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October 15, 2015, 1:00 pm - 2:30 pm ET
Healthcare Accident Investigations – The Red Cover Report
and E.H.R. Safety Community of Practice
 Session Overview

TMIT is delighted to have John Nance, a world-class patient safety leader, author, and speaker, back for a second part of a two-part series. His review of healthcare cybercrime and patient safety earned one of our highest ratings, and this month he will address his concept of applying the NTSB best practices to healthcare. This approach was a formal recommendation of the IOM four years ago, and many feel that its time has come. He will use two famous airline accidents, and a number of healthcare accidents that have harmed both patients and caregivers, to illustrate the principles we can apply to healthcare. John is also a best-selling author of Charting the Course, which is a "how-to map" for those who want to create the ideal safe hospital. It may be found at http://www.whyhospitalsshouldfly.com/. John is also the co-author of a paper proposing an NTSB for healthcare entitled "An NTSB for health care – learning from innovation: Debate and innovate or capitulate," which may be found here.

A second presentation will address a new Community of Practice for E.H.R. Patient Safety, as requested by our audience. The presentation will address excellent new assets that participants can put to work immediately. Dr. Christopher Peabody, who will be on our reactor panel, will be introduced as one of the leaders of that community, which will be launched in the next few months.

Jennifer Dingman and Franck Guilloteau, two long-time patient safety advocates and leaders, will also be on the reactor panel.

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.     

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

 When:  October 15, 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.
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Learning Objectives – John Nance Presentation

Participants will learn:

  • Awareness: Participants will become aware of the power of an NTSB-like investigation of healthcare accidents and the harm to both patients and caregivers compared to a typical root cause analysis.
  • Accountability: Participants will understand the importance of transparency of accountability on the part of patient safety and risk leaders for addressing the multifactorial causes of preventable adverse events.
  • Ability: Participants will be provided with examples of the concepts, tools, and resources they may consider using by provision of the red cover report example.
  • Action: Participants will understand actions they may consider taking that are used in NTSB investigations.

Learning Objectives – E.H.R. Safety Issues

Participants will learn:

  • Awareness: Participants will be become aware of the assets from the Office of the National Coordinator for Health IT very recently made available to the nation, including reference articles that support them to help make E.H.R. systems safer.
  • Accountability: Participants will understand how their accountability for E.H.R. safety may evolve.
  • Ability: Participants will learn how to be better prepared to serve in E.H.R. patient safety by being involved in a community of practice.
  • Action: Participants will become aware of certain actions they may take to help make their electronic health records safer using the Emergency Department example.

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. TMIT is only providing nursing credit at this time.

To request a Participation Document, please click here.

 Session Speaker
John J. Nance, JD
Red Cover Report: What If We Had NTSB-like Reports for Healthcare Accidents?

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.
Read more...

 Introduction and Moderator
Charles R. Denham, MD
Welcome and An Introduction to the TMIT E.H.R. Community of Practice Initiative

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...
Read more...

 Patient Safety Advocate
Jennifer Dingman
Discussion and Reaction to Presentations AND The Voice of the 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...

 Reaction Panelists
Christopher R. Peabody, MD, MPH
Discussion and Reaction to Presentations

Christopher R. Peabody, MD, MPH, is an Assistant Clinical Professor, Department of Emergency Medicine, at the University of California, San Francisco. He has a strong commitment to public service and healthcare delivery to vulnerable populations. Dr. Peabody completed his residency at one of the busiest safety-net hospitals in the country, Los Angeles County Hospital and was the Chief Resident in Emergency Medicine at the University of Southern California.
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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.
Read more...

Related Resources
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  2. IOM (Institute of Medicine). Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC: The National Academies Press; 2012. Available at http://www.nap.edu/download.php?record_id=13269.  
  3. IOM (Institute of Medicine). Balogh EP, Miller BT, Ball JR, eds. Improving Diagnosis in Health Care: Resources for Patients, Families, and Health Care Professionals. Washington, DC: The National Academies Press; 2015 Sep 22. Available at http://www.nap.edu/download.php?record_id=21794.  
  4. [No authors listed.] Health Information Technology Patient Safety Action & Surveillance Plan. Washington, DC: The Office of the National Coordinator for Health Information Technology; 2013 Jul 2. Available at www.healthit.gov/sites/default/files/safety_plan_master.pdf.  
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  15. Menon S, Singh H, Meyer AN, et al. Electronic health record-related safety concerns: a cross-sectional survey. J Healthc Risk Manag 2014 Jul;34(1):14-26. Available at http://www.ncbi.nlm.nih.gov/pubmed/25070253.  
  16. Murphy DR, Laxmisan A, Reis BA, et al. Electronic health record-based triggers to detect potential delays in cancer diagnosis. BMJ Qual Saf 2014 Jan;23(1):8-16. Available at http://qualitysafety.bmj.com/content/23/1/8.full.pdf.  
  17. Murphy DR, Thomas EJ, Meyer AN, et al. Development and validation of electronic health record-based triggers to detect delays in follow-up of abnormal lung imaging findings. Radiology 2015 Oct;277(1):81-87. Epub 2015 May 11. Available at http://www.ncbi.nlm.nih.gov/pubmed/25961634.  
  18. ONC. SAFER Guides. HealthIT.gov website. No date. Available at http://www.healthit.gov/safer/.  
  19. Ratwani RM, Benda NC, Hettinger AZ, et al. Electronic health record vendor adherence to usability certification requirements and testing standards. JAMA 2015 Sep 8;314(10):1070-1. Available at http://jama.jamanetwork.com/article.aspx?articleid=2434673.  
  20. Ratwani RM, Fairbanks RJ, Hettinger AZ, et al. Electronic health record usability: analysis of the user-centered design processes of eleven electronic health record vendors. J Am Med Inform Assoc 2015 Jun 6. Available at http://www.ncbi.nlm.nih.gov/pubmed/26049532.  
  21. Singh H, Ash JS, Sittig DF. Safety Assurance Factors for Electronic Health Record Resilience (SAFER): study protocol. BMC Med Inform Decis Mak 2013 Apr 12;13:46. Available at http://www.biomedcentral.com/content/pdf/1472-6947-13-46.pdf.  
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  23. Sittig DF, Ash JS, Singh H. The SAFER guides: empowering organizations to improve the safety and effectiveness of electronic health records. Am J Manag Care 2014 May;20(5):418-23. Available at http://www.ajmc.com/journals/issue/2014/2014-vol20-n5/The-SAFER-Guides-Empowering-Organizations-to-Improve-the-Safety-and-Effectiveness-of-Electronic-Health-Records/.  
  24. Sittig DF, Classen DC, Singh H. Patient safety goals for the proposed Federal Health Information Technology Safety Center. J Am Med Inform Assoc 2015 Mar;22(2):472-8. Available at http://www.ncbi.nlm.nih.gov/pubmed/25332353.  
  25. Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Qual Saf Health Care 2010 Oct;19 Suppl 3:i68-74. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3120130/pdf/nihms297306.pdf.  
  26. Sittig DF, Singh H. Electronic health records and national patient-safety goals. N Engl J Med 2012 Nov 8;367(19):1854-60. Available at http://www.nejm.org/doi/pdf/10.1056/NEJMsb1205420.  
  27. Sittig D, Singh H. The Health IT Safety Center Roadmap: What's next? Health Affairs 2015 Jul 21. Available at http://healthaffairs.org/blog/2015/07/21/the-health-it-safety-center-roadmap-whats-next/.  
  28. Upadhyay DK, Sittig DF, Singh H. Ebola US Patient Zero: lessons on misdiagnosis and effective use of electronic health records. Available at http://www.degruyter.com/view/j/dx.ahead-of-print/dx-2014-0064/dx-2014-0064.xml.  
  29. 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.     
  30. 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.     
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  34. National Quality Forum. Safe Practice 13: Order Read-Back and Abbreviations. 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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