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Archive of "Patient Safety" Category

Jeff Cooper’s Letter to the Editor Provides Important Addendum to CRICO History

Jeffrey Cooper, PhD

On December 9, 2016, the journal Patient Safety & Quality in Healthcare published an article by Susan Carr, reflecting on the 40 years CRICO has served as malpractice insurance provider for Harvard medical institutions and their affiliate programs. (Full article: https://www.rmf.harvard.edu/About-CRICO/Media/In-the-News/News/2016/December/CRICO-Celebrates-40-Years-in-Patient-Safety)

On February 27, 2017, Jeff Cooper, Executive Director Emeritus of the Center for Medical Simulation, submitted a letter to the editors of Patient Safety & Quality in Healthcare, to address some critical pieces of the history of CRICO’s leadership in patient safety, which he felt were missing from the original article.

Thank you for giving visibility to the story of CRICO’s story of leadership in patient safety. It is worthy of praise and emulation. Yet, I think there are critical pieces of the story that perhaps space didn’t permit telling, although I think they are among the most important. Then again, I have a bias because I was there . . .

The other aspects of the CRICO patient safety story are important examples of how a forward-thinking insurance company can achieve a win-win-win-win (patient, provider, hospital, insurer). But, I believe it was the leadership of the HMS anesthesia Executive Committee that led to one of CRICO’s earliest and greatest successes, and that enabled the continued concentration on patient safety.

Dr. Cooper’s full letter, along with references, can be found at the Patient Safety & Quality in Healthcare website: http://www.psqh.com/analysis/letter-to-the-editor-cricos-patient-safety-leadership-a-missing-piece/

Reflections on My Month at CMS

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Emily Fish is a resident in Anesthesia at the Massachusetts General Hospital in Boston, MA. She spent the month of October at the Center for Medical Simulation on an elective rotation. The goal of the rotation program is to expose residents to the potential and operational use of simulation for education, clinical training and research. Over the course of the month, residents develop simulation scenarios including patient records, plot, setup, debriefing notes, and references.

“I am so grateful to have spent the past month at the Center for Medical Simulation–what a remarkable experience it has been! From gaining experience in the creation of high fidelity scenarios to improving my debriefing skills, the rotation was rich with learning opportunities. I was also fortunate to take the IMS instructor course, which was a truly transformative experience. The expert guidance of the instructors and the environment of teamwork and encouragement really foster the learning and growth of participants. Participating in the course has had a powerful effect on both the quantity and quality of introspection and self-evaluation I perform. I am more cognizant of potential assumptions I may have and will strive to be mindful of these and their potential impact in debriefing and elsewhere. The course has transformed the way I communicate not only with colleagues at work but in my daily life as well. I now find myself actively working on improving my communication skills using the techniques I learned in the course. I consider the course one of the most impactful experiences I have had in my medical training thus far. In fact, it has prompted a desire to incorporate simulation into my long-term career, and I hope to enter into sim fellowship as the next step in my growth as an educator.”

–Emily Fish, MD

CMS Affiliate Mater Education Takes Home Two Simulation Awards

ASC-Award_350x350The Center for Medical Simulation congratulates CMS affiliate program Mater Education on winning two major awards at the 2016 Simulation Australasia Annual Awards Dinner in Melbourne, Australia.

Mater Education won the prestigious Simulation Australasia Project Innovation Award for their project “Opening Mater Private Hospital Springfield: Keeping Patients Safe.” In October 2015, Mater Education coordinated a one-of-a-kind simulation event before the opening of the Mater Private Hospital Springfield. In this simulation event, the entire hospital facility ran as a simulation for a full 24 hours, with volunteers performing the roles of hospital patients. This complex simulation gave Mater Education the ability to test hospital-wide processes and new facilities before the hospital opened to the public, increasing staff comfort and confidence and improving patient safety.

The Mater Education team also brought home the award for Best Poster or Short Paper Abstract, for their poster, “Simulation Based Training Program to Improve Delivery of the Impacted Fetal Head at Caesarean Section.” This poster displayed information about the program which Dr. Michael Yu, Dr. Erin Wilson, and Dr. Sarah Janssens developed, which uses the “Desperate Debra” simulator to train learners on issues involved in fetal head disimpaction at caesarean section.

 

CMS Affiliate Program
The Center for Simulation (CMS) based in Boston, MA, USA, is one of the oldest, most respected, and most influential simulation centers in the world. Through its Affiliate Program, CMS works closely with a select group of international healthcare organizations committed to developing the full potential of their simulation programs. To learn more about becoming a member of this select group of Simulation Centers of Excellence, email CMS at info@harvardmedsim.org.

Crisis Management in Acute Care Settings Available November 2016

medhead 10The Center for Medical Simulation congratulates Robert Simon and fellow co-authors Michael St Pierre and Gesine Hofinger on the upcoming publication of the third edition of their book, Crisis Management in Acute Care Settings: Human Factors and Team Psychology in a High-Stakes Environment.

Crisis Management in Acute Care Settings comprehensively addresses how human decision making and human factors can affect patient safety in acute care. The text identifies frequent errors and allows healthcare professionals to improve patient safety and give more effective treatment in emergency situations. Springer calls this book, “The required reference for all who are learning about, teaching, or providing acute and emergency healthcare.”

Crisis Management in Acute Care Settings will be available in November 2016 from Springer, in print and electronically.

 

SimonBookFlyer

 

CMS Faculty to Present at IMSH2016 in San Diego

IMSH2016 Logo

Center for Medical Simulation (CMS) faculty will be heavily involved in the upcoming 16th Annual International Meeting on Simulation in Healthcare (IMSH) in San Diego, California where they’ll be holding workshops, participating on expert panels and presenting research abstracts from January 16th-20th, 2016. A list of these activities follows with the CMS faculty members names highlighted in bold.

Members of the CMS team will be at Booth# 1013 in the Hall of Discovery where they will be tweeting live from CMS’ Twitter account, @MedSimulation using the hashtag #IMSH2016.

WORKSHOPS & PANELS

Living Communication: Taking Cues from the Actors’ Studio (#17666)
Expert Preconference Course (Onsite)
Saturday, January 16, 2016
01:00 pm – 05:00 pm
SDCC Room 31B (Room # Subject to Change)
Speaker(s): Christine Park, MD; Jason Economus, BA; Keith Littlewood, MD; Andres Navedo, MD

Leadership Re-Boot: Put the CARE Back in Healthcare (#19646)
Expert Preconference Course (Onsite)
Sunday, January 17, 2016
08:00 am – 12:00 pm
SDCC ROOM 31A (Room # Subject to Change)
Speaker(s): Pascal Scemama de Gialluly, MD, MBA; Jeffrey Hull; Rebecca D Minehart, M.D.

CHSE-A: Portfolio Development Workshop (#17831)
General Preconference Course (Onsite)
Sunday, January 17, 2016
08:00 am – 12:00 pm
SDCC Room 30A (Room # Subject to Change)
Speaker(s): Mary Fey, PhD, RN, CHSE; Wendy L Gammon; Connie M Lopez, MSN, CNS, RNC-OB, CPHRM; Andrew E Spain, MA, NCEE, EMT-P

Pushed to the Limit: What to Do When There’s Nothing Left: A Hyper-Realistic Scenario Development Experience (#17435)
General Preconference Immersive Course (Off-site)
Sunday, January 17, 2016
08:00 am – 12:00 pm
Strategic Operations San Diego (Room # Subject to Change)
Speaker(s): Roxane Gardner, MD, MPH, DSc; Anthony LaPorta, MD, FACS; Roy Lee Alson, MD,PhD, FACEP, FAAEM; Adam Dodson, NRP, NCEE, CCEMT-P; Devin James Funk; Cory Gaconnet, MD; Jesika S Gavilanes, MA; Jordan Halasz; Tuan Hoang, MD, FACS; Joseph LaPorta, MS; Mark S Lea, MD; Tanner McClure, MS; MR EDUARDO RAUL MEDINA, RCVT, EMT-P; Alan Moloff, DO, MPH; Jamie Stiner

OPENING PLENARY SESSION: IGNITE IMSH! Impacting Lives 5 Minutes at a Time (#21400)
General Plenary Presentation
Sunday, January 17, 2016
02:00 pm – 03:15 pm
SDCC Ballroom 20 A/B/C (Room # Subject to Change)
Speaker(s): Jason Economus, BA; Jon Aharoni; Ms Rae Armantrout, poet; Susanna Cohen, DNP, CNM; Jeffrey B Cooper, PhD; David Gaba, MD; Dinker Ramananda Pai, MBBS, MS, FRCS (Edin); Takashi Shiga, MD, MPH, FAAEM

Improve Debriefing Skills Through Peer Observation and Feedback (#16720)
Expert Workshop
Monday, January 18, 2016
10:00 am – 11:30 am
SDCC Room 30D (Room # Subject to Change)
Speaker(s): Grace M. Ng, MS, CNM, RN, C-EFM; Emily Diederich; Dawn Taylor Peterson, PhD; Laura Rock, MD; Jenny Rudolph, PhD; Demian Szyld, MD, EdM; Penni Watts, PhD, RN, CHSE

Brownian Motion to Purposeful Action: Opportunities in Perioperative Simulation and Team Training (#17147)
General Workshop
Monday, January 18, 2016
10:00 am – 11:30 am
SDCC ROOM 33A (Room # Subject to Change)
Speaker(s): Roxane Gardner, MD, MPH, DSc; Ellen Brock, MD, MPH; John Darby, Associate Clinical Professor of Anesthesiology; Gladys L. Fernandez, MD, MD; Sara Goldhaber-Fiebert, MD; Anita Honkanen, MD, MS, FAAP; Colleen A Lee, RN, MS; Marco Luchetti, MD, MSc; Vincent J Miller; Mikio Nihira, MD, MPH; Jutta Novalija; John Paige, MD, FACS; Jason Seery, MD, FACS; Armand ten Haaf, CRNA; Muhammad Waseem; David Young

Pro-Con Debate: Resident-Led Curriculum? (#17197)
General Debate
Monday, January 18, 2016
01:00 pm – 02:00 pm
SDCC Room 29A (Room # Subject to Change)
Speaker(s): Paul Currier; Dan Raemer, PhD

Develop a Collaborative Simulation Educator Institute: Pilot Project and Lessons Learned (#17833)
Expert Podium Presentation
Monday, January 18, 2016
01:00 pm – 02:00 pm
SDCC Room 28A (Room # Subject to Change)
Speaker(s): Amy L Daniels, MS, RN, CHSE; Mary Fey, PhD, RN, CHSE; Susan Gross Forneris, PhD, RN, CNE, CHSE-A; Rachel Onello, PhD, RN, CHSE, CNE, CNL

Simulation in Healthcare Workshop for Authors (#16556)
General Workshop
Monday, January 18, 2016
02:15 pm – 03:45 pm
SDCC Room 25B (Room # Subject to Change)
Speaker(s): Mark W Scerbo, PhD; Jeffrey B Cooper, PhD; Michael DeVita, MD; David Gaba, MD; Rose Hatala, MD, MSc; Andreas H Meier, MD, MEd, FACS, FAAP; Elaine C Meyer; Elizabeth Sinz, MD FCCM; Dimitrios Stefanidis, MD, PhD, FACS; Rachel Yudkowsky, MD, MHPE

Nuts and Bolts: Build Your Simulation Program (#16825)
General Panel Presentation
Monday, January 18, 2016
02:15 pm – 03:45 pm
SDCC Room 28B (Room # Subject to Change)
Speaker(s): Dimitrios Papanagnou, MD, MPH; Sharon Griswold, MD, MPH, CHSE; Jane Kim, MD; Steven Kornweiss, MD; Michael Meguerdichian; Janice C Palaganas, PhD, RN, NP; Jessica Pohlman, MPA, NREMT-P; Katie L Walker, MBA, RN

Expert Debriefing: The Right Tool for the Job (#17741)
Expert Workshop
Monday, January 18, 2016
02:15 pm – 03:45 pm
SDCC Room 31A (Room # Subject to Change)
Speaker(s): Gabriel B Reedy, PhD, CPsychol; Peter Jaye, BSc, MBBS, MRCP,FCEM; Dr Mary Lavelle; Demian Szyld, MD, EdM

Become IT System Literate: Beyond Cables, Connectors and Couplers (#16717)
General Workshop
Monday, January 18, 2016
02:15 pm – 03:45 pm
SDCC Room 28C (Room # Subject to Change)
Speaker(s): Grace M. Ng, MS, CNM, RN, C-EFM; Tom Vongbandith; H. Michael Young, BBS, MDiv, CHSE

Pro-Con Debate: Death of the Simulator? Benefits and Consequences (#16334)
Expert Debate
Monday, January 18, 2016
04:00 pm – 05:30 pm
SDCC Room 24C (Room # Subject to Change)
Speaker(s): Jennifer L Arnold, MD, MSc; Sam DeMaria, MD; Daniel Lemke, MD; Adam I. Levine, MD; Dan Raemer, PhD

Interprofessional Education Courses and Curriculum Design (#17991)
General Panel Presentation
Monday, January 18, 2016
04:00 pm – 05:30 pm
SDCC Room 23C (Room # Subject to Change)
Speaker(s): Dawn M Schocken, MPH, PhD; Stephen C. Charles, MS, MA, PhD, CHSE; Chad Epps, MD; Janice C Palaganas, PhD, RN, NP

Lead Change: Substitute Simulation for Clinical in Nursing Education (#17041)
General Panel Presentation
Monday, January 18, 2016
04:00 pm – 05:30 pm
SDCC Room 24B (Room # Subject to Change)
Speaker(s): Susan Gross Forneris, PhD, RN, CNE, CHSE-A; Mary Fey, PhD, RN, CHSE; Henry Henao, MSN, ARNP, FNP-BC, CHSE; Pamela R Jeffries, PhD, RN, FAAN, ANEF; Suzan Kardong-Edgren, PhD, RN, ANEF, CHSE, FAAN; Rochelle Quinn, RN, MSN

Leadership in Healthcare Simulation in 2016: Lessons Learned from Successful Innovators (#17828)
Expert Panel Presentation
Tuesday, January 19, 2016
10:00 am – 11:30 am
SDCC BALLROOM 20 D (Room # Subject to Change)
Speaker(s): Ignacio Del Moral, MD, PhD; Jeffrey B Cooper, PhD; Paul E Phrampus, MD; Michael Seropian, MD, FRCPC; Katie L Walker, MBA, RN

Address Performance Gaps Through Debriefing (#16562)
General Workshop
Tuesday, January 19, 2016
10:00 am – 11:30 am
SDCC Room 30B (Room # Subject to Change)
Speaker(s): Laura Rock, MD; Melanie Louise Barlow; Jose M Maestre, MD, PhD; Kate Morse, PhD, ARNP-BC, CRNP, CCRN, CNE; Grace M. Ng, MS, CNM, RN, C-EFM; Janice C Palaganas, PhD, RN, NP; Dan Raemer, PhD; Jenny Rudolph, PhD; Robert Simon, EdD; Demian Szyld, MD, EdM; Toni Walzer, MD

Improving the Quality of Debriefing (#17964)
Expert Workshop
Tuesday, January 19, 2016
10:00 am – 11:30 am
SDCC Room 33A (Room # Subject to Change)
Speaker(s): James Lewis Huffman, BSc, MD, FRCPC; Ghazwan Altabbaa, MD, MSc FRCPC; Wendy E Bissett, RN, CNE; Helen Catena, RN; Jonathan Duff, MD; Kristin Fraser, MD, FRCPC; Vincent Grant, MD, FRCPC; Neel Naik; Traci Robinson, RN; Demian Szyld, MD, EdM

Debriefing Across the Curriculum (#17371)
General Workshop
Tuesday, January 19, 2016
10:00 am – 11:30 am
SDCC Room 25C (Room # Subject to Change)
Speaker(s): Mary Fey, PhD, RN, CHSE; Susan Gross Forneris, PhD, RN, CNE, CHSE-A

Communication in a Multicultural World: Words, Gestures and Styles (#16816)
General Workshop
Tuesday, January 19, 2016
10:00 am – 11:30 am
SDCC Room 24C (Room # Subject to Change)
Speaker(s): Ljuba Stojiljkovic, MD, PhD; Andres Navedo, MD; Christine Park, MD; Takashi Shiga, MD, MPH, FAAEM; Meltem Yilmaz, MD

Development of the Feedback Assessment for Clinical Education (#16664)
Expert Podium Presentation
Tuesday, January 19, 2016
01:00 pm – 02:00 pm
SDCC Room 23C (Room # Subject to Change)
Speaker(s): Rachel Onello, PhD, RN, CHSE, CNE, CNL; Rebecca D Minehart, M.D.; Janice C Palaganas, PhD, RN, NP; Jenny Rudolph, PhD

Review: 2015 IOM Report on Interprofessional Education (#17312)
General Podium Presentation
Tuesday, January 19, 2016
01:00 pm – 02:00 pm
SDCC Room 31C (Room # Subject to Change)
Speaker(s): Janice C Palaganas, PhD, RN, NP

Strategies for Successful Co-Debriefing (#16787)
General Workshop
Tuesday, January 19, 2016
02:15 pm – 03:45 pm
SDCC Room 32A (Room # Subject to Change)
Speaker(s): Traci Robinson, RN; Wendy E Bissett, RN, CNE; Gavin Burgess; Helen Catena, RN; Jonathan Duff, MD; Kristin Fraser, MD, FRCPC; Vincent Grant, MD, FRCPC; James Lewis Huffman, BSc, MD, FRCPC; Jose M Maestre, MD, PhD; Janice C Palaganas, PhD, RN, NP; Stuart C Rose; Jenny Rudolph, PhD

Show Me The Money: Creating Revenue Generating Proposals (#16629)
General Workshop
Tuesday, January 19, 2016
02:15 pm – 03:45 pm
SDCC Room 31C (Room # Subject to Change)
Speaker(s): Joanne Choi; Grace M. Ng, MS, CNM, RN, C-EFM

Debriefing Interprofessional Groups (#17298)
Expert Workshop
Wednesday, January 20, 2016
08:30 am – 10:00 am
SDCC Room 28E (Room # Subject to Change)
Speaker(s): Janice C Palaganas, PhD, RN, NP; Roxane Gardner, MD, MPH, DSc; Bradley Morrison, PhD; Kate Morse, PhD, ARNP-BC, CRNP, CCRN, CNE; Daniel Raemer, PhD; Jenny Rudolph, PhD; Robert Simon, EdD; Toni Walzer, MD

Expert Communication: Frame and Reframe for Difficult Debriefing and Real Life (#17216)
Expert Workshop
Wednesday, January 20, 2016
08:30 am – 10:00 am
SDCC Room 30D (Room # Subject to Change)
Speaker(s): Marjorie Podraza Stiegler, MD; Rebecca D Minehart, M.D.

Improve Clinical Feedback Skills: Feedback Assessment for Clinical Education (FACE) (#16661)
Expert Workshop
Wednesday, January 20, 2016
08:30 am – 10:00 am
SDCC Room 25C (Room # Subject to Change)
Speaker(s): Rachel Onello, PhD, RN, CHSE, CNE, CNL; Melanie Louise Barlow; Emily Diederich; Jose M Maestre, MD, PhD; Rebecca D Minehart, M.D.; Janice C Palaganas, PhD, RN, NP; Jenny Rudolph, PhD

In-Situ Simulation: Tool for Diagnosis and Management of Latent Error (#17369)
General Panel Presentation
Wednesday, January 20, 2016
08:30 am – 10:00 am
SDCC Room 24B (Room # Subject to Change)
Speaker(s): Komal Bajaj, MD, CHSE; Adrienne J Birnbaum, NP; Ellen S Deutsch, MD, FACS, FAAP; Mary D Patterson, MD, MEd; Dan Raemer, PhD; Katie L Walker, MBA, RN

Enhance your Organization’s Meeting by Using Simulation: The National Patient Safety Foundation Story (#17569)
General Podium Presentation
Wednesday, January 20, 2016
10:15 am – 11:15 am
SDCC Room 31A (Room # Subject to Change)
Speaker(s): Allison F Perry, MA; Jeffrey B Cooper, PhD; Jared Kutzin, DNP, MS, MPH, RN, CPPS; Connie M Lopez, MSN, CNS, RNC-OB, CPHRM

Pushed to the Limit: Behind the Scenes (#21852)
General Panel Presentation
Wednesday, January 20, 2016
10:15 am – 11:15 am
SDCC Room 23C (Room # Subject to Change)
Speaker(s): Jamie Stiner; Roxane Gardner, MD, MPH, DSc; Jordan Halasz; Anthony LaPorta, MD, FACS; Kit Lavell; Steve Markham; Geoffrey T Miller, MS, EMT-P

 

RESEARCH ABSTRACTS

Debriefing Assessment for Simulation in Healthcare Rater Version (DASH-R): Assessment of Instrument Validity with Acute Care Nurse Practitioner Students (Submission #17434).
Board #146 – Research Study, Faculty Development
Theatre 3
Kate Morse, PhD, ARNP-BC, CRNP, CCRN, CNE, Marisa Brett-Fleegler, Jenny Rudolph, PhD, Robert Simon, EdD

Pre-Licensure Simulation-Enhanced Interprofessional Education (Sim-IPE): A Review of the Research Literature (Submission #15939)
Board #166 – Research Study, Interprofessional Education
Theatre 4
Veronique Brunette, MD, Janice Palaganas, PhD, RN, NP

Ob-Gyn Clerkship Preceptor Meetings: Is there a Role for Simulation? (Submission #16832)
Board #203 – Program Innovation, Obstetrics & Gynecology
Theatre 8
Kristen Uquillas, MD, Demian Szyld, MD, EdM, Colleen Gillespie, PhD, Karen Duncan, MD, Abigail Winkel, MD, Sondra Zabar, MD, Veronica Lerner, MD

Jeff Cooper Named to Becker’s List of 50 Experts Leading the Field of Patient Safety

Jeff Cooper, CMS’ Executive Director, was recently named by Becker’s Hospital Review to its list of 50 experts leading the field of patient safety. The list includes individuals at national organizations, universities and healthcare organizations working to improve patient safety and includes advocates, professors, researchers, administrators and healthcare providers who have won awards, published articles, spoken out and led initiatives to reduce harm and ensure safety.

Congratulations Jeff!

Captain Chesley ” Sully” Sullenberger visits CMS

 

Last Thursday CMS had the honor of hosting Captain Chesley “Sully” Sullenberger”.  Captain Sullenberger is the pilot who safely landed US Airways flight 1549 in the Hudson River in January, 2009 saving everyone on board after his aircraft hit a flock of birds knocking out both engines after takeoff. Captain Sullenberger, who retired from US Airways after thirty years of services in March, 2010, is a recognized expert on airline safety.  He’s  served as an instructor and as the Air Line Pilots Association Safety Chairman where his safety work led to the development of the Federal Aviation Administration Advisory Circular. Captain Sullenberger was instrumental in developing and implementing the Crew Resource Management course that is used by US Airways.  Since 2007 he has run his own consulting firm, Safety Reliability Methods (SRM), Inc. which provides expert solutions to complex problems involving safety, high performance, and high reliability in the aviation industry. And, this past May he became the Aviation and Safety Expert for CBS News. Captain Sullenberger is  interested in learning more about what can be done to improve safety in the healthcare sector and visited CMS to see the cutting edge work we’re doing using simulation to help improve the quality and safety of care delivered to patients.