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A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing
 Session Overview

Hear directly from the father who lost a child, the pharmacist who went to jail, and experts who will share best practices that can spare suffering of ALL of the victims when an accident occurs.

Hundreds of thousands of deaths and many more suffer due to systems failure accidents in healthcare every year. The first victims are patients and families; however, the second victims are their caregivers; and there is even a third victim - the culture of the organization that fails at handling the events.

Caregivers are still being fired without supportive care, leading to suicides, broken lives, and wounded spirits. Healing can occur and patient families and caregivers can be united through forgiveness. This webinar will tell one such story.

Webinar Video and Downloads

To download a complete version of the transcript of the webinar, click here.  

Speaker Slide Sets:

Slide Sets will be available before the webinar begins. To view the file, click the desired link (please note: the files may take several minutes to download). To save to your hard drive, right click on the link and choose "Save Target As." (In some browsers it might say "Save Link As.")

Click here to download the combined speakers' slide set in PDF format.  

The slide set could take several minutes to download.

Related Resources:
Baby dies at Seattle Children's hospital after overdose  Ostrom CM  
Nurse's suicide follows tragedy  Ostrom CM  
Suicide of nurse after tragic event  –  Letters to the Editor
IHI White Papers – Respectful Management of Serious Clinical Adverse Events  Conway J, Federico F, Stewart K, et al  
Click here to view additional related resources.
Registration Information and CE Credit Information:
 Register:
Click here to register for this Webinar.

 When:  June 16, 2011 Time: 1:00 p.m.-2:30 p.m. ET
We are accepting questions now that relate to the session topics. Please e-mail any questions related to the specific session to help@safetyleaders.org with the session title in the e-mail message header.
  • Questions about the Webinar series?
    E-mail help@safetyleaders.org or call
    512-457-7676 between 9:00 a.m. and 4:30 p.m. CT.
  • Need technical assistance with registration? Call 512-457-7605 between 9:00 a.m. and 4:30 p.m. CT.
Learning Objectives
  • Learn to apply specific lessons about certain pharmacy-systems issues that can prevent adverse drug events during the preparation of medications.
  • Learn the key elements of the National Quality Forum Care of the Caregiver Safe Practice and how to apply them, and how they could have been applied to the adverse event presented.
  • Learn the best practice advice, on prevention and direct actions that can be taken after a serious clinical adverse event, from resources recently developed for all organizations.

CE Participation Documentation
For CE credit information, please click here.

 Moderators
Franck Guilloteau
Welcome and Safe Practice Overview

Franck Guilloteau received a mechanical engineering degree from the University of Texas at Austin, and subsequently pursued a fellowship in Biomedical Engineering with a minor in product development.
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Matt Listiak
The Healing Moment

Matthew Listiak is the Senior Producer for TMIT and Health Care Concepts. He has worked with TMIT and HCC for eight years, developing video and multimedia content for television broadcast, DVD distribution, and the internet.
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 Patient Safety Advocate:
Christopher Jerry
The Voice of the Patient and Family

Christopher Jerry's two-year-old daughter, Emily, tragically died from a medication error shortly after she had overcome cancer in March 2006. Subsequently, he decided to retire from a very successful business career in medical imaging to become a patient safety advocate and to establish The Emily Jerry Foundation. He now devotes all of his time to patient safety advocacy and to the foundation's efforts to improve overall patient safety in our nation's hospitals and pharmacies.
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 Session Panelists
Charles R. Denham, MD
Care of the Caregiver

Charles R. Denham, MD, is the founder and the chairman of Texas Medical Institute of Technology (TMIT), a non-profit medical research organization dedicated to driving adoption of clinical solutions in patient safety and healthcare performance improvement.
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Eric Cropp
The Emily Jerry Story

Eric Cropp was a pharmacist at Cleveland's University Hospitals Rainbow Babies & Children's Hospital in 2006, when a pharmacy technician under Mr. Cropp's supervision made an error in mixing a saline/chemotherapy solution.
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Christopher Jerry
The Emily Jerry Story

Christopher Jerry's two-year-old daughter, Emily, tragically died from a medication error shortly after she had overcome cancer in March 2006. Subsequently, he decided to retire from a very successful business career in medical imaging to become a patient safety advocate and to establish The Emily Jerry Foundation. He now devotes all of his time to patient safety advocacy and to the foundation's efforts to improve overall patient safety in our nation's hospitals and pharmacies.
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Chesley B. (Sully) Sullenberger III
Lessons From Aviation: Care of Crew (Pre-Recorded)

For 40 years, Captain Chesley B. "Sully" Sullenberger led an accomplished yet anonymous career in the skies as a pilot, instructor, and aviation safety expert. After logging over 20,000 flight hours, Sullenberger was propelled into the spotlight as an international hero, safely guiding a US Airways jetliner to an emergency landing on an icy Hudson River.
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Frank Federico, RPh
Respectful Management of Serious Clinical Adverse Events

Frank Federico, RPh, is Executive Director and safety faculty at the Institute for Healthcare Improvement in Cambridge, MA. His primary areas of focus include patient safety, application of reliability principles in health care, preventing surgical complications, and the Idealized Design of Perinatal Care. He is also faculty for the Patient Safety Officer Training Program.
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