family play a significant role as members of the health care team in making clinical decisions. .A family-centered approach depends upon the patient and family receiving the tools and the information needed post-operatively to support and enhance recovery, and this session will introduce you to and guide you through the University of Michigan Health System teaching method.
Denise O'Brien, MSN, APRN,BC, CPAN, CAPA, FAAN
Clinical Nurse Specialist, UMH
Postanesthesia Care Unit
University of Michigan Health System
Structuring for Perioperative Success: A Pediatric Model
At Children’s National Medical Center (CNMC), the Perioperative Leadership Team, concerned about issues of non-compliance with the Universal Protocol, prioritized compliance with the Universal Protocol as a major initiative. A compliance and tracking tool was developed which held all members of the operative team accountable for verifying compliance with the protocol. Iterative changes were needed to increase usability and functionality of this tool. The Center for Surgical Care at CNMC aligns all members of the perioperative team (surgeons, nursing, anesthesia) under one administrative and financial cost center. This approach aligns clinical and financial incentives, facilitates rapid iterative changes, and results indirect accountability
Kurt Newman, MD
Children’s National Medical Center(confirmed)
4:35 pm
Conference Close