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Best Practices in Medication Safety: Leading a Meaningful Event Investigation
PRESENTER(S):
Dr. Jorge Carrillo, PharmD, MS, BCPS, Director, Medication Safety, U.S. Army Medical Command
Dr. Lynn Eschenbacher, PharmD, MBA, Assistant Director Clinical Services, WakeMed Health & Hospitals
Ms. Anthea Francis, RPh, Director, Section of Inpatient Care Practitioners, American Society of Health-System Pharmacists
James Hoffman,
PharmD, MS, Medication Outcomes and Safety Officer,
St. Jude Children's Research Hospital
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James M. Hoffman, Pharm.D., M.S., BCPS, is Medication Outcomes and Safety Officer and Associate Member in Pharmaceutical Sciences at St. Jude Childrens Research Hospital in Memphis, Tennessee. At St. Jude, he leads medication use safety efforts across the hospital and conducts research focused on patient safety event detection, patient safety culture, and clinical decision support. Hoffman has been involved in a variety of patient safety and quality improvement efforts at St. Jude including development and implementation of the hospitals electronic event reporting system (EERS), patient safety culture assessment and improvement, and refinement of clinical decision support systems.
Dr. Hoffman received both his Bachelor of Science and Doctor of Pharmacy degrees from the Philadelphia College of Pharmacy. In addition, he received a Masters of Science degree in pharmacy administration from the University of Wisconsin-Madison. He also completed a residency in pharmacy administration and a fellowship in outcomes research at the University of Wisconsin Hospital and Clinics. Dr. Hoffman is a Board Certified Pharmacotherapy Specialist. He is also an Associate Professor at the University of Tennessee Health Science Center College of Pharmacy.
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Dr. Constance Hogrefe, PharmD, Pharmacy Director, Lee Memorial Health System
Patricia Kienle,
MPA, Director, Accreditation and Medication Safety,
Cardinal Health Pharmacy Solutions
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Patricia Kienle is the Director of Accreditation and Medication Safety for Cardinal Health Pharmacy Solutions.
She received her pharmacy degree from the Philadelphia College of Pharmacy and Science, a Masters in Public Administration from Marywood University in Scranton, Pennsylvania, completed an Executive Fellowship in Patient Safety from Virginia Commonwealth University, and is an Adjunct Associate Professor at Wilkes University.
She has served on the Board of Directors of ASHP and as President of the Pennsylvania Society. She is a Fellow of ASHP, named Pharmacist of the Year by PSHP, and a recipient of the Distinguished Achievement Award in Hospital and Institutional Practice from the APhA Academy of Pharmacy Practice and Management. She has served on the Pharmacotherapy Specialty Council of the Board of Pharmaceutical Specialties, as the pharmacist member of the Hospital Professional and Technical Advisory Committee of the Joint Commission, and on the Board of Governors of the National Patient Safety Foundation. She is a current member of the USP Expert Committee on Compounding.
Patti is the author of Compounding Sterile Preparations: ASHPs Visual Guide to Chapter <797> video and Companion Guide and co-author of Assuring Continuous Compliance with Joint Commission Standards: A Pharmacy Guide. She edited Understanding JCAHO Requirements for Hospital Pharmacies.
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Natasha Nicol,
PharmD, Director, Medication Safety,
Cardinal Health
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Natasha Nicol is the Director of Medication Safety for Cardinal Health Pharmacy Services.
She received her doctorate of pharmacy degree from the University of Maryland School of Pharmacy. She is faculty for the Institute for Healthcare Communication and adjunct professor for the South Carolina and Presbyterian Colleges of Pharmacy.
She is a Champion for the World Health Organizations World Alliance for Patient Safety, and a certified Just Culture trainer. She is a Fellow of the American Society of Health-System Pharmacists and a Delegate, served on the Council on Education and Workforce Development, and is program co-chair for the medication safety track for the Summer 2012 ASHP meeting. She was a nominee for the Lewis W. Blackman Patient Safety Champion Award through the South Carolina Hospital Association. She was Regional Director and Past President of the South Carolina Society of Health-System Pharmacists. She was recognized for her work as Director of Pharmacy at McLeod Health with the ASHP Award for Excellence in Medication-Use Safety and was named Pharmacist of the Year by SCSHP, and was awarded the Mentor Award. She was awarded the Customer Service Award by Cardinal Health for her work with the Bermuda Hospitals Board.
She is a frequent presenter to professional groups, primarily focusing on medication safety as it relates to culture, use of technology and development of processes.
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Dr. Jennifer Robertson, PharmD, BCPS, Medication Use Policy Coordinator, St. Jude Children's Research Hospital
Ms. Deborah Saine, MS, RPh, Medication Safety Manager, Winchester Medical Center
Kelly Saran,
MS, RN, CPHRM, Administrative Healthcare Risk Manager,
University of Michigan Health System, Risk Management
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Kelly Saran is a senior risk manager and adjunct lecturer at the University of Michigan Health Sysem. She has over 20 years of healthcare experience and is a frequent invited speaker for disclosure, transparency and patient safety. Ms. Saran's research interests include failure to rescue, opioid-induced respiratory depression, and team communication.
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Deborah Wagner,
RPh, PharmD, Associate Professor Pharmacy/Anesthesiology,
University of Michigan Hospitals and Health System
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Deborah Wagner, PharmD is a clinical associate professor for the University of Michigan College of Pharmacy a clinical associate professor for the Department of Anesthesiology in the School of Medicine. After receiving her PharmD degree from the University of Michigan College of Pharmacy, Dr. Wagner was involved with home-care delivery, nursing home services, cardiology and critical care, operating room pharmacy services and outpatient pharmacy management. She is also the current pediatric safety coordinator for the health care system. She was a finalist for the 2011 Award for Excellence in Medication Safety at the University of Michigan Hospitals and Health System.
At the University of Michigan, Dr. Wagner is currently responsible for Operating Room pharmacy practice in the areas of pediatric and obstetric anesthesia and coordination of clinical services provided by 3 satellite OR pharmacys. Dr. Wagner precepts PharmD students and residents, teaches for the College of Pharmacy, School of Medicine, and Graduate Nurse Practitioner program at the University, She actively participates in the development of clinical research studies within the Department of Anesthesiology. Dr. Wagner provides pain management consultation for the pediatric acute pain service and is a member of the hospitals pain and sedation steering committee. She is a current member of the technical support committees and QA committee within the Department of Anesthesiology.
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Often event investigations don’t get at the heart of the problems. Leading an event investigation looks and feels different when guided with an open, fair, and learning perspective. Participants will work with experts to develop new strategies to effectively conduct an event investigation and equip others to be involved in the process.
