What Will You Learn in the Patient Safety Best Practice Track at the Summit?
Since 1994, System Improvements has included information about improving Patient Safety in the Summit. This year we have a whole best Practices Track dedicated to improving patient safety and a Keynote Speaker talking about a fatal sentinel event.
Let’s start by telling you about Dr,. Carol Gunn, one of our Keynote Speakers. She is a medical doctor who was trained to use the TapRooT® Root Cause Analysis System before she became a doctor. While she was a doctor, her sister died in a hospital from “complications.” It turns out that those complications were a result of a medical error. She will tell the story of her sisters death and what can be learned when root cause analysis is used properly and what happens when sentinel events are covered up.
Now let’s look at what’s covered in the Patient Safety Best Practices Track:
Improving Patient Safety – Gaining a Win from a Loss (Michel Lindsay): Michele will share the evolution and success of their system for managing patient safety incidents and the expanded role of the Quality of Care Committee (QCC) on its journey to a high reliability organization at Southlake Regional Health Centre. A serious incident can have devastating outcomes to patients, their families, and to the caregivers involved. Even errors that result in no or mild harm to the patient can be devastating and career changing for staff and physicians. We have created structures and supports for immediate and long term organizational learning and improvements from incidents while maintaining a culture of care. Learn how the process QCC role has assisted in removing the shame and blame from an incident and turned it into a powerful lever for caring, sharing and repairing. Michele will describe the investigation processes using illustrations and case studies to describe how patient safety, learning, performance and culture has been positively impacted by their approach. The presentation includes the input from the COO & SVP Operations, Director of Surgery, the Director of Risk, the Manager of Risk, the Manager of a Cardiac Clinical Program, a Physician and the Quality Specialist.
Improving Sentinel Event Investigations (Ken Turnbull): Ken is one of the authors of the new book, Improving Patient safety with TapRooT® Root Cause Analysis (to be released somewhere around the time of the Summit) and will share some of the new ideas presented in the book.
Using Wearables to Minimize Daily Human Errors (Kevin McManus): Look at how wearables are being used both now and in the future to help prevent errors and identify problems more effectively.
Deep Dive Into the Procedures Basic Cause Category (Ralph Brickey): Procedures (checlists) are almost a new concept being used to improve patient safety. Learn from the TapRooT® procedures best practices including: Learn: the philosophy and practice of using procedures; different types of procedures and how they are addressed in the TapRooT® Root Cause Dictionary and the Root Cause Tree®; and two human performance tools to aid in proper procedure use
Influencing Change (Jonathon Kennedy): Change is what improving performance is all about. What is the best way to influence change? Hear what Jonathan Kennedy has to say.
Top 7 Secrets of a Great Investigation Interview (Barb Carr): Take your interviewing skills to the next level and collect better quality and quantity of information from your investigative interviews by harnessing the power of the seven secrets.
TapRooT® Users Share Best Practices (Linda Unger): Share best practices about root cause analysis, investigations, and performance improvement with industry leaders from around the world.
Performance Improvement Gap Analysis (Linda Unger): Evaluate where you are and where you want to go and how you will apply what you have learned at the Summit to improve performance at your facility. The goal of this session is to go back to work with a plan to improve patient safety.
That an impressive list of breakout sessions.