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January 22, 2015, 1:00 pm - 2:30 pm ET
Safety Systems Failure, Innovation, and High Reliability
 Session Overview

Please join us for a webinar featuring Nancy Conrad, wife of the late astronaut Pete Conrad, the third man on the moon, who will share the experiences that led her to patient safety. On July 8, 1999, less than three weeks before the celebrations of the 30th anniversary of the first moon landing, Pete ran off the road and crashed while motorcycling with friends in Ojai, California. His injuries were first thought to be minor, but due to internal bleeding and a systems failure he died about six hours later. Although her husband's death brought Ms. Conrad to the quality movement, it is the movement leaders who asked her to stay. Ms. Conrad's compelling story serves to personalize the need for patients and their families to take responsibility for their care, as well as to highlight the need for systemic changes in the quality of care.

Ms. Conrad will also discuss the Spirit of Innovation Challenge, a novel competition created by the Conrad Foundation aimed at challenging students to combine education, innovation, and entrepreneurship to create products that address real-world challenges and global sustainability.

Ms. Conrad will be joined by Dr. Perry Bechtle, DO, Anesthesiologist at the Mayo Clinic, and Assistant Professor of Anesthesiology at the Mayo Clinic College of Medicine, who will share personal experience that underscores why high-reliability systems and their applications matter in the front-line healthcare setting. The session will close with Dr. Denham, who will address Adverse Drug Events and the Triple Threat of Anticoagulation, Diabetic Agent, and Opioid medications.

The three speakers will then be joined by a reactor panel of leaders and patient advocates. Polling results and answers will be shared with our National Research Test Bed.

Webinar Video and Downloads

Click here to download the Polling Data.     

Speaker Slide Sets:

Click here to download the combined speakers' slide set in PDF format – one (1) slide per page.     

Click here to download the combined speakers' slide set in PDF format – four (4) slides per page.     

To view the file, click the desired link (please note: the files may take several minutes to download). To save to your hard drive, right click on the link and choose "Save Target As." (In some browsers it might say "Save Link As.")

The slide set could take several minutes to download. The "four per page" slide set may download more efficiently.

Registration Information and CE Credit Information:
 Register:
Click here to register for this Webinar.

 When:  January 22, 2015 Time: 1:00 p.m.-2:30 p.m. ET
We are accepting questions now that relate to the session topics. Please e-mail any questions related to the specific session to webinars@safetyleaders.org with the session title in the e-mail message header.
  • Questions about the Webinar series?
    E-mail webinars@safetyleaders.org or call 512-473-2370 between 9:00 a.m. and 4:30 p.m. CT.
  • Need technical assistance with registration? Call 512-457-7605 between 9:00 a.m. and 4:30 p.m. CT.
Learning Objectives

Participants will:

  • Gain new awareness of the current gaps and focus relating to the three medications that result in the majority of adverse drug events (ADEs). These ADEs include the Triple Threat of Anticoagulation, Diabetic Agent, and Opioid medications.
  • Understand through the review of two case studies how systems failures, and high-reliability systems applied in the correct manner, in the front-line healthcare setting can result in two very different outcomes.
  • Learn how story-telling can provide a strong platform to illustrate impact and to educate leadership and all caregivers within an organization.
  • Recognize certain actions that organizations can take to increase reliability and reduce systems failure, and how those approaches can be applied to ADEs.

CE Participation Documentation

Texas Medical Institute of Technology, approved by the California Board of Registered Nursing, Provider Number 15996, will be issuing 1.5 contact hours for this webinar.

To request a Participation Document, please click here.

 Session Speakers
Nancy Conrad
Systems Failure and the Spirit of Innovation

Nancy Conrad created the Conrad Foundation in 2008 to energize and engage students in science and technology through unique entrepreneurial opportunities. The organization's flagship program, the Spirit of Innovation Challenge, is a global competition challenging students to combine education, innovation, and entrepreneurship to create products that address real-world challenges and global sustainability.
Read more...

Perry S. Bechtle, DO
Why Reliability Matters

Perry S. Bechtle, DO, is a neuroanesthesiologist at Mayo Clinic in Florida and served as the Division Chairman of Neuroanesthesiology from 1997 to 2010. He also serves as the Patient Safety Officer and quality leader within the Department of Anesthesiology, and is a Mayo Quality Fellow and the Medical Director of the Interventional MRI (IMRIS) neurosurgical suite.
Read more...

Charles R. Denham, MD
Welcome and New Focus on Old Problems: ADEs – The Triple Threat: Anticoagulation, Diabetic Agents, and Opioids

During Dr. Denham's business development career spanning 30 years, he and his organizations have served hundreds of innovation teams. While in practice as a radiation oncologist, he taught biomedical engineering and product development. He has taught innovation adoption, technology transfer, and commercialization in both academia and industry. He has been an adjunct Professor of Health Services Engineering at the...
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 Reaction Panelist
Franck Guilloteau
Discussion and Reaction to Presentations

During the past 20 years with HCC Corporation, Franck Guilloteau has led multiple projects, spanning industry segments from aerospace and consumer products to software and fitness. As Chief Technology Officer, Mr. Guilloteau takes the lead role in developing Software as a Service (SaaS) offerings and knowledge management systems used by HCC's global partners, while keeping HCC on the leading edge of technological advancements in multimedia, IT, e-commerce, and product development.
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 Patient Safety Advocate
Jennifer Dingman
Discussion and Reaction to Presentations AND The Voice of Patient and Family

Jennifer Dingman realized, after her mother's death in 1995 due to errors in medical diagnoses and treatment, that there is little to no help available for patients and their families in similar situations. This life-changing experience left her feeling vulnerable, and she decided to dedicate her life to help prevent medical tragedies from happening to others.
Read more...

Related Resources
  1. TremorX Video. To open the video,click here.
  2. Dugan RE, Gabriel KJ. "Special Forces" innovation: how DARPA attacks problems. Harvard Business Review 2013 October. Available at https://hbr.org/2013/10/special-forces-innovation-how-darpa-attacks-problems/ar/. Last accessed January 20, 2015.
  3. Conrad Spirit of Innovation Challenge website: http://www.conradchallenge.org/
  4. National Quality Forum. Safe Practice 1: Culture of Safety Leadership Structures and Systems. IN: Safe Practices for Better Healthcare – 2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010. Available at http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx.     
  5. National Quality Forum. Safe Practice 2: Culture Measurement, Feedback, and Intervention. IN: Safe Practices for Better Healthcare – 2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010. Available at http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx.     
  6. National Quality Forum. Safe Practice 3: Teamwork Training and Skill Building. IN: Safe Practices for Better Healthcare – 2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010. Available at http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx.     
  7. National Quality Forum. Safe Practice 4: Improving Patient Safety by Matching Healthcare Needs with Service Delivery Capability. IN: Safe Practices for Better Healthcare – 2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010. Available at http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx.     
  8. National Quality Forum. Safe Practice 5: Improving Patient Safety by Facilitating Information Transfer and Clear Communication. IN: Safe Practices for Better Healthcare – 2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010. Available at http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx.     
  9. National Quality Forum. Chapter 9: Opportunities for Patient and Family Involvement. IN: Safe Practices for Better Healthcare – 2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010. Available at http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx.     
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