Foundation Program Sites

2022 - 19th Annual Northwest Patient Safety Conference

The 19th Northwest Patient Safety Conference: Advancing Patient Safety in Today’s World”

October 18th and 19th, 2022
8:00 AM – 1:00 PM Pacific
Virtual Event

Conference Registration Is Open!
Click on the Registration tab to the left for more details

The 2022 Washington Patient Safety Coalition’s Northwest Patient Safety Conference is following up on last year’s most attended conference. Given the events of the past two years, this conference is about what lies ahead. We’re acknowledging the reality we’re living and working in, and we’re not interested in “how to deal with it”. We wanted faculty who will offer you new, and perhaps, provocative ideas and useful tools to improve safety and quality. You will be inspired, learn and entertained! We kept the fees the same as last year, $75 for the entire program including CEs. Its free to patients, their families and students.

Keynote Presentations
Click on the Speakers tab to the left for the full list of presenters

Jessie Singer, author of: There Are No Accidents.”
Going beyond the traditional system approaches, Jessie brings a fresh and expanded perspective to harm reduction outside of the usual healthcare approach we’re used to hearing about. You’ll view safety systems not only as tangible mechanisms, but as social systems.  Jessie is a journalist whose writing appears in The Washington Post, The Atlantic, The Nation, Bloomberg News, BuzzFeed, New York magazine, The Guardian, and elsewhere.

Anne Roberts and panel of advocates: “Lessons Learned from “Dr. Death”.
We invite you to hear the story of the now infamous case of Christopher Duntsch, aka “Dr. Death”, firsthand, from the physicians that petitioned the Texas Medical Board to revoke Dr. Duntsch’s license, and the attorneys that they partnered with to prosecute him in criminal court resulting in his current life sentence in prison. This case highlighted significant failures in the healthcare system that contributed to the death and/or permanent injury of 33/38 patients that he operated on.

Michelle Schreiber, MD, Deputy Director, Center for Clinical Standards and Quality, Centers for Medicare and Medicaid Services: The  2022 CMS Quality Strategy, CMS Levers of Safety. Dr. Schreiber will discuss the CMS National Quality Strategy that focuses on a person-centric approach from birth to death as individuals journey across the continuum of care. While past CMS strategies attained important achievements, in many cases they have not been sustained or been inclusive of underserved communities. On April 12, 2022, the agency launched the CMS National Quality Strategy, an ambitious long-term initiative that aims to promote the highest quality outcomes and safest care for all individuals.

Carole L.Hemmelgarn: “Who killed patient safety?” Carole, Martin Hatlie, Susan Sheridan and Beth Daley Ullem wrote the provocative opinion piece “Who killed patient safety?” in the May 5th edition of the Journal of Patient Safety and Risk Management. If you haven’t read it, do. While the World Health Organization and its member states are ramping up efforts, it appears to us that patient safety is adrift in the United States. The organizations who used to oversee, lead, and support safety have moved on to other priorities. Safety is no longer a critical part of their strategies, oversight, and programmatic funding. It is time those organizations and others do a deeper pause on their work to contemplate if they are leading in safety or they are complicit in the decline of safety in the U.S.  She will discuss why patient safety has fallen off the national agenda and identify how patients’ advocates can be the catalyst to revitalizing patient safety.

Armando Nahum, Patients for Patient Safety: Engaging Patients and Families in Quality and Safety: A deep, transparent partnership. In 2006, Armando Nahum and his wife Victoria began their work in patient advocacy and engagement by establishing Safe Care Campaign after 3 members of his family became infected in 3 different hospitals, in 3 different states in 10 months’ time, culminating with the death of his son, Josh. He was 27. He will describe the importance of Patient Experience and the Key Benefits of Person and Family Engagement. We’ll take a peek at the next generation of Patient and Family Advisory Councils and will describe the current state of Patient and Family Advisory Councils due to the pandemic and our current solution to rejuvenate them.

In addition to the keynotes there are nine breakout sessions with regional, national and international experts, thought leaders and your colleagues sharing tools and experiences on such topics as: restorative approaches after healthcare harm, tools to improve diagnosis, responding to culture of safety surveys, alternatives to traditional informed consent, burnout and wellness, shared decision making, impact of technology, “patient ergonomics”, wait WHAT??? Attend and find out. 

Sponsor Opportunities Are Available!
Click on the Become a Sponsor tab to the left

We are pleased to invite interested sponsors to support our 19th annual conference. All sponsors will be recognized on the Washington Patient Safety Coalition website and marketing materials. In addition to those benefits, there are several packages that offer improved visibility and marketing options. As a sponsor you are helping to defray the cost of the conference to healthcare staff and provide free attendance to families, patients and students. Sponsorship applications, benefits and details are available here

We want to thank this year’s sponsors:

Bronze: BETA Healthcare Group, First Choice Health
Friends: New Canvas Advising

Poster Applications Are Now Open!

  • Posters provide a visual display describing innovative approaches to practice, education, or research via short written narratives, tables, graphs, pictures, and/or charts.
  • In this virtual space, posters may be exhibited in a variety of formats on the conference web page from the beginning of the conference on October 18th. Poster formats may include but are not limited to: a virtual pdf of the poster, a slide deck, recorded video presentations. Poster presenters are encouraged to be available for online Q&A before the plenary sessions and during breaks to discuss their poster via chat with conference attendees.
  • All posters must be free of commercial bias.

Who attends

  • Patient safety practitioners, risk managers, quality leaders, and healthcare executives
  • Clinical program leaders and frontline clinicians from across the spectrum of care
  • Claims representatives and insurance professionals
  • Patient advocates and patient experience officers, patient and family advisory council members
  • Graduate and undergraduate health professions students
  • Interested patients, family members of patients, and community members

If you are interested in presenting please complete either the (on-line form) or (downloadable Word document).

This year’s conference is presented in collaboration with the Oregon Patient Safety Commission and the BC Patient Safety and Quality Council.

Conference Format: Virtual, you will receive a secure link to the conference presentations.

Dates and times: October 18, 8 a.m. – 1:00 p.m. & October 19, 8 a.m. – 12:30 p.m. Pacific Time

Total hours of presentations: 14.5

Fees:

  • Healthcare professionals and anyone seeking continuing educational credits, $75
  • Patients, their families, and students, Free
  • Discounts are offered for registrants with CPPS, CPHQ and BCPA certifications.

Payments accepted: all major credit cards via PayPal.

Last day to register: October 19, 2022

Continuing educational credits: Attendees are eligible for a variety of educational credits including, but not limited to, CNE, CPHQ, CPPS, BCPA and ACHE face to face credits.

Will the conference presentations be recorded? Yes. Registration is required to view recordings.

Is the conference open to anyone? Yes. If you are a healthcare professional or patient (aren’t we all?) you will find the conference rewarding.

Registration questions? Contact wpsc@qualityhealth.org or call Steve Levy, executive director, 206-204-7383.

Anne Roberts - Lessons Learned from “Dr. Death”

The now infamous case of Christopher Duntsch, aka “Dr. Death”, has highlighted significant failures in the healthcare system that contributed to the death and/or permanent injury of 33/38 patients that he operated on. The physicians that petitioned the Texas Medical Board to revoke Dr. Duntsch’s license, and the attorneys that they partnered with to prosecute him in criminal court resulting in his current life sentence in prison, invite you to hear their story, firsthand.

The panel will discuss the following:
• The complications discovered post-operatively for some of the most egregious of Duntsch’s cases
• The failure to disclose pertinent information from the training program, ensure sufficient training and significant conflicts of interest
• The failure of several hospital’s peer review programs and the Texas Medical Board to properly address significant complaints/peer review issues in a timely manner
• The breakdown at hospitals that inappropriately granted temporary privileges, ignored credentialing red flags or placed profit over patient safety
• How it took the criminal justice system, not the healthcare/peer review system, to ultimately stop him
• What physician leaders and administrators can do to strengthen their credentialing & peer review processes to avoid these pitfalls

Learning Objectives
• How the case went from malpractice to criminal
• System Failures that contributed to the injury of 33/38 patients he operated on
• Lessons learned and tips to avoid this type of failure within the overall healthcare system

Armando Nahum, Patients for Patient Safety - Engaging Patients and Families in Quality and Safety: A deep, transparent partnership

This session will describe the importance of Patient Experience and the Key Benefits of Person and Family Engagement. We’ll take a peek at the next generation of Patient and Family Advisory Councils and will describe the current state of Patient and Family Advisory Councils due to the pandemic and our current solution to rejuvenate them.

Leaning objectives
• Connecting the head with the heart
• Redefine Person and Family Engagement
• The importance of the Patient’s voice to improve Safety

Carole Hemmelgarn - Who killed patient safety?

Carole, Martin Hatlie, Susan Sheridan and Beth Daley Ullem wrote the provocative opinion piece “Who killed patient safety?” in the May 5th edition of the Journal of Patient Safety and Risk Management. If you haven’t read it, do. While the World Health Organization and its member states are ramping up efforts, it appears to us that patient safety is adrift in the United States. The organizations who used to oversee, lead, and support safety have moved on to other priorities. Safety is no longer a critical part of their strategies, oversight, and programmatic funding. It is time those organizations and others do a deeper pause on their work to contemplate if they are leading in safety or they are complicit in the decline of safety in the U.S. She will discuss why patient safety has fallen off the national agenda and identify how patients’ advocates can be the catalyst to revitalizing patient safety.

Learning objectives
• Discuss why patient safety has fallen off the national agenda.
• Identify how patients advocates can be the catalyst to revitalizing patient safety.

Chris Goeschel (New tools for improving diagnosis) - Improving Diagnostic Capacity: It takes a Team, Tools, and Tenacity

This session will provide a succinct overview of Diagnostic Improvement Tools and resources developed under a multiyear contract from the Agency for HealthCare Research and Quality. (Patient and Family Engagement in Diagnosis; TeamSTEPPS to Improve Diagnosis, Measure Dx; and Calibrate Dx.; along with 8 separate issue briefs on unique diagnosis related topics). PFE focuses specifically on helping patients and families speak up during the diagnostic process and understand the importance of their voice. TeamSTEPPS focuses on leveraging team contributions to diagnostic improvement; Measure Dx focuses on how organizations can identify and begin to measure opportunities for diagnostic improvement and Calibrate Dx is a tool that focuses on individual providers and the diagnostic process.

Learning objectives
• Define diagnostic error and its’ importance as a patient safety issue
• Explain the impact of provider communication breakdowns on diagnostic safety
• Define the diagnostic team and discuss barriers to effective teamwork and how to overcome them

Haavi Morreim - Artificial Intelligence in Healthcare: Reckoning with Errors in Medical Records

This session will provide a succinct overview of Diagnostic Improvement Tools and resources developed under a multiyear contract from the Agency for HealthCare Research and Quality. (Patient and Family Engagement in Diagnosis; TeamSTEPPS to Improve Diagnosis, Measure Dx; and Calibrate Dx.; along with 8 separate issue briefs on unique diagnosis related topics). PFE focuses specifically on helping patients and families speak up during the diagnostic process and understand the importance of their voice. TeamSTEPPS focuses on leveraging team contributions to diagnostic improvement; Measure Dx focuses on how organizations can identify and begin to measure opportunities for diagnostic improvement and Calibrate Dx is a tool that focuses on individual providers and the diagnostic process.

Learning objectives
• Define diagnostic error and its’ importance as a patient safety issue
• Explain the impact of provider communication breakdowns on diagnostic safety
• Define the diagnostic team and discuss barriers to effective teamwork and how to overcome them

Jessie Singer - There Are No Accidents

“There Are No Accidents” will provide a history lesson and primer on unintentional injury death, including the current crisis, and the historical framings of injury causality. She will provide stories of the corporate profitability of an “individual blame” model and evidence of the effectiveness of a systemic harm reduction model, as well as inspiration of the effectiveness of systemic injury prevention throughout history. She will also present a new conception of the “Swiss Cheese” model that accounts for social determinants of health.

Learning objectives
• Understanding the important differences in looking at “accident” causality through a human error vs. dangerous conditions model
• Learning why we blame human error, and why it is a disastrous tendency
• Learning what’s possible when we incorporate social determinants of health into our conception of injury prevention

Jodie Errington - Survey Results to Tangible Actions: Maximizing Impact of the Culture of Safety Survey

This session will focus on describing an innovative approach to the development of action items that address low scoring items on Fred Hutch Cancer Center’s biennial Culture of Safety Survey (CoSS). There is a paucity of literature on how to develop and implement targeted action items to address CoSS results. The existing literature is clear that safety culture is a unit level phenomenon co-created by all disciplines that work collaboratively in that area. Our Patient Safety Team developed a triad leadership approach to ensure accountability for review, discussion, development and follow up of action items: (1) Identification of Physician, NP/PA-C and Nurse Manager triad with established accountability for their unit’s CoSS results; (2) Development of a Tableau dashboard to easily visualize clinic results and specific strengths and opportunities; (3) Patient Safety led Action Planning Meeting with triad leaders to brainstorm contributing factors for lowest scoring item and develop 1 action item targeted to address that item; (4) 3-month follow up to check-in on status of action item.

Learning objectives
• Learn about an approach to establish multi-disciplinary creation and ownership for Culture of Safety Survey results by clinic area
• Review a practical, step by step methodology to develop an action item to target low scoring items from the Culture of Safety Survey for each clinic area
• Discuss lessons learned and specific challenges experienced throughout the development and implementation of this approach

John James - From Informed Consent to Probability Based, Shared Decision-Making

From Informed Consent to Probability Based, Shared Decision-Making John will use personal stories, legal decisions, and research findings to show how inadequate the concept of informed has become. It is being slowly replaced by shared decision-making (SDM) in which the preferences of the patient are combined with the knowledge of the clinician to optimize the patient’s medical care. He will describe ways in which SDM has fallen far short of what reasonable patients wish to know. John will describe in detail the findings of his research in which the voice of patients is finally being heard in the debate over what information should be disclosed. He will characterize the challenges of delivering SDM and how probability-based-shared decision making (PB-SDM) must replace traditional SDM to better inform patients of the risks they may be facing during their medical care.

Learning objectives
• Learn the shortcomings of traditional informed consent
• Learn the attributes and limitations of shared decision-making
• Understand the essentials of probability-based, shared decision making

Meghann Brinoni - Transformative Change in British Columbia: Advancing Cultural Safety and Relationship Based Approaches to Healing

Widespread and systemic racism, stereotyping, and discrimination against Indigenous peoples in the British Columbia (BC) health systems have resulted in a range of negative impacts, up to and including, harm and even death. This session will review advancements made in BC to affect systems change and improve Indigenous patient safety. The creation of BC Cultural Safety and Humility organizational standard – the first of its kind in Canada, and emerging work in applying restorative approaches to prevent and heal from health care harms will be discussed and explored.

Learning objectives
• Understand the need for a systems change approach to improving safety for Indigenous people in health care
• Identify how organizations can address systemic racism in their institutions
• Describe the principles of restorative approaches and how they might be applied to complaint management and dispute resolution

Michelle Schreiber - The 2022 CMS Quality Strategy and CMS Levers of Safety

Dr. Schreiber will discuss the CMS National Quality Strategy that focuses on a person-centric approach from birth to death as individuals journey across the continuum of care. While past CMS strategies attained important achievements, in many cases they have not been sustained or been inclusive of underserved communities. On April 12, 2022, the agency launched the CMS National Quality Strategy, an ambitious long-term initiative that aims to promote the highest quality outcomes and safest care for all individuals.

Rich Holden & Nichole Werner- Patient ergonomics – applying the science of patient work to design safer systems for patients and care partners

Patient Ergonomics” – the science of patient work – and how to design systems to improve safety by accommodating the work of patients and care partners. When patient work activities are unseen or underappreciated, patients may be denied formal assistance and expected to bear the burden alone or may not receive help in advance. Clinicians and patients may also end up with discordant ideas about what a patient is able to do, needs, or wants. When designers fail to see patient work, they fail to design systems to accommodate patients and other nonprofessionals’ roles in their own health. This presentation will describe tools and techniques for understanding “patient ergonomics” – the science of patient work – and how to design systems to improve safety by accommodating the work of patients and care partners.

Learning objectives
• Apply methods for studying and designing work to the domain of patient and care partner work
• Analyze how patient work contributes to patient safety during transitions of care
• Understand consistent findings about the nature of patient work and patient work systems

Robert Robson, Allison Kooijman and Meghann Brinoni - Restorative Practices: Enhancing healing and learning after healthcare harm

This session will briefly discuss the present structural and legislative barriers to (a) healing after healthcare harm (involving all direct participants – patients, families, communities, and healthcare providers), and (b) systemic and individual learning about a particular adverse event. The presentation will then review restorative principles and relational approaches in responding to harm events and contrast these with restorative justice. Case studies will be presented and, time permitting, a short video presentation. Finally, the presentation will review the initial experience of feasibility projects evaluating the introduction of restorative approaches after healthcare harm in two Health Authorities in B.C. will be reviewed including the course to train facilitators in restorative processes.

Learning objectives
• Participants will understand the structural, legislative and systemic barriers to promoting learning and healing after healthcare harm
• Participants will become familiar with the principles of restorative processes and understand the nature of relational approaches
• Participants will learn about the challenges of introducing and implementing restorative approaches in healthcare.

Skye McKennon - Restorative Practices: Safe and Well: Utilizing Evidence-Based Strategies to Promote Health Professional Well-Being and Patient Safety

Healthcare professionals were exhibiting distress prior to the COVID-19 pandemic including, but not limited to, stress, emotional exhaustion, depersonalization, and burnout. The already precarious state of health professional well-being has worsened in the last several years. Research has established the correlation between health professional burnout and worsening patient safety. The need to foster well-being for the safety of both patients and professionals is urgent. This seminar will teach strategies to cultivate well-being, promote resilience, and prevent burnout in your health systems, teams, and selves. We will begin with a brief overview of burnout. This will be followed by a robust active learning session focused on evidence-based and evidence-informed tools and approaches for well-being. Interventions stemming from the systems level will be the primary focus, but team and individual strategies will also be included. The learner will leave knowing factors that contribute to burnout, the inverse relationship between resilience and burnout, proven ways to promote resiliency and well-being, and how to access useful resources.

Learning objectives
• State the prevalence of healthcare professional burnout.
• Define moral injury.
• Outline approaches (systems-based, team-based, and individual-based) that improve healthcare professional well-being.
• Access resources to support healthcare professional well-being.

NWPSC22 Sponsors Image hyperlinks

Anne Roberts - Lessons Learned from “Dr. Death”

Anne Roberts is a dual-certified and nationally recognized consultant with over 25 years of experience assisting hospitals nation-wide with developing best practice credentialing, privileging and peer review programs. She serves as Of Counsel at the award winning trial law firm of Van Wey, Metzler & Williams in Dallas, Texas representing patients and families harmed by medical errors. She is also the System Vice President, Medical Affairs Operations at Mount Sinai Health System in New York City, and an award-winning author of numerous books published with a primary focus on legal strategies to prevent negligent credentialing and privileging in healthcare systems.

The panel of advocates presenting include:
• Anne Roberts
• Martin Lazar, MD – Neurosurgeon that served as the expert reviewer for the Texas Medical Board and advocated for revocation of his license and continues to advocate for patient safety and improved credentialing & peer review processes.
• Robert Henderson, MD – Orthopedic Spine Surgeon who performed numerous corrective surgeries after Duntsch injured the patients, and advocated for the Texas Medical Board, the ACGME and the Am. Board of Neurosurgery to strengthen their programs
• Kay Van Wey – Attorney who represented a great deal of the patients harmed and worked with the prosecution to distinguish between malpractice and criminal intent
• Michelle Shugart – Dallas Assistant District Attorney who partnered with the physicians and malpractice attorneys to prosecute Dr. Duntsch for his crimes and to prevent him from being able to harm more patients
• Robert Oshel, PhD – Retired Assoc. Director for Research & Disputes at the NPDB discusses NPDB reporting requirements, common misunderstandings and statistical breakdowns of report data

Armando Nahum, Patients for Patient Safety - Engaging Patients and Families in Quality and Safety: A deep, transparent partnership

Armando Nahum is the Co-Founder and President of Safe Care Campaign, an organization dedicated on Infection Prevention.

In 2006, Armando Nahum and his wife Victoria began their work in patient advocacy and engagement by establishing Safe Care Campaign after 3 members of his family became infected in 3 different hospitals, in 3 different states in 10 months’ time, culminating with the death of his son, Josh. He was 27.

The Nahums have not only turned their family’s tragedy into a positive tribute to their young son, but Armando’s educational presentations “Hospital Associated Infections: What YOU Should Know” and “Change One Thing, Change Everything” inspire hospital administrations and frontline caregivers to remind, provoke and motivate all who work in the continuum of care of their most noble challenge and moral duty to prevent these infections that annually infect more than 1.7 million and kill more than 99,000 patients in the U.S.

The story of Safe Care Campaign’s work has been featured on many national and local television and radio programs, including the CBS Evening News with Katie Couric, FOX News, CNN: The Situation Room with Wolf Blitzer and The Dr. Oz Show, as well as in numerous articles in journals and publications including Infection Control Today and CNN’s The Empowered Patient, as well as in numerous articles in journals and publications including: The Wall Street Journal, The Washington Post, The New York Times and Infection Control Today.

Armando has co-produced, with the Centers for Disease Control and Prevention (CDC), APIC and a grant from Kimberly-Clark, a patient safety video – the health care counterpart to the FAA safety demonstration that airlines are required to show passengers before every flight. The video was created to be used as part of every hospital admission to teach patients how to insist on safe care through the practice of hand hygiene.

Armando currently sits on the CDC Council on Infection Prevention, the Georgia Hospital Association Advisory Board to Prevent Infection, the Georgia Department of Public Health HAI Advisory Committee, a member of MedStar Health System Patient and Family Advisory Council for Quality and Safety (SPFACQS) and a voting member of the Presidential Advisory Council for Combating Antibiotic Resistant Bacteria (PACCARB). Along with his wife Victoria, Marty Hatlie and Dr. Tim McDonald, Armando has launched the Healthcare and Patient Partnership Institute (H2Pi) to effectively train Hospitals to achieve the stated goals of CMS’ Partnership for Patients by bringing the Patient and Family member’s voice into structured and sustainable Advisory Councils. Armando is a member of MedStar Health System Patient and Family Advisory Council for Quality and Safety (SPFACQS). He has been a driving force in establishing Patient and Family Advisory Council for Quality and Safety (PFACQS) at each of the 10 MedStar Hospitals as well as countless of PFACs across the country through a partnership with Vizient, Inc.

Carole Hemmelgarn - Who killed patient safety?

Carole Hemmelgarn, MS, MS, has worked in healthcare for 30 years. Her personal interest in the field of Patient Safety has lead Carole to get a Master of Science Degree in the field of Patient Safety Leadership from the University of Illinois Chicago. Carole is an adjunct professor at the University of Illinois Chicago and Georgetown University teaching in their master’s programs for Patient Safety. She holds a second Master’s Degree in Health Care Ethics from Creighton University. Carole is involved in patient safety work across the country. She sits on the Patient and Family Advisory Council for Quality and Safety at MedStar Health, Board of Quality, Safety and Experience at Children’s Hospital Colorado, Pediatric Sepsis Outcomes Collaborative at Children’s Hospital Colorado, Clinical Excellence Council for Colorado Hospital Association, Board of Directors for the Collaborative for Accountability and Improvement and MedStar Institute for Quality and Safety Advisory Board. Her passion resides in the area of Communication and Resolution Programs, health care communication, storytelling in health care and the aftermath endured by providers, patients and families when medical harm transpires.

Chris Goeschel (New tools for improving diagnosis) - Improving Diagnostic Capacity: It takes a Team, Tools, and Tenacity

Dr. Christine (Chris) Goeschel is a system leader, implementation scientist and quality and safety researcher at MedStar Health. She serves as Assistant Vice President in the MedStar Institute for Quality and Safety (MIQS) and inaugural Director of the Center for Improving Healthcare Diagnosis.A professor in the Georgetown University School of Medicine, Dr Goeschel is also Associate Faculty in the Johns Hopkins Bloomberg School of Public Health, where she co-directs a required course in the Master of Hospital Administration program.

The author of over 70 peer reviewed publications, Dr Goeschel currently serves on the board of a multi hospital healthcare system in Michigan, was appointed to the National Advisory Committee for the Coalition to Improve Diagnosis, and in 2019 received a 3-year appointment from the U.S. Department of Health and Human Services to the National Advisory Council for Quality and Safety Research (NAC). Dr Goeschel is Principal Investigator for the MedStar AHRQ ACTION III contract and PI on three unique multi-year awards focused on building diagnostic capacity and improving the diagnostic process.

Haavi Morreim - Artificial Intelligence in Healthcare: Reckoning with Errors in Medical Records

Jessie Singer - There Are No Accidents

Jessie Singer is a journalist whose writing appears in the Washington Post, The Atlantic, The Nation, Bloomberg News, BuzzFeed, New York magazine, The Guardian, and elsewhere. She studied journalism at the Arthur L. Carter School of Journalism at New York University, and under the wing of the late investigative journalist Wayne Barrett. Her book “There Are No Accidents is available at Simon & Schuster.

Jodie Errington - Survey Results to Tangible Actions: Maximizing Impact of the Culture of Safety Survey

Jodie Errington is a Quality & Patient Safety Program Manager at the Fred Hutch Cancer Care (FHCC). After earning her BSN from the University of British Columbia, Jodie worked as a chemotherapy certified nurse on the inpatient oncology unit at the British Columbia (BC) Cancer Agency in Vancouver, Canada. After 8 years there, she accepted a rural-remote position with an outpatient chemotherapy unit in Northern Canada’s Yukon Territory where she was one of two oncology nurses serving the entire Territory. After spending a year and a half in the North, Jodie returned to the Pacific Northwest where she continued to work per diem at the BC Cancer Agency while providing full-time support as a Clinical Specialist with the medical technology company Becton Dickinson, Canada, specializing in vascular access and biohazard safety. Prior to her role in the Quality Department, she worked as a staff nurse and Professional Practice Coordinator on the Apheresis unit at FHCC. Jodie can be contacted at jlerring@seattlecca.org.

Sarah Jaaskelainen is passionate about innovative solutions that lead to even safer healthcare systems for those who receive and provide it. Sarah is an experienced Registered Nurse with an extensive background in Medical-Surgical, Trauma, and Emergency Nursing and has worked in Chattanooga, TN and Seattle, WA. In 2019 she earned her master’s degree in International Development / Public Health from Andrews University. Sarah currently works at Fred Hutch Cancer Center (FHCC) as a Quality and Patient Safety Program Manager. Sarah can be contacted at sjaaskelai@seattlecca.org

John James - From Informed Consent to Probability Based, Shared Decision-Making

By profession John James was a toxicologist for NASA for 25 years, having retired in 2014. He became a patient safety activist because of his son’s death due to uninformed and unethical medical care. He published a book in 2007 called A Sea of Broken Hearts – Patient Rights in a Dangerous, Profit Driven Healthcare System. He published a seminal paper in 2013 showing that medical errors cause far more deaths than the Institute of Medicine estimated. He was told that his paper was the most cited paper ever published in the Journal of Patient Safety. He testified to a Senate Subcommittee on that subject in 2014 and coedited a book called The Truth about Big Medicine in 2015. He have given patient safety talks to medical students and physicians, to law students and lawyers, to nurses and nursing students, and to the public. In 2017 He turned to making the public smarter about getting safe healthcare. In 2019 He published a seminal paper on the wishes of patients when facing an invasive procedure.

Meghann Brinoni - Transformative Change in British Columbia: Advancing Cultural Safety and Relationship Based Approaches to Healing

Meghann began her career as a clinician in mental wellness and substance misuse at Interior Health and with First Nations across Secwepemc, Tsilhqot’in, and Dakelh territory. Later she conducted research related to mental wellness and land based approaches to healing. In 2014, Meghann joined First Nations Health Authority (FNHA) as the Manger of Research, Knowledge Exchange and Evaluation and in 2018 became the first Director of FNHA’s Quality department. Meghann resides in rural Northern Secwepemc territory and her passion is health systems improvement.

Michelle Schreiber - The 2022 CMS Quality Strategy and CMS Levers of Safety

Dr. Schreiber is currently the Deputy Director of the Center for Clinical Standards and Quality at CMS, and the Director of the Quality Measurement and Value-Based Incentives Group. While at CMS Dr. Schreiber has led many quality initiatives, including MIPS transformation to value pathways, the modernization of the Hospital Stars program, as well as advancing digital quality measurement systems. She is on the boards of ACCME (continuing medical education), Leapfrog, and a member of HITACH (the national health information advisory committee) among others. Prior to joining CMS she also participated in numerous state and national quality committees including the Board of Directors for the Michigan Hospital Association Keystone Center and the Patient Safety Organization, the Board of Directors of MPRO (Michigan Peer Review Organization – the Michigan QIO), the National Quality Forum Patient Safety Metrics Committee, and the National Quality Partners. She has worked with the Institute for Healthcare Improvement (IHI) including as part of its Leadership Alliance, the Pursuing Equity initiative, and an initiative to enhance Board of Trustees engagement in quality through a partnership with IHI and National Patient Safety Foundation. Dr. Schreiber has also served as a member of the Epic Safety Forum, and the Cerner Academic Advisory Group.

Rich Holden & Nicole Werner- Patient ergonomics – applying the science of patient work to design safer systems for patients and care partners

Dr. Rich Holden is an engineer, psychologist, and academic scientist with over 20 years’ experience working to improve health and healthcare. He is an internationally recognized innovator of human-centered systems engineering tools, and his work has been published in over 150 books and articles and supported by over $75 million in federal funding. He earned a joint PhD in Industrial Engineering and Psychology from the University of Wisconsin and is now at the Indiana University School of Public Health, where he is a Professor, Dean’s Eminent Scholar, and Chair of Health & Wellness Design.

Nicole Werner, PhD is an Associate Professor in the Department of Health and Wellness Design at the Indiana University School of Public Health-Bloomington. Trained in Human Factors and Applied Cognitive Psychology, she is a systems thinker and human-centered design evangelist committed to transforming the quality and safety of healthcare for people living with chronic conditions through human-centered system design. Her research, funded by the National Institutes of Health and the Agency for Healthcare Research and Quality, has produced innovative but realistic health technology and care process interventions to improve the quality and safety of healthcare within and across healthcare settings, with a particular focus on older and vulnerable populations and their care partners.

Robert Robson, Allison Kooijman and Meghann Brinoni - Restorative Practices: Enhancing healing and learning after healthcare harm

Rob Robson brings more than 20 years of direct experience in the patient safety field combined with more than 30 years as a healthcare mediator and conflict engagement practitioner, to supplement his ongoing practice as a primary care physician. He obtained his Master’s in Human Factors and system Safety at Lund University in Sweden and studied under Sidney Dekker and Erik Hollnagel. Rob has participated directly and indirectly in more than 1500 adverse event reviews and has developed a systemic nonlinear approach to promote learning after such reviews.

Meghann Brinoni, Director, Quality. First Nations Health Authority
Meghann began her career as a clinician in mental wellness and substance misuse at Interior Health and with First Nations across Secwepemc, Tsilhqot’in, and Dakelh territory. In 2014 ,Meghann joined First Nations Health Authority (FNHA) as the Manger of Research, Knowledge Exchange and Evaluation and in 2018 became the first Director of FNHA’s Quality department. Meghann resides in rural Northern Secwepemc territory and her passion is health systems improvement.

Allison Kooijman,PhD Student, Faculty of Health and Social Development, University of British Columbia Okanagan Campus
Injured as a result of a cancer misdiagnosis, Ali speaks with firsthand experience about the harm, after harm, that results when responses to patient safety incidents are less than ideal. Ali is a former licensed practical nurse and a current PhD student at the University of British Columbia, Okanagan Campus where she explores the contributions that a restorative approach could make to changing the culture of how harm is responded to in the healthcare context. Ali is grateful to reside on the Lands of the Syilx People in Coldstream, B.C.

Skye McKennon - Restorative Practices: Safe and Well: Utilizing Evidence-Based Strategies to Promote Health Professional Well-Being and Patient Safety

Skye McKennon is an educator, pharmacist, and author with a passion to empower others to live healthier, more intentional, and more resilient lives. Dr. McKennon is the Thread Director of Pharmacology and Interprofessional Education at the Washington State University Elson S. Floyd College of Medicine, where she also serves as a Clinical Associate Professor. She is a licensed pharmacist and board-certified pharmacotherapy specialist with over a decade of experience as a faculty member. She has experience delivering well-being, burnout prevention, and resiliency workshops and continuing education sessions for healthcare professionals regionally and nationally and has authored multiple book chapters and textbooks related to pharmacy, integrative health, and mind/body medicine.

NWPSC22 Sponsors Image hyperlinks

REGIONAL COLLABORATORS

 

 

 

 


BRONZE SUPPORTERS

 

 

 

 


SUPPORTERS OF PATIENT SAFETY

 

We are pleased to invite interested sponsors to support our 19th annual conference. As a sponsor you are helping to subsidize the cost of the conference to healthcare staff and provide free attendance to patients, families, and students.

THIS YEAR’S PACKAGES OFFER SEVERAL LEVELS FROM WHICH TO CHOOSE.

Details of package benefits are described in the application.

  • Platinum Sponsor – $10,000 (1 available)
  • Gold Sponsor(s) – $7,500 (3 available)
  • Silver Sponsor(s) – $5,000
  • Bronze Sponsor(s) – $2,500
  • Supporter(s) of Patient Safety -$1,500

All sponsors will be recognized on the Washington Patient Safety Coalition website and marketing materials with sponsor logos linking to a webpage of your choice.

Platinum, Gold, Silver and Bronze sponsors have access to a dedicated page on the conference website which can include images, videos, links, etc.

COMING SOON…

WELCOME TO THE 2022 19TH ANNUAL NORTHWEST PATIENT SAFETY CONFERENCE!

On the day of the conference, click on the button to enter the event portal. To gain access, you will be required to enter your attendee confirmation code that you can find at the bottom of your registration confirmation email. If you have any trouble getting in, please contact Steve Levy at 206-204-7383 or Amelina Kassa at 206-204-8384.