Poster Presentations from the First International High5s Hospitals

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Poster Presentations from the First International High5s Hospitals
Poster Presentations
from the
First International
High5s Hospitals
Meeting
19 October 2012
World Health Organization
Geneva, Switzerland
http://www.who.int/patientsafety/en/
Contact: [email protected]
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© World Health Organization 2012
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This publication contains the report of the 1st International High 5s Hospital Meeting
and associated poster presentations, and does not necessarily represent the decisions
or policies of the World Health Organization.
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Poster Presentations
from the
First International
High5s Hospitals
Meeting
19 October 2012
World Health Organization
Geneva, Switzerland
http://www.who.int/patientsafety/en/
Contact: [email protected]
“This work was carried out as part of the High 5s Project set up by the World Health Organization in 2007
and coordinated globally by the WHO Collaborating Centre for Patient Safety, The Joint Commission in
the United States of America, with the participation of the following Lead Technical Agencies including:
Australian Commission on Safety and Quality in Healthcare Care, Australia; Canadian Patient Safety
Institute, Canada and the Institute for Safe Medication Practices, Canada; National Authority for HealthHAS, France, EVALOR (EVAluation LORraine), France ( from 2009 -2011) OMEDIT Aquitaine (Observatoire
du Medicament, Dispositi fs medicaux et Innovation Therapeutique), France (from 2011-2015) and
CEPPRAL-Qualité et Sécurité en santé, France; German Agency for Quality in Medicine, Germany and the
German Coalition for Patient Safety, Germany; CBO (a TNO company) Dutch Institute for Healthcare
Improvement, the Netherlands; Singapore Ministry of Health, Singapore; Trinidad and Tobago Ministry of
Health, Trinidad & Tobago; Former National Patient Safety Agency, United Kingdom of Great Britain and
Northern Ireland ; and the Agency for Healthcare Research and Quality, USA.”
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CONTENTS
Introduction
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First International High5s Hospital Meeting Information Note
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Meeting Agenda
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Meeting Summary
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Instruction for Posters
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Best Poster Awards
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Correct Site Surgery Posters
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France
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Germany
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Singapore
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Medication Reconciliation Posters
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Australia
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France
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Germany
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The Netherlands
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Event Analysis Poster
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List of Participants
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List of Hospitals
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INTRODUCTION
The one-day First International High 5s Hospital Meeting took place at the
World Health Organization (WHO) Headquarters in Geneva on 19 October
2012. The meeting provided a platform where High5s hospital teams and
Lead Technical Agencies (LTAs) met to discuss experiences, share best practices, compare evaluation data and provide recommendations and best ways
forward for the High 5s Project. The hospital meeting served as a hub for an
inter-country exchange of knowledge and implementation experiences to
strengthen and motivate commitment by hospitals.
The meeting brought together 80 participants representing 31 High 5s hospitals from Australia, France, Germany, The Netherlands, Singapore and the
United States of America. Participants included technical and management
hospital staff, LTAs, WHO Collaborating Centre and WHO Patient Safety
Programme staff. Three High 5s experts from Canada and the United States
of America joined the meeting.
This publication presents the meeting report and posters exhibited at WHO
by the participating High5s hospitals from Australia, France, Germany, The
Netherlands and Singapore.
For further information regarding the High 5s Project, please visit WHO website at http://www.who.int/patientsafety/implementation/solutions/high5s/
en/index.html and the High 5s website at www.high5s.org.
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MEETING SUMMARY
The First International High 5s one-day Hospital Meeting took place at the
World Health Organization (WHO) Headquarters in Geneva on 19 October
2012. The meeting provided a platform where High5s hospital teams and Lead
Technical Agencies (LTAs) met to discuss experiences, share best practices,
compare evaluation data and provide recommendations and best ways forward for the High 5s Project. The hospital meeting served as a hub for an inter
-country exchange of knowledge and implementation experiences to
strengthen and motivate hospitals’ commitment.
The meeting brought together 80 participants ( see List of Participants)
representing 31 High 5s hospitals (see List of Hospitals) from Australia, France,
Germany, The Netherlands, Singapore and the United States of America.
Participants included technical and management hospital staff, LTAs, WHO
Collaborating Centre and WHO Patient Safety Programme staff. Three High
5s experts from Canada and the United States of America joined the meeting.
The meeting was opened by WHO and CBO representatives.
Global experiences of the High5s Project
Each participating country had selected one hospital per Standardized Operating Protocol (SOP) to share SOP implementation experiences and lessons
learnt.
Presentations of country experiences were started with Australia with Linda
Graudins from Alfred Health, Australia, presenting on implementation of the
Medication Reconciliation (Med Rec) SOP. This was followed by France with
Hervé Arnould from the Centre Hospitalier Bourg-en-Bresse on the Correct
Site Surgery (CSS) SOP and Edith Dufay from the Centre Hospitalier Luneville
on the Med Rec SOP. Germany followed with Michael Baehr, representing the
University Medical Center Hamburg-Eppendorf sharing the experiences of the
Med Rec SOP. Elske Dettmers from the Netherlands then presented on implementation of the Med Rec SOP at the Hospital Group Twente – ZGT Almelo/
Hengelo, followed by Jacqueline Dayuta from Singapore giving an overview of
implementation of the CSS SOP at the KK Women’s and Children’s Hospital.
The country experiences presentations were concluded with the USA, with
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Arta Ethridge, from Baylor University Medical Center, summarizing their implementation experiences with the CSS SOP.
All hospital presentations are posted on the High 5s website, on the shared
resources page: https://www.high5s.org/bin/view/Community/
SharedResources.
Poster Exhibit
High5s hospitals from Australia, France, Germany, The Netherlands and Singapore presented 30 posters. Hospital data showed that SOP implementation
has had a positive impact on hospital processes and patient care. The poster
jury consisting of the three High 5s experts, namely Margaret Colquhoun,
Richard J. Croteau and Carolyn Hoffman together selected one poster per SOP
for the “High 5s Achievement Award”. This was given to the winning teams at
the end of this one-day meeting.
Keynote presentation
The keynote presentation was given by Professor Dr. Tjerk van der Schaaf on
the critical importance of protocols, rules and procedures for safer care. The
presentation is posted on the High 5s website, on the shared resources page
(https://www.high5s.org/bin/view/Community/SharedResources).
Break-out session
Meeting participants formed five Working Groups to discuss about the High 5s
project, exchange information on SOP implementation challenges, qualitative
and quantitative evaluation activities and the impact of the SOPs across diverse country cultures and settings. Hospital participants were able to discuss
directly with High 5s Steering Group members about their experiences and
challenges, and to contribute ideas on the best ways forward. Session outcomes were subsequently presented to the whole group.
Each Working Group nominated a Chair to lead the discussions and a Rapporteur to summarize and present the outcomes at the plenary session. The table
below lists the questions debated in each Working Group.
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Break out Session Questions for Each Working Group
Plenary discussion
The Working Group discussion outcomes were presented in plenary, providing
further qualitative information on SOP implementation and evaluation.
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1. SOP for Medication Reconciliation
The Medication Reconciliation group consisted of representatives from Australia, France, Germany and The Netherlands.
1.1 Challenges to integration of the SOP into existing processes of care
Implementation of this SOP shows that it has been easier than expected to obtain support and enthusiasm to integrate the SOP into existing processes of
care in hospitals as the problem of medication reconciliation is well recognised.
Difficulties encountered while implementing the SOP and integrating it into
existing processes of care were identified as:
1.
staff motivation in the emergency department (ED) who were not used to
working with a pharmacist. Efforts were required to develop trust among
these staff;
2.
lack of integration of paper forms with IT systems; hospitals using ehealth records did not include medication reconciliation;
3.
obtaining information for patients who did not have a primary care doctor
in French hospitals, or a standard pharmacy to purchase medications;
4.
turnover of junior doctors and the continuous need for training whenever
their rosters were changed;
5.
turnover of pharmacy students responsible for performing medication
reconciliation, as students required to be trained every six months. One
hospital solved this by using a pharmacist mentor to supervise and answer
questions.
1.2 Resistance to change from within or outside the organization and how
this was addressed
Although the need for medication reconciliation was fully recognised, the main
resistance from within the organization was related to time and resources
needed to implement the Med Rec SOP. Solutions to overcome this resistance
included:
1.
developing a business case using pharmacy technicians; and
2.
approaching insurance companies for funding based on the added value
of the process.
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One French hospital reported resistance from medical staff who disagreed
with pharmacists adding anything to the patients’ medical records. The most
important solutions proposed included:
1.
using the results of the performance measures to inform medical staff
about the extent of the problem;
2.
introducing a Med Rec form that enables documentation of the discrepancies and proposed action on the form. This form would be added to
the patient’s notes.
In the Netherlands, resistance from outside the organization was mainly targeted at issues related to the privacy of patient information which potentially
could hinder access to community pharmacy medication records. As country
guidelines and accreditation standards supported the process, it was proposed that informed consent be obtained from the patient.
1.3 The effectiveness of measurements and improving the burden of
measuring
The answer to the question whether there were too many measurements to
evaluate the quality of Med Rec was ‘Yes’ and ‘No’, e.g. French hospitals were
in favour of continuing measuring MR1 on an ongoing basis, while Australian
hospitals supported the collection of MR1 at 48 hours.
The quality measures were considered complex to measure and too general to
be of use to clinicians as measures of the benefits of Med Rec. They were,
however, considered useful in helping to identify that the process of medication reconciliation was not under control and required further investigation.
The Group questioned whether they were measuring the right things. It was
suggested that measuring omissions would be a good indicator and could
replace MR2 and MR3. The question was posed as to whether it was possible
to put a process in place to continuously report on discrepancies identified,
such as a function of an electronic system for Med Rec. The Group agreed that
Med Rec was the first step in the medication management pathway and the
person performing reconciliation could review the medicines at the same time
and intervene if therapy was inappropriate or could cause harm. However, this
would not be interpreted as a Med Rec discrepancy.
Collecting data on discrepancies likely to cause harm was considered useful.
This information was of particular interest to medical staff. The number of intercepted discrepancies per reconciled patients was also suggested as a useful
means of feedback to clinicians. Another potential measure suggested was to
audit those patients who were not reconciled, e.g. patients seen at weekends
or after hours, and record the discrepancies identified after the Best Possible
Medication History (BPMH) was performed.
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To reduce the burden of measurements, there was agreement that the
measures could be simplified by combining MR2 and MR3 into one measure
of discrepancies irrespective of type. Alternatively collecting information on
omissions could be used as a surrogate of quality. The Group agreed that it
was not possible to come up with replacement indicators within 20 minutes
and it would be useful to spend more time identifying the indicators later on.
An important question was whether hospitals would continue measuring after
the project had finished. They would continue measuring MR1 and MR4, but
some proposed to only measure MR4 in the future, considered the only
meaningful measurement.
1.4 Synergy and competition addressed with existing in-country project
priorities
The Group mainly discussed strategies for dealing with resource constraints
and how the High 5s Project could further support hospitals in their implementation efforts.
1.5. Issues related to resources for SOP implementation and data collection
Five strategies were suggested to address resource constraints related to SOP
implementation and data collection.
1.
Involving pharmacy technicians and pharmacy students in the process;
however, additional training would be needed;
2.
Re-considering the best way to work, e.g. focusing on high-risk patients;
3.
Re-prioritizing existing resources as none of the participating hospitals
had new resources to allocate to the implementation of the Med Rec
SOP;
4.
Involving patients, e.g. reminding them to bring their medication list/
plan when being admitted to hospital; and
5.
Raising awareness of hospital administrators/managers of the problem
of medication errors and convincing them that using the Med Rec SOP is
important. Three aspects were addressed to convince hospital administrators/managers to invest resources for medication reconciliation:
1)
external influence such as national policies, directives, accreditation or professional standards, and recommendations by the
Ministry of Health, other regulatory bodies or WHO;
2)
letter from WHO to hospital management emphasizing the importance of patient safety and acknowledging the hospital’s leading role in implementing the Med Rec SOP. The Group suggested
that WHO send such as letter as a follow-up to this meeting.
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3)
quality improvement teams to collect data demonstrating the
impact of the Med Rec SOP, e.g. which harm has been averted
so far by this SOP, the number of discrepancies identified and
reconciled, in addition to the other measures.
1.6 Better support from LTAs/High 5s to hospitals to expand SOP
implementation hospital wide
Four suggestions were proposed to expand SOP implementation hospital
wide.
1.
The Group agreed that the upcoming High 5s Interim Report, should
be finalized by the spring of 2013, and serve as a useful tool to update
Ministries of Health and hospital managers on the importance of the
Med Rec SOPs and of the positive results obtained so far.
2.
The High 5s Steering Group was asked to host webinars and set up a
list server so that all High 5s parties and hospitals could directly and
efficiently share questions, tools, publications, data collection
methodologies and results.
3.
The development of a new measure to assess the clinical significance
of Med Rec, which would be introduced at an international level.
4.
LTA site visits as very helpful for increasing awareness of hospital
administrators to expand SOP implementation hospital-wide.
2. SOP for Correct Site Surgery
The Correct Site Surgery group included representatives from France,
Singapore and the United States of America.
2.1 Challenges to integration of the SOP into existing processes of care
Singapore did not face difficulties in implementing the SOP as many of the
pre-op, site mark and time-out checks were already in place. However,
implementing this SOP required a change of practices to follow the steps
of the CSS SOP correctly. The Singapore General Hospital had experienced
a couple of wrong site surgeries just prior to the CSS SOP implementation,
which facilitated buy-in from surgeons. Challenges faced at hospital level
in Singapore included:
1.
the presence of various different on-going initiatives and so many
changes taking place too rapidly in hospitals;
2.
the burden of additional tasks for nurses due to other concurrent patient safety projects.
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In France, the need to balance economic challenges and safety concerns was
important. The suggestion that if the SOP became integrated into the nurses’
activities, implementation would be easier because surgeons’ co-operation is
harder to attain.
In the USA., a similar case of wrong site surgery facilitated buy-in by hospital
managers to implement this SOP.
2.2 Resistance to change from within or outside the organization and how
this was addressed
In Singapore, there were pockets of resistance from certain disciplines, including:
1.
Surgeons: they considered the SOP as baseless; for example, colorectal
surgeons said their point of entry for surgery was only ever through one
entrance, same response from urology surgeons. However, the colorectal department had a wrong site surgery at one point and Singapore General Hospital (SGH) was able to use that incident to implement the SOP.
2.
Surgeons who were obliged to re-design aspects of their work, e.g. at the
National University Hospital (NUMS) surgery center, surgeons had to
come out of the Operating Theatre (OT) to mark the site because the patients arrived straight from the ward to the OT. The key success factor
was that nurses refused to let patients pass through to the OT until the
site was marked. However, this approach did not work in the USA, because nurses were not sufficiently empowered.
3.
Senior surgeons who resisted the CSS SOP because of their individual approach to safety; Singapore has a resident teaching programme that includes patient safety as part of the curriculum and seeing their mentors
adopting the SOP was important for students.
4.
Specialized hospital centres whose workload was too high to re-design
the workflow, e.g. the endoscopy centers in SGH.
Reasons for resistance in French hospitals included:
1.
Different disciplines having different concerns, thus, if the SOP could be
tailored for different subgroups such as Orthopedic or General Surgery
(GS), it would help because the former is concerned with site/side and
implants, whilst GS or GI surgeons only need to ensure that pre-op and
time-out are done properly.
2.
Surgeons’ perceived hassle to mark the site and therefore the workflow
should be re-designed in a way to facilitate site-marking.
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3.
Individual and specific approaches to site marking and safety having
been developed by senior surgeons over many years’ experience, and
who believe that changing their practice now will not improve things.
4.
Students who have not been educated on patient safety issues.
The resistance in the USA. was mainly related to financial considerations. In
addition, the individual perceptions of surgeons added to resistance towards
SOP implementation.
2.3 The effectiveness of measurements and improving the burden of measuring
In Singapore, measurements are important in motivating staff to follow an
SOP. Outcome-related indicators could therefore be better than process indicators. NUHS has set up an electronic system that includes the checklist so
that 100% of the data can be captured.
Prof. Dr. van der Schaaf said:
“even if you never have wrong-site surgery, the measurements show that you
have near-misses being monitored, which by itself is a successful safety check.
It is important to show data that catch/record near-misses, which is what the
measurements for the SOP implementation is all about”.
2.4 Synergy and competition addressed with existing in-country project priorities
In Singapore, five crucial factors contributed to the success of the project.
1.
Strong commitment by the Ministry of Health;
2.
Financial support for participating hospitals with one person assigned per
hospital and paid for by the Ministry of Health;
3.
Strong leadership by Professor Ong, being an important patient safety
champion;
4.
The emphasis on developing a safety culture;
5.
Practitioners act less as individuals and are less independent.
In France, the Ministry of Health endorsed the High 5s project, but there was
no financial support from the government to the participating hospitals. In addition, there was a relative lack of leadership at hospital management and
organizational levels to implement the High5s Project. The Haute Autorité de
Santé (HAS) has opened a competition between projects of High 5s and the
Surgical Checklist through its hospital accreditation programme.
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In the USA., there are already many surgical safety initiatives going on. Difficulties are related to the fact that the cost of the project must be borne entirely by the hospital. The length of the project is an issue in situations of financial constraints where benefits and results are expected within a much
shorter period.
2.5. Issues related to resources for SOP implementation and data collection
The Group felt that funding was not necessarily the main barrier to the optimal implementation of SOPs. One of the most important limiting factors appeared to be a lack of leadership. Resources were not an issue for implementing SOPs, although they were required for evaluation, communication
and training.
Regarding the event analysis, it was stressed that a limited number of good
analyses concerning actual adverse events or near misses would be just as
sufficient and useful as the more exhaustive approach adopted by the High 5s
Project. These should address events encountered during the preintervention phase, errors in site marking or difficulties in performing the time
-out. The Group agreed that there is a demand for more observational audits
to assess the actual quality of the time-outs.
2.6 Better support from LTAs/High 5s to hospitals to expand SOP implementation hospital-wide
There were three key strategies addressed by the Group to support and expand SOP implementation in hospitals.
1.
Increase patient awareness of the importance of SOPs;
2.
Increase awareness of them among health-care professionals;
3.
Communicate data on the number of near misses in the pre-intervention
pathway and of site marking errors, thus showing the importance of
standardising processes to intercept errors.
3 Global issues of the High 5s Project
3.1 Effectiveness of standardization across diverse countries
The Group decided that international standardization is difficult to apply in local or regional settings. It would be helpful to determine the key elements of
the SOP implementation to determine how local resources can be raised to
implement the SOP effectively. The Group proposed that WHO can help define the standards and necessary (local) expertise required to level-up and
meet international health-care standards. WHO’s role, however is to help set
international standards and guidelines that can subsequently be adapted
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implement the SOP effectively. The Group proposed that WHO can help define the standards and necessary (local) expertise required to level-up and
meet international health-care standards. WHO’s role, however is to help set
international standards and guidelines that can subsequently be adapted
and used by country-level institutions and therefore has little part to play in
national or local standard adaptation or required expertise which it sees as
the role of national health authorities.
3.2 Improving global coordination and knowledge management.
WHO and the Collaborating Centre can improve global coordination of the
High 5s Project and knowledge management by collecting success stories,
creating inventories of project experiences and highlighting lessons learned.
This knowledge could be shared with LTAs and hospitals via the Wiki
platform, in news alerts and LTA’s continuous communication with the participating hospitals. The Group suggested that an annual hospital meeting would
help to spread knowledge and related implementation experiences.
3.3 Active role of hospitals to further promote SOPs in their communities,
countries and partner countries.
The Group agreed that it was still premature to extend SOP implementation
outside the High 5s community at this point when measurements are still being compiled and analyzed. Preliminary data demonstrate that the SOPs do
work, however further analysis is needed to provide more evidence to convince others of this.
The High 5s participating hospitals could act as ‘High 5s Embassies’ to support the expansion of the project to other countries. In order to spread the
SOP experiences and lessons learned globally, the Group emphasized the importance of using the same patient safety language, i.e. the same definitions
and classification of terms.
High 5s Achievement Award
Singapore National University Hospital won the “High 5s Achievement
Award” for the CSS SOP and the “High 5s Achievement Award” for the Med
Rec SOP was awarded to The Netherlands Medical Center Alkmaar.
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Best Poster
Awards
Singapore National University
Hospital for Correct Site Surgery
The Netherlands Medical Center
Alkmaar for Medication
Reconciliation
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Correct Site
Surgery Posters
France
Centre Hospitalier Bourg-en-Bresse
Centre Hospitalier Joseph Ducuing, Toulouse
Cornouaille Hospital, Quimper-Concorneau
Léon-Bérard Cancer Centre, Lyon
Pasteur Hospital, Nice
Germany
Agency for Quality in Medicine
Institute for Patient Safety, University of Bonn
Solingen City Hospital (Städtisches Klinikum Solingen)
Singapore
Changi General Hospital
KK Women’s and Children’s Hospital
National University Hospital
Singapore General Hospital
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FRANCE
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GERMANY
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SINGAPORE
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Medication Reconciliation Posters
Australia
Alfred Health
France
Centre Hospitalier Lunéville
Centre Hospitalier Universitaire Grenoble
Centre Hospitalier Universitaire Nimes
Centre Hospitalier Universitaire Strasbourg
Hospital Center of Compiegne
Hôpital St Marcellin
Hôpitaux Universitaires Paris Nord Val de Seine
Germany
University Hospital Aachen, University of Aachen
The Netherlands
CBO (a TNO company), Dutch Institute for Healthcare Improvement
Antonius Hospital - Sneek/Emmeloord
Elkerliek Hospital - Helmond
Haga Hospital - The Hague
Hospital Gelderse Vallei - Ede
Hospital Group Twente – ZGT Almelo/Hengelo
Medical Center Alkmaar
Radboud University, Nijmegen Medical Centre
Tergooi Hospitals - Blaricum/Hilversum
VU University Medical Centre Amsterdam
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AUSTRALIA
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FRANCE
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GERMANY
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THE NETHERLANDS
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Event Analysis
Poster
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EVENT ANALYSIS
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List of Participants
Australia
Margaret Duguid
Pharmaceutical Advisor
Australian Commission on safety and Quality in Health Care
Linda Graudins
Senior Pharmacist, Medication Safety
Alfred Health
Canada
Margaret Colquhoun
Project Leader
Institute for Safe Medication Practices Canada
France
Charles Bruneau
Scientific Advisor
Authority for health HAS
Anne Farge Broyart
Project Leader LTA
Authority for health HAS
Claire Chabloz
Coordinatrice CEPPRAL
CEPPRAL
Karen Fanget
Project Assistant
CEPPRAL
Eric Le Bihan
Project Manager
OMEDIT Aquitaine
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Myriam Rodaut
OMEDIT Aquitaine
Bertrice Loulière
Pharmacist Coordinator
OMEDIT Aquitaine
Blandine Fort
Resident
CEPPRAL
Agnès Guichette-Debord
Centre Hospitalier de Bourg en Bresse
Risk manager
Dr Dominique Beaudouin
Risk manager
Centre Hospitalier de Chambéry
Dr Caroline Deyrolle
Surgeon
Centre Hospitalier de Chambéry
Bruno Michel
Hospital Pharmacist
Centre Hospitalier Universitaire Strasbourg
Benoit Allenet
Hospital Pharmacist
Centre Hospitalier Universitaire Grenoble
Véronique Berard
Hospital Pharmacist
Hôpital St Marcellin
Marie Christine Roussel-Gall
Hospital Pharmacist
Hôpital St Marcellin
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Emmanuelle Pappy
Hospital Pharmacist
Centre Hospitalier Universitaire
Bichat Claude Bernard (Paris)/ Hôpitaux Universitaires Paris Nord Val de Seine
Edith Dufay
Hospital Pharmacist
Centre Hospitalier Luneville
Sébastien Doerper
Hospital Pharmacist
Centre Hospitalier Luneville
Clarisse Roux Marson
Hospital Pharmacist
Centre Hospitalier Universitaire Nimes
Florent Weppe
Staff Surgeon
Centre Hospitalier St Joseph St Luc, Lyon
Irene Philip
Director, Clinical Quality
Centre Anticancéreux Lyon
Herve Arnould
Staff Surgeon
Centre Hospitalier Bourg en Bresse
Monique Fabre
Diretrice générale des soins
Centre Hospitalier Joseph Ducuing, Toulouse
Dr Sylvie Fristch
Director of Surgery Department
Centre Hospitalier Joseph Ducuing, Toulouse
Michel Lonjon
Director, Surgery Department
Centre Hospitalier Universitaire, Nice
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Germany
Liat Fishman
Research Scientist / Project Manager
Agency for Quality in Medicine
Michael Baehr
Director of Hospital Pharmacy
University Medical Center Hamburg-Eppendorf
Simone Melzer
Hospital pharmacist
University Medical Center Hamburg-Eppendorf
Konny Ramacher
Deputy Head of Nursing
Solingen City Hospital (Städtisches Klinikum Solingen)
Katharina Franzen
Pharmacist
University of Aachen Medical Centre
Netherlands
Erica (van der Schrieck-) de Loos
Project Leader LTA NL/Senior Advisor
CBO (a TNO company), Dutch Institute for Healthcare Improvement
J. (Annemieke) van Groenestijn,
LTA NL/Advisor
CBO (a TNO company), Dutch Institute for Healthcare Improvement
Angela Hentzepeter
Pharmaceutical Consultant
Radboud University Nijmegen Medical Centre
Maaike Vermeulen
Pharmaceutical Consultant
Radboud University Nijmegen Medical Centre
Mirian Kaal
Hospital Pharmacist
Gelderse Vallei
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Sebastiaan Rebel
Head of Unit Distribution
Gelderse Vallei
Annelies van Velzen
Pharmacist
Haga Hospital
Liesbeth Bosma
Hospital Pharmacist
Haga Hospital
Mariëlle Nijeboer
Pharmacy Assistant
Hospital Group Twente – ZGT Almelo/Hengelo
Elske (Engel-) Dettmers
Hospital Pharmacist
Hospital Group Twente – ZGT Almelo/Hengelo
Emil Hofstra
Team Leader ED
VU University Medical Centre Amsterdam
Pierre Bet
Hospital Pharmacist
VU University Medical Centre Amsterdam
Tjerk van der Schaaf
Keynote Speaker
Prisma Safety Management Systems
Jacqueline Groenewegen
Pharmacy Practitioner
Tergooi Hospitals
Willemien (Lagas-) de Graaf
Hospital Pharmacist
Tergooi Hospitals
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Marjan Tiebosch
Pharmacy Assitant
Elkerliek Hospital
Bjorn Brassé
Hospital Pharmacist
Elkerliek Hospital
Petronella (Petra) Bolten
Pharmacist
Medical Center Alkmaar
Lydia (Takens-) de Vries
Medication Safety Platform
Medical Center Alkmaar
Irene Oldenkamp
Pharmacist
Medical Center Leeuwarden/
Antonius Hospital Sneek/Emmeloord
Joris Arts
Hospital Pharmacist
Antonius Hospital Sneek/Emmeloord
Singapore
Katherine Soh
Manager, Health Standards
Ministry of Health
Deborah Wild
Deputy Director, Clinical Services
Changi General Hospital
Ho Le Onn
Medical Officer, Clinical Governance
Singapore General Hospital
Ong Lay Teng
Senior Nurse Clinician, MOT
KK Women’s and Children’s Hospital
65
Jacqueline Dayuta
High 5s Executive
KK Women’s and Children’s Hospital
Sandhya Mujumdar
Deputy Director, Medical Affairs
National University Hospital
Alice Mayachandra Alisjahbana
Healthcare Performance Office, Executive
Tan Tock Seng Hospital
United States of America
Peter Goldschmidt
President
World Development Group, Inc
Jeremiah C. Bowman
Grants & Contracts Manager
American College of Surgeons
Arta Ethridge
Department of Surgery
Baylor University Medical Center
Tammy Fisher
Manager, Surgical Education
Baylor University Medical Center
WHO Collaborating Centre on Patient Safety Solutions-The Joint Commission
Jerod M. Loeb
Executive Vice President
Division of Healthcare Quality Evaluation
The Joint Commission
Anapam Dayal
Project Director
Joint Commission Resources
Brette Tschurtz
Associate Project Director
Division of Healthcare Quality Evaluation
The Joint Commission
66
Scott Williams
Associate Director
Division of Healthcare Quality Evaluation
The Joint Commission
Richard J. Croteau
Patient Safety Advisor
Joint Commisssion International
Dennis S. O’Leary
Consultant, President Emeritus
The Joint Commission
Sherri Loeb
Clinical Trials Coordinator
Evanston Hospital, Evanston
World Health Organization
Agnès Leotsakos
Leader, Global Patient Safety Capacity Building and Education
WHO Patient Safety Programme
Carolyn Hoffman
WHO Senior Advisor, High 5s
Vice President, Clinical Perfomance Improvement Alberta Health Services
Hao Zheng
Senior Consultant
WHO Patient Safety Programme
Eirini Rousi
Consultant
WHO Patient Safety Programme
67
List of Hospitals
Correct Site Surgery
France
Centre Hospitalier Bourg-en-Bresse
Centre Hospitalier Joseph Ducuing, Toulouse
Cornouaille Hospital, Quimper-Concorneau
Léon-Bérard Cancer Centre, Lyon
Pasteur Hospital, Nice
Germany
Agency for Quality in Medicine
Institute for Patient Safety, University of Bonn
Solingen City Hospital (Städtisches Klinikum Solingen)
Singapore
Changi General Hospital
KK Women’s and Children’s Hospital
National University Hospital
Singapore General Hospital
United States of America
Baylor University Medical Center
Medication Reconciliation
Australia
Alfred Health
France
Centre Hospitalier Lunéville
Centre Hospitalier Universitaire Grenoble
Centre Hospitalier Universitaire Nimes
Centre Hospitalier Universitaire Strasbourg
Hospital Center of Compiegne
Hôpital St Marcellin
Hôpitaux Universitaires Paris Nord Val de Seine
68
Germany
University Hospital Aachen, University of Aachen
The Netherlands
CBO (a TNO company), Dutch Institute for Healthcare Improvement
Antonius Hospital - Sneek/Emmeloord
Elkerliek Hospital - Helmond
Haga Hospital - The Hague
Hospital Gelderse Vallei - Ede
Hospital Group Twente – ZGT Almelo/Hengelo
Medical Center Alkmaar
Radboud University, Nijmegen Medical Centre
Tergooi Hospitals - Blaricum/Hilversum
VU University Medical Centre Amsterdam
69
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