UNIVERSITY OF ILLINOIS CHICAGO IDPH ADMINISTRATIVE PERINATAL CENTER

PATIENT SAFETY

WHEN ERRORS TURN DEADLY


Virtual Conference | Case Discussion

October 19, 2022 1200 - 1630 CST

OBJECTIVES:

  • Identify possible system related gaps in safety practice related to medication errors

  • Identify the need and data to support Care for the Caregiver Programs

  • Examine the influence of regulation on healthcare systems safety practices.

Target Audience:

RNs, Physicians, Advanced Practice Nurses

The criminal prosecution and conviction of a nurse for a medical error that resulted in a patient’s demise highlighted the fallibility of medical safeguards and the need to foster sustainable safety-promoting environments at an individual and organizational level.

Conference Agenda

1200 - 1215

UIC Administrative Perinatal Center

Overview & Intro

De-Ann Pillers, MD, PhD, FAAP

Co-Director, UIC-IDPH Perinatal Administrative Center, University of Illinois, Chicago

The University of Illinois at Chicago (UIC) clinical and administrative perinatal centers are located within the University of Illinois Hospital & Health Sciences System. This brings together academia, clinical research, and advanced clinical services in one location. UIC APC has had a continuous record of providing of exemplary professional education for our network hospitals and beyond.

De-Ann Pillers, MD, PhD, FAAP

1215 - 1245

Patient Safety & Medical Errors

James Barry, MD

  • Associate Professor of Pediatrics, University of Colorado School of Medicine

  • Medical Director of University of Colorado Hospital NICU

  • Chair University of Colorado Hospital Quality, Peer Review Committee

  • Chair University of Colorado Health Newborn System Clinical Oversight Group

  • Executive Committee Member of the SoNPM representing District 8 and of the Clinical Leaders Group of the SoNPM.


I have been a leader involved in quality and patient safety since 2007. As a medical director and hospital leader, I have been privileged to have a unique view of hospital and unit systems that support clinical care to promote better quality and safer healthcare. I am currently getting my MBA where I aim to be involved in innovative to further promote more effective care

James Barry, MD

1245 - 1305

Case Presentation - Vaught Case

Sherri Hill Mavrais, PhD, RN

Dr. Sherri Hill is an Assistant Clinical Professor and Assistant Program Director in the UIC Patient Safety Leadership program. Her healthcare leadership background includes over 25 years of operational experience and executive roles leading strategic projects designed to remain competitive in today’s complex healthcare environment. Her industry experience in a variety of healthcare settings includes quality management and improvement, patient experience, health information management, and care coordination. With a deep understanding and expertise in high reliability organizational models, Dr. Hill leads health system board governance and leadership teams to commit to zero patient harm, a fully functional culture of safety, and use of Robust Process Improvement methods. As the Associate Vice President at the third largest healthcare delivery system in Illinois, Dr. Hill brings real-world expertise to students’ educational experiences.


Sherri Hill Mavrais, PhD, RN


1305 - 1335

Just Culture

Jonathan Cohen, MD, MS, FASA

& Gerald Maloney, DO, MS

Jonathan Cohen, MD, MS, FASA, is an anesthesiologist at Moffitt Cancer Center in Tampa, Florida and an associate professor at the University of South Florida. He is board certified in both anesthesiology and critical care medicine and holds a Master of Science degree in Patient Safety Leadership from the University of Illinois. At Moffitt, he has been the patient safety officer of the anesthesiology department since 2012, the vice chair of the perioperative safety committee since 2017 and has been the recipient of Moffitt’s Excellence in Safety Award for two consecutive years. He has been an invited speaker on the topics of patient safety and naloxone administration at several national meetings, including the annual meetings of the American Society of Anesthesiology (ASA), the International Anesthesia Research Society (IARS) and the National Patient Safety Foundation (NPSF). Dr. Cohen is currently a member of the ASA Anesthesia Patient Safety Editorial Board and the ASA Committee on Patient Safety and Education.


Gerald Maloney, DO, MS, is board certified in emergency medicine and medical toxicology, and practices at the Cleveland VA Medical Center. A recent graduate of the Master of Science in Patient Safety Leadership program at UIC, Dr. Maloney is active in general patient safety and medication safety measures at UIC, and designed a pilot program on diagnostic error for medical students at Case Western Reserve University. He is most interested in the role of HIT in patient safety, especially AI as a tool to reduce medication and diagnostic errors.

Jonathan B. Cohen, MD, MS, FASA

Gerald Maloney, DO, MS

1335 - 1400 BREAK OUT #1

(2 ROOMS)

Room A

Error Science |Risk |Disclosure


Moderators:

Amanda Kuentsler, RN


Room B

Process Improvement


Moderators:

Kari Gali, DNP, APRN, PNP-BC

Amy Pham, DO

1400 - 1425 BREAK OUT #2

(2 ROOMS)


Room A

Process Improvement

Moderators:

Kari Gali, DNP, APRN, PNP-BC

Amy Pham, DO

Room B

Error Science |Risk |Disclosure

Moderators:

Amanda Kuentsler, RN


1425 - 1435 REPORT OUT

1435 - 1450 BREAK

1450 - 1515 BREAK OUT #3

(2 ROOMS)


Room A

Leadership





Moderators:

George Vukotich, PhD

Aarti Raghavan, MD, FAA, MS

Room B

The Health Care Regulatory Environment and How it Relates to Patient Safety



Moderators:

CJ Wolf, MD, M.Ed.

Lily Lou, MD, FAAP

1515 - 1545 BREAK OUT #4

(2 ROOMS)


Room A

The Health Care Regulatory Environment and How it Relates to Patient Safety



Moderators:

CJ Wolf, MD, M.Ed.

Lily Lou, MD, FAAP

Room B

Leadership





Moderators:

George Vukotich, PhD

Aarti Raghavan, MD, FAA, MS

1540-1550 REPORT OUT

1550 - 1620 Panel discussion - From above speakers

1620 - 1630 Wrap up & Evaluation