MARYLAND PATIENT SAFETY CONFERENCE - 14th ANNUAL

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14 th ANNUAL
        MARYLAND PATIENT SAFETY
             CONFERENCE
                               APRIL 13, 2018           |   HILTON BALTIMORE

Transparency and Communication: The Gateway to Patient Safety

                               Opening                                                        Closing
                               Keynote Speaker                                                Keynote Speaker
                               Rosemary Gibson                                                Ridley Barron
                               Senior Advisor,                                                Author, speaker and
                               The Hastings Center                                            patient safety advocate
                                                                                              Ridley Barron Ministries

       This educational activity is jointly provided by AXIS Medical Education and by Maryland Patient Safety Center.
2018 MARYLAND PATIENT SAFETY CONFERENCE • APRIL 13, 2018 • BALTIMORE HILTON
Target Audience: This activity would most likely appeal to those with an interest or occupation in the following fields: Nursing, Pharmacy, Physician, Quality,
Patient Safety, Risk Management, Clinical, Nursing Home Administrator. Purpose: The 2018 Maryland Patient Safety Conference provides the setting for health
care professionals from across the health care continuum and the region to discuss, learn and network with like-minded colleagues about topical patient safety issues
and solutions to generate positive change within the represented organizations. Overview: The 2018 Maryland Patient Safety Conference will bring together an
estimated 1,300 healthcare workers. In its 14th year, the conference will focus on today’s most pressing safety issues and how transparency and communication are
fundamental to improving the quality and safety of patient care. Objectives and descriptions will be listed with each session.

                                                                    DAY-AT-A-GLANCE
7:00am 		Registration, Breakfast, Visit Exhibitors and Patient Safety Poster Presentations
Key Ballroom lobby/Foyer
8:00am–8:15am 	Welcome & Introductions:
Key
		  Ballroom      James Rost, MD, FAAP, Vice President, Chief Medical Officer, Washington Adventist Hospital, MPSC Board Chair.
8:15am–9:15am 		 Opening Keynote Address: A Moment to Celebrate How Far We Have Come and Be Inspired to
Key Ballroom      Take the Next Big Leap.
			Rosemary Gibson, Senior Advisor, The Hastings Center.
9:15am–9:30am 	Recognition of the Minogue Award for Patient Safety Innovation Winner and Distinguished
Key Ballroom      Achievement in Patient Safety Innovation Winner

 9:30am–10:00am                    Break, Visit Exhibitors and Patient Safety Poster Presentations: Key Ballroom Lobby & Foyer

                                 Key Ballroom A                       Key Ballroom B                          Key Ballroom C                          Key Ballroom D
                                     Track 1                             Track 2                                 Track 3                                 Track 4

10:00am–11:00am            Intra-facility Patient Transfers:        Communication Access:                FY 17 Office of Health Care               From Deny and Defend
                                   Risky Business                 Improving Patient Safety by           Quality Patient Safety Update                   to CANDOR –
                               Cheryl Connors, MS, RN              Decreasing Communication                Anne Jones, RN, BSN, MA                 A Comprehensive and
                                 Patient Safety Specialist              Barriers in the                     Nurse Program Consultant               Principled Approach to
                             Armstrong Inst. for Patient Safety       Healthcare Setting                   Office of Health Care Quality          Responding when Patient
                                       and Quality                Denise McCall, MA, CCC-SLP                                                        Safety Events Occur
                                Johns Hopkins Medicine                   Program Director                                                              Martin Hatlie, JD
                                                                  Lisa Thornburg, MA, CCC-SLP                                                              Co-Director
                            Dennis Jones, DNP, RN, CCNS
                                                                         Assistant Director                                                            Kelly Smith, PhD
                                 Safety & Quality Officer
                                                                        SCALE@The League                                                           Senior Director, Research
                             Lifeline Critical Care Transport
                                                                                                                                               MedStar Institute for Quality & Safety
                            Program, Johns Hopkins Hospital

  11:00am–11:15am                  Break, Visit Exhibitors and Patient Safety Poster Presentations: Key Ballroom Lobby & Foyer

  11:15am–12:15pm              Medication Assisted                The End of Life Care Journey:                 Minogue Award for                 Evidence over Ideology:
                                    Treatment:                      Ensuring the Safest Care                      Patient Safety                Aligning SUD science, policy
                              A Priority Response to                    for our Patients                        Innovation Winner:                      and practice
                              Maryland’s Opioid Crisis                     Carol Cronin                   S.T.A.R.T. with the Patient               Tracey Myers-Preston
                             Kathleen Rebbert-Franklin,                  Executive Director              Leslie Clark, RN, LBSW, MSN                        Strategist
                                       LCSW-C                         Informed Patient Institute           Director, Population Health          The Maryland Addictions Directors
                                       Director,                         Seth Krevat, MD                  Lori Wilson, RN, BSN, MA                           Council
                             Health Promotion & Prevention,        Palliative Medicine, MedStar            Assistant VP, Patient Services           Kathleen O’Brien, PhD
                                   Behavioral Health               Georgetown University Hospital             UM Upper Chesapeake                    Chief Executive Officer
                                     Administration                          Moderator                            Medical Center                    Walden Behavioral Health
                             Maryland Department of Health               Matt Austin, PhD
                                                                         Assistant Professor
                                                                   Johns Hopkins University in the
                                                                        Armstrong Institute for
                                                                       Patient Safety & Quality

  12:15pm–1:00pm                  Lunch, Visit Exhibitors and Patient Safety Poster Presentations: Key Ballroom Lobby & Foyer

  1:00pm–2:00pm              What’s next when a cup of            Voices of Patients & Families:            Distinguished Achievement               The Safety Learning
                               coffee is not enough?                   A Panel Discussion                        in Patient Safety                Collaborative: Redefining
                            Addressing the highly valued             Cheryl & Paul Douglass                     Innovation Winner:                     Patient Safety
                             (“untouchable”?) clinician              Patient & Family Advocates          Reducing Opioid Prescribing:              Jeanne Huddleston, MD
                            who undermines your culture                     Jack Gentry                   A Health System Responds                     President and CEO
                               of safety and respect.                Patient & Family Advocate                 to the Epidemic                     HB Healthcare Safety, SBC
                                 Gerald Hickson, MD                       Ginger Rosela                     Barry Meisenberg, MD                         Tony Calabria
                             Senior Vice President for Quality,      Patient & Family Advocate          Director, DeCesaris Cancer Institute      Clinical Quality & Regulatory
                                 Safety & Risk Prevention                    Moderator                     Anne Arundel Medical Center                  Programs Director
                                   Vanderbilt University                  Robert Imhoff                                                        MedStar Institute for Quality & Safety
                                                                     President & CEO, MPSC

  2:00pm–2:30pm                    Break, Visit Exhibitors and Patient Safety Poster Presentations: Key Ballroom Lobby & Foyer

                                                                                            Key Ballroom

                                                                         Closing Keynote Address: Every 1/2 Second Counts
  2:30pm–3:30pm
                                                                    Ridley Barron, Author and Patient Advocate, Ridley Barron Ministries

       3:30pm                                                                     Closing Remarks and Adjournment:
                                                                      Robert Imhoff, President & CEO, Maryland Patient Safety Center
TRANSPARENCY AND COMMUNICATION: THE GATEWAY TO PATIENT SAFETY

                                                                                 made and their unique contributions to help ensure safer care.
                                           Key Ballroom                          Open and honest communication with patients, families, and
                                                                                 each other is the next big leap. Participants will come away
                                8:15 am – 9:15 am                                inspired to take that big leap together!
                                Opening Keynote
                                A Moment to Celebrate How Far                    Learning Objectives
                                We Have Come and Be Inspired                     1. Identify areas of progress in patient safety and reflect on the impact
                                                                                    their work has had on patients; and
                                to Take the Next Big Leap                        2. State one action step you will take to improve open and honest
                           Substantial improvements have oc-                         communication.
                           curred in patient safety in the nearly                Presenter
two decades since the IOM report, To Err is Human. During                        Rosemary Gibson
this presentation, participants will have the opportunity to step                Senior Advisor, The Hastings Center
back from their day-to-day work and reflect on the progress

               9:15 am – 9:30 am Recognition of 2018 Winners of Patient Safety Innovation Awards
               9:30 am – 10:00 am Break and Visit Exhibitors and Patient Safety Poster Presentations

                                                        CONCURRENT SESSIONS
                                                                                 3. L ist the steps taken by the State to increase access to medications, specifi-
               Track 1 (Key Ballroom A)                                             cally buprenorphine
                                                                                 Presenters:
10:00 am - 11:00 am                                                              Kathleen Rebbert-Franklin, LCSW-C
Intra-facility Patient Transfers: Risky Business                                 Director, Health Promotion & Prevention, Behavioral Health
Transporting patients to different departments and different                     Administration, Maryland Department of Health
caregivers can be risk-prone. The process can involve several
caregivers with varying skill sets, who may not be familiar with                 12:15 pm – 1:00 pm Lunch and Visit Exhibitors and
the patient. Johns Hopkins conducted an in-depth analysis to                     Patient Safety Poster Presentations
identify the root causes of risk during transport. This session will
share relevant risks and strategies to improve safety for patients               1:00 pm – 2:00 pm
during transport.                                                                What’s next when a cup of coffee is not enough?
Learning objectives:                                                             Addressing the highly valued (“untouchable”?)
1. List the risks that may occur during patient transport                        clinician who undermines your culture of safety
2. Identify at least two strategies to improve safety during patient transport   and respect.
3. Use a checklist to assess safety during transport
                                                                                 Unprofessional behavior by 2-8% of physicians and advanced
Presenters:                                                                      practice professionals in virtually all medical groups is associated
Cheryl Connors, MS, RN                                                           with greater risk of patient complaints, professional liability claims,
Patient Safety Specialist, Armstrong Institute for Patient Safety                post-procedure complications, impaired teamwork, symptoms of
and Quality, Johns Hopkins Medicine                                              burnout and reduced loyalty of patients and staff.
Dennis Jones, DNP, RN                                                            Based on Vanderbilt’s 20+ years of research and experience with
Safety and Quality Officer, Lifeline Critical Care Transport                     medical groups now numbering more than 66,000 physicians,
Program, Johns Hopkins Hospital                                                  we’ve learned that every organization needs a plan, a tiered inter-
                                                                                 vention process (a “Professionalism Pyramid), and an infrastructure
11:15 am – 12:15 pm                                                              for early identification and action in support of that small propor-
Medication Assisted Treatment: A Priority Response                               tion of professionals who disproportionately dissatisfy their patients
to Maryland’s Opioid Crisis                                                      and/or raise concerns among their co-workers. This presentation
This presentation will provide the audience with information                     begins with the case of Dr. X, a highly valued (“untouchable”?)
about how Maryland is addressing the opioid crisis, particularly                 clinician who nevertheless undermines the organization’s culture of
through expanding access to medication-assisted treatment. Opi-                  safety and respect. The presentation describes how Dr. X’s leaders
oid overdose prevention is a major priority for Maryland, and                    learned to begin with informal feedback (“cup of coffee conver-
improving access to evidence-based services is a key component.                  sations”) from colleagues, but when that didn’t work, learned to
The presenter will discuss addressing stigma, expanding bu-                      intervene with local and national peer-comparative data and stories.
prenorphine prescribers, and partnering with hospital and other                  Based on a tiered intervention approach his feedback is designed
health systems to implement early intervention activities.                       to make Dr. X aware of her/his status vs. others both in the lo-
                                                                                 cal medical group and in the particular practice specialty nation-
Learning Objectives:                                                             ally. These non-directive, non-judgmental feedback sessions are
1. Identify the overarching goals of the State in addressing the opioid
   overdose crisis                                                               designed to prompt physician/APP self-regulation, which occurs
2. Describe how public awareness activities can address stigma                   75-80% of the time. Unfortunately, Dr. X failed to self-regulate, so
TRANSPARENCY AND COMMUNICATION: THE GATEWAY TO PATIENT SAFETY

the presentation describes the next steps involving carefully tailored              system, we will explore with experts in patient-centered and
interventions guided by an authority. The authorities develop ac-                   palliative care how the healthcare system can better ensure
tion plans involving ongoing assessment and accountability and                      end of life care that is both safe and follows the values and
improve results for more than 60% of intervention recipients.                       preferences of our patients.
As a result of interventions guided by Dr. X’s authority (Clinical
                                                                                    Learning Objectives:
Department Chair, Chief, VPMA, CMO or equivalent), Dr. X’s                          1. Describe where patient safety concerns exist in the provision of end of life
patient and co-worker complaints fell substantially, reducing Dr.                       care
X’s malpractice claims and risk of other adverse outcomes to Dr.                    2. Identify solutions that the health care delivery system could adopt to
X’s organization and patients. The presentation concludes with                          improve patient safety in end of life care
                                                                                    3. Describe how the health care delivery system can best incorporate the
an overview of best practices associated with our tiered interven-                      patient’s voice into improving the safety of end of life care
tion approach and tools leaders need that address, support, incen-
tivize, and monitor those clinical colleagues identified as high risk.              Presenters:
                                                                                    Matt Austin, PhD
Learning Objectives:                                                                Assistant Professor, Johns Hopkins University in the Armstrong
1. Describe a range of unprofessional behaviors that increase risk of profes-
   sional liability claims and adverse surgical outcomes;                           Institute for Patient Safety and Quality – Panel Moderator
2. L ist key elements of an organizational infrastructure required to support      Carol Cronin
    effective efforts to reduce unprofessional conduct among clinicians;            Executive Director, Informed Patient Institute
3. Identify the levels of a model of tiered accountability for addressing single
    incidents, apparent patterns, and persistent patterns of unprofessional         Seth Krevat, MD
    behavior; and                                                                   Palliative Medicine, MedStar Georgetown University Hospital
4. Discuss how the same infrastructure and model of tiered accountability
    may be implemented to increase the likelihood of successful organiza-
    tional safety and quality improvement initiatives.                              12:15 pm – 1:00 pm Lunch and Visit Exhibitors and
                                                                                    Patient Safety Poster Presentations
Presenter:
Gerald Hickson, MD                                                                  1:00 pm – 2:00 pm
Senior Vice President for Quality, Safety and Risk Prevention,                      Voices of Patients and Families: A Panel Discussion
Vanderbilt University                                                               This panel discussion will explore the importance of the
                                                                                    communication exchange between patients and clinicians.
               Track 2 (Key Ballroom B)                                             Patient and family experiences from three different perspectives
                                                                                    will be presented. Included in the discussion around these
10:00 am – 11:00 am                                                                 patient perspectives will be the importance and necessity for
Communication Access: Improving Patient Safety by                                   transparency. An opportunity for audience interaction with
Decreasing Communication Barriers                                                   panelists will be provided.
Effective patient-provider communication is an essential com-
ponent of quality healthcare and patient safety, as well as a                       Learning Objectives:
                                                                                    1. Discuss the impact of transparent communication after medical error,
basic right of every patient. However, employees in health care                         including disclosing the mistake to the patient
settings are typically unaware of methods of facilitating com-                      2. Describe the benefits of adverse event disclosure to patients and families
munication for individuals who have difficulty speaking, hearing,                   Presenters:
seeing, understand, reading, writing or remembering. This pre-                      Robert Imhoff
sentation will provide participants with the knowledge, training,                   President and CEO, Maryland Patient Safety Center – Panel
tools and resources needed to implement change in their health                      Moderator
care setting. Tool kits and free downloadable resources will be                     Cheryl and Paul Douglass, Patient and Family Advocates
presented, with action ideas for implementing these materials.                      Jack Gentry, Patient and Family Advocate
Learning Objectives:                                                                Ginger Rosela, Patient and Family Advocate
1. Describe the impact of ineffective patient–provider communication on
    patient safety
2. Define the barriers to effective patient–provider communication
3. E xplore on-line communication tools, videos and training materials
                                                                                                   Track 3 (Key Ballroom C)
    designed to reduce safety risks
4. Name supportive communication tools and techniques to improve                   10:00 am – 11:00 am
    effective communication in medical settings.
                                                                                    FY 17 Office of Health Care Quality Patient Safety
Presenters:                                                                         Update
Denise McCall, SLP                                                                  This session presents adverse event cases reported through the
Program Director, SCALE @ The League                                                Office of Health Care Quality’s mandatory hospital reporting
Lisa Thornburg, SLP                                                                 system. Trends in reported events, root causes, and corrective
Assistant Director, SCALE @ The League                                              actions will be discussed, as well as findings from submitted
                                                                                    RCAs and individual case studies. In addition, an in-depth look
11:15 am – 12:15 pm                                                                 at the 54 preventable deaths from FY 17 will be presented.
The End of Life Care Journey: Ensuring the Safest                                   Learning Objectives:
Care for our Patients                                                               1. Describe the data regarding reported events for FY17.
Through the lens of a patient’s journey through the healthcare                      2. Explain the context of trends and meaningful single events, and
TRANSPARENCY AND COMMUNICATION: THE GATEWAY TO PATIENT SAFETY

3. Identify some commonalities among the preventable deaths from FY17               Learning Objectives:
Presenter:                                                                          1. Describe the role medically prescribed opioids play in generating and
                                                                                        sustaining opioid addiction.
Anne Jones, RN, BSN, MA                                                             2. L ist the details of a multi-faceted approach to reducing opioid demand
Nurse Program Consultant, Office of Health Care Quality                                 and prescribing within a health system.
                                                                                    3. Identify the major educational points and data support for prescriber
                                                                                        educational sessions.
                           11:15 am – 12:15 pm                                      Presenter:
                           Minogue Award for Patient                                Barry Meisenberg, MD

           8
                           Safety Innovation Winner                                 Director, DeCesaris Cancer Institute,
                           S.T.A.R.T. with the Patient                              Anne Arundel Medical Center
                        The “S.T.A.R.T. with the Patient: A Safe
                        Transition Assessment and Risk Tool” pre-
                        sentation will guide the audience through                                  Track 4 (Key Ballroom D)
the creation and implementation of University of Maryland
Upper Chesapeake Health’s START Status Board. This tool                             10:00 am – 11:00 am
assesses patients for readmission risks from the time of admission                  From Deny and Defend to CANDOR – A
through discharge, and seeks to alert the clinical teams to obtain                  Comprehensive and Principled Approach to
appropriate resources and interventions for these patients. During                  Responding when Patient Safety Events Occur
this presentation, the audience will also learn about the process,                  Disclosure and apology after medical error emerged in the
collaboration and subsequent interventions that made the success                    1990s as both public policy goal and risk management strategy.
of this work possible, and improve outcomes and experiences of                      Two decades later, CANDOR (Communication and Optimal
care transitions for their patients.                                                Resolution) has evolved as a principled and comprehensive
Learning Objectives:                                                                approach focused on empathic communication after Patient
1. Describe the process of development and implementation of the START             Safety events occur, transparency, learning & prevention, and
    Status Board in the context of a collaborative interdisciplinary workgroup.     fair & effective management of liability exposure. Innovators
2. Identify risk stratification methods, interventions that mitigate readmission
    risk factors, and appropriate resources for patient transitions.                have demonstrated impact on event reporting, practice patterns
3. Discuss sustainability strategies for the START tool to improve the quality     and liability reduction. Care for healthcare workers has emerged
    and experience of care transitions for patients.                                as important to harm prevention as well as workforce well-
Presenters:                                                                         being. This session will describe CANDOR components and
Leslie Clark, RN, LBSW, MSN                                                         the rationale behind a CANDOR approach. Participants will
Director, Population Health                                                         also explore implementation opportunities and challenges
Lori Wilson, RN, BSN, MA                                                            using a case study of impact on patient safety at one large MD
Assistant VP, Patient Services                                                      health system.
UM Upper Chesapeake Medical Center                                                  Learning Objectives:
                                                                                    1. Describe the importance of transparency and empathy in responding
12:15 pm – 1:00 pm Lunch and Visit Exhibitors and                                       to patient safety events, maximizing learning and managing liability
Patient Safety Poster Presentations                                                     exposure
                                                                                    2. Identify the opportunities and challenges for health systems in adopting
                                                                                        CANDOR
1:00 pm – 2:00 pm                                                                   3. Discuss one health system’s early results after embedding a CANDOR
Distinguished Achievement in Patient Safety                                             within their comprehensive patient safety program
Innovation Winner                                                                   Presenter:
Reducing Opioid Prescribing: A Health System                                        Martin Hatlie, JD
Responds to the Epidemic                                                            Co-Director, MedStar Institute for Quality & Safety
This session will describe actions taken to reduce opioid pre-                      Kelly Smith, PhD
scribing within various services of a health system, including                      Senior Director, Research, MedStar Institute for Quality &
patient and public education, prescriber education, prescriber                      Safety
oversight, empowerment of medical directors with actual data
of prescribing patterns and enhanced electronic medical record                      11:15 am – 12:15 pm
(EMR) tools to facilitate referrals to substance abuse services.                    Evidence over Ideology: Aligning SUD (Substance
Outcomes of this work include a >50% decrease in overall                            Use Disorder) Science, Policy and Practice
prescribing amounts both in volume and rate of opioid prescrip-                     Addiction is a complex social and medical issue that requires
tions. The trend has spread from initial target areas, to other                     well-informed and complex solutions. Our current treatment
departments, suggesting spreading culture change in approach                        system often fails those in need because of its entrenchment in
to prescribing these medications. Patient satisfaction with pain                    flawed views of the disease of addiction and approaches that are
management did not decrease during the roll-out of these inter-                     based on ideology rather than the science at hand. In this session,
ventions. The presentation will highlight some of the interven-                     participants will gain insight on dismantling the long-standing
tions used to achieve these results including the content of the                    and flawed assumptions that hinder high-quality addiction-
academic detailing for prescribers, the data report created for                     related healthcare and put science at the center of policy making
medical directors and elements of the patient education.                            and clinical best practices.
TRANSPARENCY AND COMMUNICATION: THE GATEWAY TO PATIENT SAFETY

Learning Objectives:                                                                                  explore principles of high reliability that will enable them to
1. Identify effective communication strategies that raise SUD care standards                          look beyond peer review and toward inter-professional change.
2. Discuss how to increase transparency around data-driven decision                                  Safety problems facing healthcare will be considered, and
   making and outcomes
3. List activities that promote evidence-informed policies and practices.                             evidence will show that acts of omission, not commission are
                                                                                                      the largest.
Presenters:
Tracey Myers-Preston                                                                                  Learning Objectives:
Strategist, The Maryland Addictions Directors Council                                                 1. I mplement a learning system that embodies principles of high reliability
Kathleen O’Brien, PhD                                                                                     — specifically, deference to expertise
                                                                                                      2. Outline strategies to move beyond the medical model of peer review to a
Chief Executive Officer, Walden Behavioral Health                                                         process of inter-professional learning that leads to actionable information
                                                                                                          and change
                                                                                                      3. Define the largest safety problems facing health care today: acts of
12:15 pm – 1:00 pm Lunch and Visit Exhibitors and                                                         omission, not commission.
Patient Safety Poster Presentations
                                                                                                      Presenters:
1:00 pm – 2:00 pm                                                                                     Jeanne Huddleston, MD
The Safety Learning Collaborative: Redefining                                                         President and CEO, HB Healthcare Safety, SBC
Patient Safety                                                                                        Tony Calabria
This session will provide learners with the information to                                            Clinical Quality & Regulatory Programs Director, MedStar
                                                                                                      Institute for Quality & Safety

                                                                                         Key Ballroom

2:30 pm – 3:30 pm Closing Keynote                                                                      leave the session with practical steps to promote safety in their
Every 1/2 Second Counts                                                                                culture.

                        What can be done in our healthcare                                             Learning Objectives:
                                                                                                       1. Recognize how to create consumer./user friendly environments
                        systems to improve overall quality? As                                         2. Demonstrate increased awareness of individual patient concerns in
                        people continue to serve in healthcare,                                           regards to their safety
                        there will continue to exist a human                                           3. Create patient-centered care that takes place in threat free environments
                                                                                                           through greater awareness of safety issues
                        component—the potential for error. In                                          4. E xplain concerns centered around the “second victim” (health care
                        this session, participants will learn from                                         workers involved in adverse events)
                        the family member of one victim. They
                        will be challenged by seven simple                                             Presenter:
                        principles that are drawn directly from                                        Ridley Barron
his personal experience. Participants will be encouraged to                                            Author, Speaker, Patient Advocate,
apply these principles to the own situations. Listeners will                                           Ridley Barron Ministries

                                                                                     The strategic initiatives and priorities of the Maryland Patient Safety Center
Meet the Board of Directors                                                          are guided by a voluntary board of directors.

CHAIR                                       Badia Faddoul, RN, DNP, CCR, CPHQ,                 Andrea M. Hyatt, CASC                                    Sherry Perkins, PhD, RN, FACHE
James R. Rost, MD                           Director of Quality & Safety                       President		                                              Executive Vice President & Chief
Vice President & Chief Medical Officer      University of Maryland Community Medical Group     Maryland Ambulatory Surgery Association		                Operating Officer
Adventist Healthcare                                                                                                                                    Dimensions Health
                                            E. Robert Feroli, Jr., PharmD, FASHP,              Robert Imhoff
Washington Adventist Hospital
                                            FSMSO                                              President & CEO                                          Podge M. Reed Jr.
Gerald Abrams                               Medication Safety                                  Maryland Patient Safety Center                           Former Hospital Administrator
Director                                    Armstrong Institute Johns Hopkins Hospital                                                                  Patient Advocate
                                                                                               Sen. Katherine Klausmeier
Abrams, Foster, Nole & Williams, PA
                                            Brian J. Frankel                                   Maryland State Senate, District 8                        Del. Sheree Sample-Hughes
Kelly Corbi                                 Assistant Fire Chief                                                                                        Maryland House of Delegates, District 37A
                                                                                               Lawrence S. Linder, MD, FACEP, FAAEM
Chief Operating Officer                     Prince George’s County Fire/EMS Dept.
                                                                                               Former President and CEO                                 Nicole Dempsey Stallings
Northwest Hospital
                                            Eugene A. Friedman, Esq.                           University of Maryland Community Medical Group           Vice President, Policy & Data Analytics
Joseph DeMattos, Jr., MA,                   Former Corporate Counsel, 1st Mariner Bank                                                                  Maryland Hospital Association
                                                                                               Martin A. Makary MD, MPH, FACS
President                                   Trustee, LifeBridge Health
                                                                                               Professor of Surgery, Johns Hopkins School of Medicine   Barbara Tachovsky, MSN, PN, NEA-BC,
Health Facilities Association of Maryland
                                            Paul Fronstin, PhD                                 Professor of Health Policy & Management,                 FACHE
Barbara Epke                                Director, Center for Research on Health            Johns Hopkins University School of Public Health         Former President
Vice President                              Benefits Innovation                                Chief, Islet Transplant Surgery                          Mainline Hospitals, Paoli, PA
LifeBridge Health, Inc. & Sinai Hospital    Employee Benefit Research Institute                Johns Hopkins Hospital
                                                                                                                                                        Michael R. Yochelson, MD, MBA,
of Baltimore
                                            Jack Gentry                                        David B. Mayer, MD                                       FACHE
                                            Retired Police Officer, Baltimore City             Corporate Vice President, Quality & Safety               Chief Medical Officer
                                            Patient Advocate                                   MedStar Health                                           Shepherd Center, Atlanta GA
REGISTRATION

      14TH ANNUAL MARYLAND PATIENT SAFETY CONFERENCE
                        APRIL 13, 2018

                      ONLINE REGISTRATION CLOSES March 30, 2018

       To Register:
       • Visit MarylandPatientSafety.org. Complete all individual registration information, most
           importantly the registrant’s email address (You may include a secondary email address for
           others to receive correspondence regarding registration and program information).

       • I f you will be submitting a check request through your organization, please choose the
           “Register and Pay Later” option.

       • You will receive correspondence immediately following your submission of the registration
           online.

       • I f you do not receive a confirmation email or if you have any questions regarding our
           registration process, please contact Lorie Catsos at 410.540.9210 or
           lcatsos@marylandpatientsafety.org.

       FEE for all participants
       FREE with Maryland Patient Safety Center membership (Register by March 30, 2018).
       Early Registration and payment received by Friday, March 16, 2018: $299
       Late Registration and payment received between March 17–March 30, 2018: $345
       On-site Registration and payment (including those not yet paid): $399
       Full-time Student: $99 (student ID required)

       “No shows” and cancellations received after April 3 will be subject to a $125 cancellation fee
       per the Center’s policy

       All attendees, including Maryland Patient Safety Center member organizations and
       non-members, must register by March 30, 2018 to receive special pricing. All on-site
       registrations must provide payment of $399.

Breakfast and lunch                   Weather Policy:                       Special Note:
will be provided.                     In the event of adverse weather       The Maryland Patient Safety Center wishes to en-
While we do provide a vegetarian      conditions, the decision to cancel    sure that no individual with a disability is excluded,
option, please contact Lorie Catsos   or delay the Conference will be       denied services, segregated or otherwise treated
if you have any other dietary         made by 5:00 a.m. the morning of      differently from other individuals because of the
restrictions at                       the Conference. To find out if the    absence of auxiliary aids and services. If you need
lcatsos@marylandpatientsafety.org.    Conference is delayed or cancelled,   any of the auxiliary aids or services identified in
                                      please call 410-540-9210 after        the Americans With Disabilities Act, please contact
                                      5:00 a.m. on April 13.                Lorie Catsos at lcatsos@marylandpatientsafety.org.
CONTINUING EDUCATION

Accreditation Statement                                                                     Matt Austin, PhD			                        Nothing to disclose
In support of improving patient care, AXIS Medical Education is jointly                     Carol Cronin				                           Nothing to disclose
accredited by the Accreditation Council for Continuing Medical Education                    Seth Krevat				                            Nothing to disclose
(ACCME), the Accreditation Council for Pharmacy Education (ACPE), and                       Kathleen Rebbert-Franklin		                Nothing to disclose
the American Nurses Credentialing Center (ANCC), to provide continuing                      Leslie Clark, RN, LBSW, MSN		              Nothing to disclose
education for the healthcare team.                                                          Lori Wilson, RN, BSN, MA		                 Nothing to disclose
                                                                                            Tracey Myers-Preston			                    Nothing to disclose
Credit Designation for Physicians
AXIS Medical Education designates this live activity for a maximum of 5.0                   Kathleen O’Brien, PhD			                   Nothing to disclose
AMA PRA Category 1 Credits™. Physicians should claim only the credit com-                   Gerald Hickson, MD			                      Nothing to disclose
mensurate with the extent of their participation in the activity.                           Cheryl Douglass 			                        Nothing to disclose
                                                                                            Paul Douglass 			                          Nothing to disclose
Credit Designation for Pharmacists                                                          Jack Gentry				                            Nothing to disclose
This knowledge based activity is approved for 5.0 contact hours of continuing               Ginger Rosela			                           Nothing to disclose
pharmacy education credit ( JA4008106-9999-18-013-L05-P).                                   Robert Imhoff			                           Nothing to disclose
                                                                                            Barry Meisenberg, MD			                    Nothing to disclose
Credit Designation for Nursing                                                              Jeanne Huddleston, MD			                   Nothing to disclose
AXIS Medical Education designates this continuing nursing education                         Richard (Tony) A. Calabria, Jr.		          Nothing to disclose
activity for 5.0 contact hours.
                                                                                            Ridley Barron			                           Nothing to disclose
Learners are advised that accredited status does not imply endorsement by the provider or
ANCC of any commercial products displayed in conjunction with an activity.
                                                                                            The planners and managers reported the following financial relationships
Quality Professionals                                                                       or relationships they or their spouse/life partner have with commercial inter-
This program has been approved by the National Association for Healthcare                   ests related to the content of this continuing education activity:
Quality for 5.0 CPHQ continuing education hours.
                                                                                            Name of Planners			                        Reported Financial Relationship
Risk Management                                                                             Dee Morgillo, MEd., CHCP		                 Nothing to disclose
This program is pending approval for a total of 5.0 contact hours of continu-               Ronald Viggiani, MD			                     Northing to disclose
ing education credit toward fulfillment of the requirements of ASHRM                        Bonnie DiPietro, MS, RN, NEA-BC, FACHE     Nothing to disclose
designations of fellow (FASHRM) and distinguished fellow (DFASHRM)                          Robert Imhoff			                           Nothing to disclose
and towards certified professional in healthcare risk management (CPHRM)
renewal.
                                                                                            Disclaimer
Respiratory Therapists                                                                      Participants have an implied responsibility to use the newly acquired informa-
Application has been made to the American Association for Respiratory Care                  tion to enhance patient outcomes and their own professional development.
(AARC) for continuing education contact hours for respiratory therapists.                   The information presented in this activity is not meant to serve as a guideline
                                                                                            for patient management. Any procedures, medications, or other courses of di-
Long Term Care Administrators                                                               agnosis or treatment discussed in this activity should not be used by clinicians
This program has been submitted (but not yet approved) for Continuing                       without evaluation of patient conditions and possible contraindications on
Education for 5.0 total clock hours from NAB/NCERS.                                         dangers in use, review of any applicable manufacturer’s product information,
                                                                                            and comparison with recommendations of other authorities
AXIS Contact Information
For information about the accreditation of this program please contact AXIS                 Disclosure of Unlabeled Use
at info@axismeded.org.                                                                      This educational activity may contain discussion of published and/or inves-
                                                                                            tigational uses of agents that are not indicated by the FDA. The planners of
Disclosure of Conflicts of Interest                                                         this activity do not recommend the use of any agent outside of the labeled
AXIS Medical Education requires instructors, planners, managers and other                   indications.
individuals and their spouse/life partner who are in a position to control the
content of this activity to disclose any real or apparent conflict of interest they         The opinions expressed in the educational activity are those of the faculty
may have as related to the content of this activity. All identified conflicts of            and do not necessarily represent the views of the planners. Please refer to the
interest are thoroughly vetted by AXIS for fair balance, scientific objectivity             official prescribing information for each product for discussion of approved
of studies mentioned in the materials or used as the basis for content, and                 indications, contraindications, and warnings.
appropriateness of patient care recommendations                                             Americans with Disabilities Act
The faculty reported the following financial relationships or relationships                 In compliance with the Americans with Disabilities Act, we will make every
they or their spouse/life partner have with commercial interests related to the             reasonable effort to accommodate your request. For any special requests,
content of this continuing education activity:                                              please contact Maryland Patient Safety Center at 410-540-9210 or at
                                                                                            lcatsos@marylandpatientsafety.org before the meeting date.
Name of Faculty/Presenter/Planner Reported Financial Relationship
Rosemary Gibson			                Nothing to disclose                                       Requirements for credit:
                                                                                            • Attend/participate in the educational activity and review all course
Cheryl Connors			                 Nothing to disclose
                                                                                               materials.
Dennis Jones, DNP, RN, CCNS		     Nothing to disclose
                                                                                            • Complete the CE Declaration/Evaluation form online by 11:59 pm ET on
Martin Hatlie			                  Speakers Bureau: MedStar Health,
                                                                                               May 13, 2018. Instructions will be provided. If you do not complete the
				Vizient Inc.                                                                               online evaluation by this date, you will not be able to get CME/CE credit
Kelly Smith				                   Nothing to disclose                                          for this event.
Anne Jones, RN, BSN, MA 		        Nothing to disclose                                       • Upon successful completion of the online form, your statement of comple-
Denise McCall, MA, CCC-SLP		      Nothing to disclose                                          tion will be presented to you to print. Pharmacists, your record will be
Lisa Thornburg, MA, CCC-SLP		     Nothing to disclose                                          automatically uploaded to CPE Monitor.
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