Complimentary Webinar

This one hour webinar will examine critical incident reporting, relevant fatal case studies with lessons learned for improving care, and provide recommendations for hospitals to decrease potential medication errors involving opioids.

Learning Objectives:

• Highlight the Patient Safety Review Committee (PSRC) cases of the Office of the Chief Coroner for Ontario involving medications with a focus on hydromorphone
• Describe how a detailed incident analysis can assist in identifying underlying contributing factors
• Review recommended actions for hospitals to decrease potential medication errors involving opioids

Senior administrators, VPs of patient services, directors, individuals in patient safety, patient relations, quality & risk, physicians, nurses, and front-line staff.

Date:	Wednesday, March 6, 2013
Time:	9:00 am – 10:00 am PST 10:00 am – 11:00 am MST 11:00 am – 12:00 pm CST 12:00 pm – 1:00 pm EST 1:00 pm – 2:00 pm AST 1:30 pm – 2:30 pm NST      Time zone map
Duration:	1 hour
Cost:	Funding support for this complimentary webinar is provided by the Ontario Ministry of Health and Long-Term Care and Health Canada.
Presenter:	Julie Greenall, RPh, BScPhm, MHSc (Bioethics), FISMPC Operations Leader Institute for Safe Medication Practices Canada (ISMP Canada)

Contact Us: webinars@ismp-canada.org

Speaker

Julie Greenall, RPh, BScPhm, MHSc (Bioethics), FISMPC Julie has more than 30 years of clinical and management experience in pharmacy practice in community hospitals, long-term care and community pharmacy. Julie joined ISMP Canada in 2004 to complete the inaugural Canadian Fellowship in Safe Medication Management. In her current position as Operations Leader, she is responsible for coordinating, supervising and conducting medication system reviews, analyses of sentinel events and other consultation projects, as well as participating in strategic and operational planning and day to day management activities as part of the ISMP Canada senior leadership team. Julie holds an active practice pharmacy license and in addition to her work with ISMP Canada, continues to work in a community hospital to maintain her practice skills and awareness of current issues. Since joining ISMP Canada, Julie has participated in numerous medication system reviews, root cause analyses of sentinel medication incidents and prospective risk assessment projects. Julie is a co-author of the 2006 Canadian Root Cause Analysis Framework and the revised Canadian Incident Analysis Framework released in 2012, in addition to numerous medication safety-related articles published in healthcare journals. Julie has provided educational presentations and workshops on a variety of medication safety topics across Canada and internationally.

Background

Investigations of sudden and unexpected deaths in hospitals are challenging for many reasons. They often involve a medically complex patient; there may be allegations by the family of medical error or negligence related to the care; and health care providers may perceive that the subsequent investigation is looking to find fault or ascribe blame. These deaths typically invoke a significant emotional response, which may be experienced not only by family, but also by care providers and the investigators themselves.

The Office of the Chief Coroner for Ontario has a mandate of public and patient safety. A number of Death Review Committees have been established by the Office of the Chief Coroner for Ontario as a means of better understanding the circumstances of certain deaths, and to use this knowledge to generate recommendations to help improve public and patient safety and prevent future deaths in similar circumstances. Four of these Committees have a direct relationship with the health care setting. In Ontario, all coroners are physicians with clinical expertise and experience that greatly facilitates the investigation of these deaths.

Contact Information