2012 Midyear Clinical Meeting
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From Drug Shortage to Order Entry Error to Device Failure: Managing a TPN Event in a Large Health System
Track:
Education Sessions (CE)
Program Code: 284-L05
Date: Wednesday, December 5, 2012
Time: 8:00 AM to 9:45 AM EST
Location:
South Seas D, Level 3, South Convention Center
PRESENTER(S):
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Michael Cohen,
RPh, MS, ScD (hon), President,
Institute for Safe Medication Practices
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Michael R. Cohen, RPh, MS, ScD (hon.), DPS (hon.), is president of The Institute for Safe Medication Practices, a non-profit healthcare organization that specializes in understanding the causes of medication errors and providing error-reduction strategies to the healthcare community, policy makers, and the public. He is editor of the textbook, Medication Errors (2007 American Pharmaceutical Association) and serves as co-editor of the ISMP Medication Safety Alert! publications that reach over 2 million health professionals and consumers in the US, as well as regulatory authorities and others in over 30 foreign countries. He is editor for the ISMP consumer website, www.consumermedsafety.org and writes a weekly blog for the Philadelphia Inquirer website, Philly.com (www.philly.com/philly/health_and_science/97905324.html) that which also appears occasionally in the newspaper. Dr. Cohen currently serves as Vice Chair of the Patient Safety Advisory Group for the Joint Commission (which creates the National Patient Safety Goals). He has also served as a member of the National Quality Forums Voluntary Consensus Standards Maintenance Committee (CSMC) on Safe Practices and serves as a consultant to the US Food and Drug Administrations Drug Safety and Risk Management Committee. In 2005 he was recognized as a MacArthur Fellow by the John D. and Catherine T. MacArthur Foundation.
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Rollin (Terry) Fairbanks,
MD, MS, Director, National Center for Human Factors Engineering in Healthcare,
MedStar Institute for Innovation, MedStar Health
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Rollin J. (Terry) Fairbanks, MD, MS, FACEP, joined the MedStar Health System and the Georgetown University Department of Emergency Medicine in 2010 to become the founding director of the National Center for Human Factors Engineering in Healthcare. This Center is part of the MedStar Institute for Innovation, in association with the MedStar Health Research Institute. Dr. Fairbanks is Associate Professor of Emergency Medicine at Georgetown University, and an attending Emergency Physician at Washington Hospital Center. He holds an adjunct faculty appointment in the Department of Industrial and Systems Engineering at the University at Buffalo, as well as at the Department of Emergency Medicine at the University of Rochester School of Medicine. He also serves as the Interim Director of MedStar Healths Simulation & Training Environment Laboratory (SiTEL). Terry is a physician and a human factors engineer/industrial systems engineer and uses this background to apply safety engineering techniques and research methodology to medical systems. He has received funding for patient safety-related research from the NIH, AHRQ, industry, and several foundations. Terry is a 2008 graduate of the HRET/NPSF Patient Safety Leadership Fellowship, and serves on national patient safety committees and advisory groups. He regularly presents his research and delivers lectures at national and international meetings, has served as an expert witness in patient safety/Human Factors Engineering cases, and as a consultant. Terry has published over 70 journal articles, book chapters, and proceedings papers in the human factors engineering and medical literature. He was PI of the Emergency Pharmacist Research Project, was a mentor in ASHPs Patient Care Impact Program for five years, and is a frequent presenter at ASHP meetings.
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Bonnie Levin,
PharmD, MBA, Corporate AVP, Pharmacy Services,
MedStar Health
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Bonnie Levin, PharmD, MBA, is Corporate Assistant Vice President of Pharmacy Services for MedStar Health; an integrated health system in Maryland and Washington that includes nine hospitals, eight outpatient pharmacies and a centralized IV Admixture service that serves inpatient and home infusion patients.
Dr. Levins responsibilities include leading MedStars Communities of Pharmacy, ongoing networks of clinical specialists, buyers, directors and informaticists; co-chairing the system Pharmacy & Therapeutics Committee and Antibiotic Subcommittee, technology assessment and implementation and supply chain contracting. Previously, Dr. Levin was Director of Pharmacy and Behavioral Health at a community hospital where she implemented technology and innovative clinical services. Her interests include medication safety, informatics, clinical decision support and mentoring new and emerging leaders.
Dr. Levin received her PharmD from the University of Maryland School of Pharmacy and an MBA from Johns Hopkins University. She has held leadership positions in state chapters of ASHP, has been active in ASHPs Section of Pharmacy and Technology and is currently Vice-Chair of the ASHP Advisory Group on Multi-hospital Health System Pharmacy Leaders. She co-edited the ASHPs Informatics Pearls, published in 2009.
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PROGRAM CHAIR:
Click the plus sign to see more detailed information about each speaker.
Bonnie Levin,
PharmD, MBA, Corporate AVP, Pharmacy Services,
MedStar Health
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Bonnie Levin, PharmD, MBA, is Corporate Assistant Vice President of Pharmacy Services for MedStar Health; an integrated health system in Maryland and Washington that includes nine hospitals, eight outpatient pharmacies and a centralized IV Admixture service that serves inpatient and home infusion patients.
Dr. Levins responsibilities include leading MedStars Communities of Pharmacy, ongoing networks of clinical specialists, buyers, directors and informaticists; co-chairing the system Pharmacy & Therapeutics Committee and Antibiotic Subcommittee, technology assessment and implementation and supply chain contracting. Previously, Dr. Levin was Director of Pharmacy and Behavioral Health at a community hospital where she implemented technology and innovative clinical services. Her interests include medication safety, informatics, clinical decision support and mentoring new and emerging leaders.
Dr. Levin received her PharmD from the University of Maryland School of Pharmacy and an MBA from Johns Hopkins University. She has held leadership positions in state chapters of ASHP, has been active in ASHPs Section of Pharmacy and Technology and is currently Vice-Chair of the ASHP Advisory Group on Multi-hospital Health System Pharmacy Leaders. She co-edited the ASHPs Informatics Pearls, published in 2009.
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Description
Error Description, Bonnie Levin, PharmD, MBA
Immediate Corrective Action: Communication and Patient Monitoring, Bonnie Levin, PharmD, MBA
ISMP's Assessment and Corrective Action Planning, Michael R. Cohen, RPh, MS, ScD (hon)
Human Factors Engineering Assessment and Corrective Action Planning, Rollin (Terry) J. Fairbanks, MD, MS
Other Consultants' Assessments, Corrective Action Planning and Leadership Strategy; Full Disclosure with Physicians, Patients, Boards of Pharmacy, Bonnie Levin, PharmD, MBA
LEARNER OUTCOMES:
- Analyze process improvements which can be used to effectively prevent the identified potential failures.
- Describe leadership strategies and tactics to effectively handle a serious medication error or other patient safety event.
- Describe the safety processes which should be required to replace drugs that cannot be obtained due to shortage.
- Evaluate the use of the "Just Culture" concept and its implementation during a serious medication error.
- Identify common pharmacy human factors failure points which could lead to extensive system errors.
