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July 17, 2014, 1:00 pm - 2:30 pm ET
John Nance: Medical Accidents and the RED Cover Report

 Session Overview

The debate is growing to use an NTSB approach to incident investigation and compare it to the root cause analysis traditionally used. A “Red Cover Report” would be the output of an NTSB-like investigation of medical accidents similar to the “Blue Cover Report” reviewed by pilots for common and preventable accidents. This approach to healthcare could save lives, save money, and bring value to communities. Join John Nance, a leader and a pioneer in both aviation and medical safety and quality, and for the past 18 years a familiar face as the Aviation Analyst for ABC World News and Good Morning America, for a discussion of this opportunity and a call to action of healthcare suppliers, providers, and purchasers. His concept could reinvigorate their adoption of aviation best practices as the market transitions from a fragmented, provider-volume-centered to an integrated, patient-value-centered world. Hear about how this work could be applied to Care of the Caregiver after an event occurs, and how and why patients and families should be included in such investigations.

Following the presentations, a panel of experts will share their reactions to the presentation and answer questions from the webinar participants.
Webinar Video and Downloads

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Related Resources:
U.S. Congress. Senate. Subcommittee on Primary Health and Aging. 2014. More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety. 113th Congress, 2nd sess., 17 Jul. http://www.c-span.org/video/?320495-1/hearing-patient-safety&live (July 17, 2014).  
"An unflinching look at medical errors promotes patient-centered design."  
Ford D. Case in Point 2013 Dec;11(12).
"An NTSB for health care: learning from innovation: debate and innovate or capitulate."  
Denham CR, Sullenberger CB 3rd, Quaid DW, Nance JJ. J Patient Saf 2012 Mar;8(1):3-14.
"Disclosure through our eyes."  
Sheridan S, Conrad N, King S, Dingman J, Denham CR. J Patient Saf 2008 Mar;4(1):18-26.
National Quality Forum. "Safe Practice 8: Care of the caregiver." IN: Safe Practices for Better Healthcare – 2010 Update: A Consensus Report.  
Washington, DC: National Quality Forum; 2010.
Registration Information and CE Credit Information:
Click here to register for this Webinar.

 When:  July 17, 2014 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.
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Learning Objectives

Participants will:

  • learn about gaps that exist in current healthcare event investigation that could be closed with aviation best practices.
  • be able to communicate the value of learning from publicized reports of preventable accidents.
  • be able to introduce the concepts of Care of the Caregiver as they relate to post-event investigations of medical accidents.
  • understand the rationale for including patients and families in post-event investigations.

CE Participation Documentation

TMIT is not offering Continuing Education for this Webinar; however, a participation certificate will be made available upon request.

To request the Participation Document, please click here.

 Session Speakers and Reactors
John J. Nance, JD
Medical Accidents and the RED Cover Report

One of the key thought leaders to emerge in American healthcare in the past decade, John J. Nance brings a rich and varied professional background to the task of helping doctors, administrators, boards, and front-line staff alike survive and prosper during the most profoundly challenging upheaval in the history of modern medicine. Having helped pioneer the renaissance in patient safety as one of the founders of the National Patient Safety Foundation in 1997, his efforts (and healthcare publications) are dedicated to reforming American healthcare from a reactive cottage industry to an effective and safe system of prevention and wellness.

Becky Martins
Discussion and Reaction to Presentation

Becky Martins' advocacy spirit derives from the days when she was driving a family member 150 miles round-trip, three days a week, to dialysis treatments. She spent countless hours at the unit visiting with patients and their families. It was through their stories that she learned of the many challenges faced by patients living with chronic illness. It was by their example that she learned of the resilience of the human spirit to face health and health-related challenges head-on.

Jennifer Dingman
Discussion and Reaction to Presentation

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.

Mary E. Foley, RN, PhD
Discussion and Reaction to Presentation

Mary E. Foley, RN, PhD, is the Director in the Center for Nursing Research and Innovation at the University of California, San Francisco (UCSF). She has worked with the Center as Associate Director since 2004 in partnership with three Bay Area academic medical centers. Mary has worked with the Collaborative Alliance for Nursing Outcomes (CALNOC) since 2004, and in 2009 was appointed Director, Education Services for CALNOC.

 Patient Safety Advocate
Dan Ford, MBA
The Voice of Patient and Family and Discussion and Reaction to Presentation

Dan Ford, MBA, is a recently retired Vice President of Furst Group, a healthcare executive search firm; a patient advocate; a former member of NQF's Patient Safety Committee; and a former member of patient safety, quality, patient- and family-centered care committees of AzHHA, CHN and APIPS in Arizona, and CHP, IHI, and The Joint Commission nationally.

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