Patient Safety: Where Do We Begin?
John J. Nance, JD, ABC News Correspondent / Aviation Expert and founding board member of the National Patient Safety Foundation
Martin J. Hatlie, JD; President, Partnership for Patient Safety (p4ps)

This session presented an overview of the challenges and opportunities facing the patient safety movement, nationally and locally, in both the healthcare delivery system and the external environment in which it operates. Mr. Nance and Mr. Hatlie outlined a framework for patient safety accountability and outline key components of a "culture of safety."

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Opening Remarks
The Commonwealth’s Perspective
The Honorable John Hager, Lieutenant Governor of Virginia
Introduced by:
Tom G. Snead Jr.
Chairman of the Board and CEO
Trigon Blue Cross Blue Shield

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From Aviation to Medicine: Near Hits and Sentinel Events
John J. Nance, JD, ABC News Correspondent /Aviation Expert and founding board member of the National Patient Safety Foundation

Using dynamic examples from commercial aviation, the military and other sectors that manage risk in complex, dynamic environments, Mr. Nance discussed the lessons learned as other high-risk industries developed systems approaches to optimizing safety. His presentation, which included galvanizing and unforgettable examples, called upon Virginia leaders to align incentives and develop a learning culture based on a modern understanding of human performance in high-pressure work environments.

Mr. Nance then led an audience discussion about the patient safety issues that are emerging in Virginia.

Error Reporting and Accountability for Patient Safety
Kenneth W. Kizer, MD, MPH, President & CEO, National Forum for Health Care Quality Measurement and Reporting, Washington, DC
Introduced by:
Mark E. Rubin, Esq
Shuford Rubin & Gibney, PC

Safety cultures, in healthcare and elsewhere, are shaped by the rules, policies and attitudes of the broader cultures in which they operate. The IOM recommends a series of state and federal actions designed to promote safety, and several federal bills are pending. The IOM also recommends a series of private sector initiatives. What is likely to happen in the federal arena? What issues are best left to the states, or to the private sector? What kind of "error reporting" is optimal? This section of the program investigated these issues.

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Additional Links
In his talk, Dr. Kizer stressed the problem of medical abbreviations and drugs with similar-sounding names.  The United States Pharmacopeial Convention website has very useful reference materials regarding these topics:

United States Pharmacopeia

Panel Discussion  
Moderator:
P.J. Maddox, Ed.D, RN, Center for HealthCare Policy, George Mason University

Panelists:
David L. Alpert, President of Alpert & Alpert —Small Business/Consumer Representative;
Victor G. Freeman, MD, Medical Director for Quality/Outcomes Management for the Inova Health System.;
Daniel A. Herbert, RPh, FACA, President, Richmond Apothecaries; Trustee, American Pharmaceutical Association;
Lois L. Kercher, DNSC, RN, Vice President, Nurse Executive, Sentara Virginia Beach General Hospital; 
Robert Ukrop, President/Chief Executive Officer, Ukrop's Super Markets;

This discussion outlined how different healthcare stakeholders perceive medical errors.  Each participant articulated the competing needs among stakeholders for different types of information.

Advancing Patient Safety-The Role of the Press
Larry Tye, Reporter, The Boston Globe
Introduced by:
Bev Orndorff, Richmond Times Dispatch ,Health and Science Journalist (retired)

Larry Tye, health reporter for The Boston Globe, discussed his award-winning series on medical error.  In addition, his speech gave insights into how the press can play a crucial role in advancing patient safety. 

Four Part Boston Globe Series:

• Family's tragedies reveal flaws in medical systems
• Mistakes plaguing system
• Review system for hospitals is ailing
• Seeking a prescription against mistakes

Errors in Health Care — A Case Study
Facilitators:
Florence Jones-Clarke, MS, RN, President VNA;
John J. Nance;

Building a safety culture in the high stress environment of healthcare is no easy challenge. Crucial first steps include acknowledging the problem and talking about it openly across the "invisible walls" that separate healthcare stakeholders. This session used a dramatic video case study entitled First Do No Harm (note: this video is available through p4ps, ltd.), based on real failures of the healthcare team, to examine the challenges clinicians face in creating safety on a day-to-day basis. 

The 18-minute video served as the launching point for a "town meeting"-style discussion.  With over 400 attendees from diverse disciplines (ie,  consumer, government, health administration, medicine, nursing, pharmacy, and risk management), the debate was both lively and informative. 

Joseph Hilbert presented a detailed overview of the role of state and federal government in reducing medical error in healthcare settings.  He outlined recent legislative activity in Virginia as well as other states.

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Moving Forward Together — How should VIPC&S proceed?

This session captured the ideas and suggestions flushed out during this history-making conference.  The group initiated a discussion about first priorities. Meeting participants were asked to meet in moderated small groups for 30 minutes and list priorities, followed by a 30 minute wrap-up session outlining next steps.

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Moderated by:
Carl Armstrong, MD, President of VIPC&S, Senior Medical Advisor, Virginia Hospital & Healthcare Association & American Hospital Association
John J. Nance, JD

With Group Leaders:
Judith B. Collins, MS, RNC, WHNP, FAAN;
Sally S. Cook, MD, Chief Medical Officer, Virginia Health Quality Center;
Richardson Grinnan, MD, Senior Vice President of Quality Management, Trigon Blue Cross Blue Shield;
Mike Jurgenson, Medical Society of Virginia;
H. Lane Kneedler, Esq.;
Reed Smith Hazel & Thomas LLP;
Becky Snead, RPh, Executive Director, Virginia Pharmacy Association;
Lynn Warren, RN, MPH, Virginia Association of Health Plans;