6–8 p.m.
Registration – Sheraton Ballroom Foyer
Conference Schedule
Wednesday, September 17, 2003
Thursday, September 18, 2003
7:30–8 a.m.
Registration and Continental Breakfast – Sheraton Ballroom Foyer
8–8:15 a.m.
Opening Plenary Session – Sheraton Ballroom
Welcome and Setting the Work Agenda
Perry A. Pugno, MD, MPH, CPE, AAFP, Director, Division of Medical Education
John Hickner, MD, MS, AAFP, Director, National Network for Family Practice and Primary Care Research
8:15–8:45 a.m.
Keynote: AHRQ Perspectives on Ambulatory Primary Care Patient Safety – Sheraton Ballroom
Helen Burstin, MD, MPH, AHRQ Director of the Center for Primary Care Research
8:45–9:30 a.m.
Engaging Patients in Promoting Safety – Sheraton Ballroom
Gerald Hickson, MD, Vanderbilt University, Associate Dean for Clinical Affairs; Director, Center for Patient & Professional Advocacy
9:30–9:45 a.m.
Participant Comments and Questions for Speakers – Sheraton Ballroom
9:45–10 a.m.
Refreshment Break – Sheraton Ballroom Foyer
Registration and Continental Breakfast – Sheraton Ballroom Foyer
8–8:15 a.m.
Opening Plenary Session – Sheraton Ballroom
Welcome and Setting the Work Agenda
Perry A. Pugno, MD, MPH, CPE, AAFP, Director, Division of Medical Education
John Hickner, MD, MS, AAFP, Director, National Network for Family Practice and Primary Care Research
8:15–8:45 a.m.
Keynote: AHRQ Perspectives on Ambulatory Primary Care Patient Safety – Sheraton Ballroom
Helen Burstin, MD, MPH, AHRQ Director of the Center for Primary Care Research
8:45–9:30 a.m.
Engaging Patients in Promoting Safety – Sheraton Ballroom
Gerald Hickson, MD, Vanderbilt University, Associate Dean for Clinical Affairs; Director, Center for Patient & Professional Advocacy
9:30–9:45 a.m.
Participant Comments and Questions for Speakers – Sheraton Ballroom
9:45–10 a.m.
Refreshment Break – Sheraton Ballroom Foyer
Concurrent Sessions #1
10–11:30 a.m.
Moderator: Deborah Cummins, PhD – Chicago
A Curriculum for Medical Errors – Presenter: Alan Rubin, MD, University of Vermont, College of Medicine
Co-Authors: Benjamin Littenberg, MD, Anupam Goel, MD, Charles MacLean, MD, Dana Walrath, PhD, Dryver Houston, PhD, Tania Bertsch, MD, Paul Turner, PhD, Tracey Niquette, RN, ANP
Effects of a Collaborative Patient Safety/Medical Fallibility Curriculum on Second-Year Medical Students – Presenter: Wendy S. Madigosky, MD, University of Missouri-Columbia School of Medicine
Co-Author: Linda Headrick, MD, MS
Patient Safety Education for Medical Students: Report of 3 Years of a Curriculum at New York Medical College – Presenter: Joseph L. Halbach, MD, New York Medical College
Co-Author: Laurie Sullivan, PhD, CSW
DEER (Diagnostic Error Evaluation Research) Study - Presenter: Martin L. Kabongo, MD, PhD, San Diego Unified Research in Family Medicine
Moderator: Nancy C. Elder, MD – Sheraton II
Pediatric Care in Ambulatory Settings – Presenter: Julie J. Mohr, MSPH, PhD, University of Chicago
Co-Author: Carole Lannon, MD, MPH
Patient Safety Event Reports from Family Physicians, Staff and Patients in Family Practice Offices: A Pilot Study – Presenter: John M. Hickner, MD, MS, American Academy of Family Physicians
Co-Authors: Bob Phillips, MD, MSPH, Deborah Graham, MSPH, Jennifer Kappus, Susan Dovey, PhD, James Galliher, PhD, Nancy Elder, MD
Understanding Medical Errors in Primary Care – Presenters: Anton J. Kuzel, MHPE and Steven H. Woolf, MD, MPH, Virginia Commonwealth University Department of Family Practice
“I never thought it would happen to me” How Experiencing Medical Error has Changed Patients Interactions in Primary Healthcare – Presenter: Nancy C. Elder, MD, University of Cincinnati
Co-Authors: Jeff Jacobson, PhD, Therese Zink, MD, Lora Hasse, PhD, and Morgan Sill, BA
11:30–1p.m.
Working Luncheon – Luna Atrium
Tables organized by the following topics for informal discussions:
Moderator: Deborah Cummins, PhD – Chicago
A Curriculum for Medical Errors – Presenter: Alan Rubin, MD, University of Vermont, College of Medicine
Co-Authors: Benjamin Littenberg, MD, Anupam Goel, MD, Charles MacLean, MD, Dana Walrath, PhD, Dryver Houston, PhD, Tania Bertsch, MD, Paul Turner, PhD, Tracey Niquette, RN, ANP
Effects of a Collaborative Patient Safety/Medical Fallibility Curriculum on Second-Year Medical Students – Presenter: Wendy S. Madigosky, MD, University of Missouri-Columbia School of Medicine
Co-Author: Linda Headrick, MD, MS
Patient Safety Education for Medical Students: Report of 3 Years of a Curriculum at New York Medical College – Presenter: Joseph L. Halbach, MD, New York Medical College
Co-Author: Laurie Sullivan, PhD, CSW
DEER (Diagnostic Error Evaluation Research) Study - Presenter: Martin L. Kabongo, MD, PhD, San Diego Unified Research in Family Medicine
Moderator: Nancy C. Elder, MD – Sheraton II
Pediatric Care in Ambulatory Settings – Presenter: Julie J. Mohr, MSPH, PhD, University of Chicago
Co-Author: Carole Lannon, MD, MPH
Patient Safety Event Reports from Family Physicians, Staff and Patients in Family Practice Offices: A Pilot Study – Presenter: John M. Hickner, MD, MS, American Academy of Family Physicians
Co-Authors: Bob Phillips, MD, MSPH, Deborah Graham, MSPH, Jennifer Kappus, Susan Dovey, PhD, James Galliher, PhD, Nancy Elder, MD
Understanding Medical Errors in Primary Care – Presenters: Anton J. Kuzel, MHPE and Steven H. Woolf, MD, MPH, Virginia Commonwealth University Department of Family Practice
“I never thought it would happen to me” How Experiencing Medical Error has Changed Patients Interactions in Primary Healthcare – Presenter: Nancy C. Elder, MD, University of Cincinnati
Co-Authors: Jeff Jacobson, PhD, Therese Zink, MD, Lora Hasse, PhD, and Morgan Sill, BA
11:30–1p.m.
Working Luncheon – Luna Atrium
Tables organized by the following topics for informal discussions:
- Undergraduate Patient Safety Curriculum
- Residency Patient Safety Curriculum
- Undergraduate/Residency Patient Safety Curriculum
- Medication Errors
- Error Reporting Systems and Taxonomy
- Information Technology and Patient Safety
- Laboratory and Diagnostic Imaging Errors
1–1:40 p.m.
Plenary Session – Sheraton Ballroom
Research Challenges in Ambulatory Primary Care Patient Safety: David Bates, MD, MSc, Partners Health Care, Medical Director of Clinical & Quality Analysis
1:40–1:50 p.m.
Participant Comments and Questions
Plenary Session – Sheraton Ballroom
Research Challenges in Ambulatory Primary Care Patient Safety: David Bates, MD, MSc, Partners Health Care, Medical Director of Clinical & Quality Analysis
1:40–1:50 p.m.
Participant Comments and Questions
Concurrent Sessions #2
1:50–3:20 p.m.
Moderator: Deborah Cummins, PhD – Chicago
Approaches to Error Reduction in a Teaching Family Practice – Presenter: Lawrence R. Wu, MD, Duke University School of Medicine
Promoting Safe Use of Medications in the Ambulatory Setting – Presenter: Miriam Chan, PharmD
Reducing Medical Error in a Family Practice Residency Program – Presenter: Osman N. Sanyer, MD, University of Utah
Co-Author: Michael P. Silver, MPH
Enhancing the Disclosure of Medical Errors in Primary Care – Presenter: Thomas H. Gallagher, MD, University of Washington School of Medicine
Co-Authors: Amy D. Waterman, PhD, Alison Ebers, Wendy Levinson, MD, Vicky Fraser, MD
Moderator: Nancy C. Elder, MD – Sheraton II
Improving the Quality of Abnormal Test Result Follow-up in the Ambulatory Setting – Presenter: Eric G. Poon, MD, MPH, Brigham and Womens Hospital/Partners Information Systems
Identification and Prevalence of Serious Drug-Drug Interactions in the Ambulatory Care Setting (Part 1) – Presenter: Jacob Abarca, Pharm D., University of Arizona
Co-Authors: Daniel C. Malone, PhD, Edward P. Armstrong, PharmD, Amy J. Grizzle, PharmD, Richard B. Lipton, MD, Philip D. Hansten, PharmD, Babette Edgar, PharmD, MBA /
Prevalence of Clinically Important Drug-Drug Interactions in the Ambulatory Setting and the Impact of a Systems Approach to Improving Patient Safety: Evidence from a Large Nationwide Pharmaceutical Claims Database – Presenter: David S. Hutchins, MBA, MHSA, AdvancePCS
Co-Authors: Heather Haupert, MS, Daniel C. Malone, RPh, PhD, Philip Hansten, PharmD, Babette Duncan, PharmD, Robin C. Van Bergen, BS, Steven L. Solomon, MD, Richard B. Lipton, MD
Novel Use of Hazard Ratings from Safety Engineering to Target Error Reductions in Primary Care – Presenter: Gurdev Singh, PhD, SUNY Buffalo Department of Family Medicine
Minimizing Errors, Maximizing Outcomes (MEMO) – Presenter: Mary Beth Plane, PhD, UW Department of Family Medicine
3:20–3:40 p.m.
Refreshment Break – Sheraton Ballroom Foyer
Moderator: Deborah Cummins, PhD – Chicago
Approaches to Error Reduction in a Teaching Family Practice – Presenter: Lawrence R. Wu, MD, Duke University School of Medicine
Promoting Safe Use of Medications in the Ambulatory Setting – Presenter: Miriam Chan, PharmD
Reducing Medical Error in a Family Practice Residency Program – Presenter: Osman N. Sanyer, MD, University of Utah
Co-Author: Michael P. Silver, MPH
Enhancing the Disclosure of Medical Errors in Primary Care – Presenter: Thomas H. Gallagher, MD, University of Washington School of Medicine
Co-Authors: Amy D. Waterman, PhD, Alison Ebers, Wendy Levinson, MD, Vicky Fraser, MD
Moderator: Nancy C. Elder, MD – Sheraton II
Improving the Quality of Abnormal Test Result Follow-up in the Ambulatory Setting – Presenter: Eric G. Poon, MD, MPH, Brigham and Womens Hospital/Partners Information Systems
Identification and Prevalence of Serious Drug-Drug Interactions in the Ambulatory Care Setting (Part 1) – Presenter: Jacob Abarca, Pharm D., University of Arizona
Co-Authors: Daniel C. Malone, PhD, Edward P. Armstrong, PharmD, Amy J. Grizzle, PharmD, Richard B. Lipton, MD, Philip D. Hansten, PharmD, Babette Edgar, PharmD, MBA /
Prevalence of Clinically Important Drug-Drug Interactions in the Ambulatory Setting and the Impact of a Systems Approach to Improving Patient Safety: Evidence from a Large Nationwide Pharmaceutical Claims Database – Presenter: David S. Hutchins, MBA, MHSA, AdvancePCS
Co-Authors: Heather Haupert, MS, Daniel C. Malone, RPh, PhD, Philip Hansten, PharmD, Babette Duncan, PharmD, Robin C. Van Bergen, BS, Steven L. Solomon, MD, Richard B. Lipton, MD
Novel Use of Hazard Ratings from Safety Engineering to Target Error Reductions in Primary Care – Presenter: Gurdev Singh, PhD, SUNY Buffalo Department of Family Medicine
Minimizing Errors, Maximizing Outcomes (MEMO) – Presenter: Mary Beth Plane, PhD, UW Department of Family Medicine
3:20–3:40 p.m.
Refreshment Break – Sheraton Ballroom Foyer
Concurrent Sessions #3
3:40–5 p.m.
Moderator: Deborah Cummins, PhD – Chicago
The National Patient Safety Agency has Developed an Electronic Learning Programme for Root Cause Analysis (RCA) – Presenter: Maureen Baker, DM, FRCGP
Patient Safety: The Other Side of the Quality Equation – Presenter: Christel Mottur-Pilson, PhD, American College of Physicians (ACP)
Using a Comprehensive Breast Program to Illustrate Ways to Improve Patient Safety – Presenter: Marjie Grazi Harbrecht, MD
HRSA-Funded Collaborative Patient Safety Training to Address ACGME Core Competencies – Presenter: Ranjit Singh, MD, SUNY Buffalo Department of Family Medicine
Moderator: Nancy C. Elder, MD – Sheraton II
Drug-Related Hospital Admissions of Family Medicine Patients: The High Cost of Non-Adherence – Presenter: Tom Lynch, PharmD, Eastern Virginia Medical School and Virginia Commonwealth University School of Pharmacy
Medication Errors and Potential Adverse Drug Events Among Outpatients – Presenter: Tejal K. Gandhi, MD, MPH, Brigham and Womens Hospital
Co-Authors: Saul N. Weingart, MD, PhD, Lucian L. Leape, MD, Andrew C. Seger, RPh, Elisabeth Burdick, MS, David W. Bates, MSc
Interventions to Improve Medication Safety in Primary Care Practice – Presenter: Kimberly A. Galt, PharmD, Creighton University
Co-Authors: Eugene C. Rich, MD, Wendy Taylor, BBL, Ann Rule, PharmD, J.D. Bramble, PhD, Wayne Young, PharmD, Bruce Houghton, MD, Bartholemew Clark, PhD, Mark Siracuse, PhD, Ron Markert, PhD Curt Barr, PharmD
Identifying and Resolving Drug-Related Issues through the Iowa Medicaid Case Management Program – Presenter: William R. Doucette, PhD
Co-Authors: Randal P. McDonough, PharmD, Barry Carter, PharmD, Elizabeth A. Chrischilles, PhD, and Donald Klepser, MBA
6–7p.m.
Reception – Luna Atrium/Luna Grill
Moderator: Deborah Cummins, PhD – Chicago
The National Patient Safety Agency has Developed an Electronic Learning Programme for Root Cause Analysis (RCA) – Presenter: Maureen Baker, DM, FRCGP
Patient Safety: The Other Side of the Quality Equation – Presenter: Christel Mottur-Pilson, PhD, American College of Physicians (ACP)
Using a Comprehensive Breast Program to Illustrate Ways to Improve Patient Safety – Presenter: Marjie Grazi Harbrecht, MD
HRSA-Funded Collaborative Patient Safety Training to Address ACGME Core Competencies – Presenter: Ranjit Singh, MD, SUNY Buffalo Department of Family Medicine
Moderator: Nancy C. Elder, MD – Sheraton II
Drug-Related Hospital Admissions of Family Medicine Patients: The High Cost of Non-Adherence – Presenter: Tom Lynch, PharmD, Eastern Virginia Medical School and Virginia Commonwealth University School of Pharmacy
Medication Errors and Potential Adverse Drug Events Among Outpatients – Presenter: Tejal K. Gandhi, MD, MPH, Brigham and Womens Hospital
Co-Authors: Saul N. Weingart, MD, PhD, Lucian L. Leape, MD, Andrew C. Seger, RPh, Elisabeth Burdick, MS, David W. Bates, MSc
Interventions to Improve Medication Safety in Primary Care Practice – Presenter: Kimberly A. Galt, PharmD, Creighton University
Co-Authors: Eugene C. Rich, MD, Wendy Taylor, BBL, Ann Rule, PharmD, J.D. Bramble, PhD, Wayne Young, PharmD, Bruce Houghton, MD, Bartholemew Clark, PhD, Mark Siracuse, PhD, Ron Markert, PhD Curt Barr, PharmD
Identifying and Resolving Drug-Related Issues through the Iowa Medicaid Case Management Program – Presenter: William R. Doucette, PhD
Co-Authors: Randal P. McDonough, PharmD, Barry Carter, PharmD, Elizabeth A. Chrischilles, PhD, and Donald Klepser, MBA
6–7p.m.
Reception – Luna Atrium/Luna Grill
Friday, September 19, 2003
7:30–8 a.m.
Continental Breakfast – Sheraton Ballroom Foyer
8–8:15 a.m.
Plenary Session – Sheraton Ballroom
Welcome and Setting the Work Agenda
John M. Pascoe, MD, Childrens Medical, Dayton, Ohio
Norman B. Kahn, Jr., MD, AAFP, Vice President Science and Education
8:15–8:45 a.m.
Education Challenges in Ambulatory Primary Care Patient Safety: Joseph Scherger, MD, MPH, Clinical Professor, Department of Family and Preventive Medicine, University of California, San Diego
8:45–8:55 a.m.
Participant Comments and Questions
Continental Breakfast – Sheraton Ballroom Foyer
8–8:15 a.m.
Plenary Session – Sheraton Ballroom
Welcome and Setting the Work Agenda
John M. Pascoe, MD, Childrens Medical, Dayton, Ohio
Norman B. Kahn, Jr., MD, AAFP, Vice President Science and Education
8:15–8:45 a.m.
Education Challenges in Ambulatory Primary Care Patient Safety: Joseph Scherger, MD, MPH, Clinical Professor, Department of Family and Preventive Medicine, University of California, San Diego
8:45–8:55 a.m.
Participant Comments and Questions
Concurrent Sessions #4
9:00 –10:20 a.m.
Moderator: Deborah Cummins, PhD – Chicago
Teaching Tools to Enhance Patient Safety in Ambulatory Care Practice – Presenter: Sharon Muret-Wagstaff, PhD, MPA, Childrens Hospital Boston
Teaching Patient Safety: A Curriculum for Residents in Training – Presenter: Stasia Miaskiewicz, MD, FACP, UPMC McKeesport
Co-Author: T. Michael White, MD
Appropriate Tracking of Diagnostic Tests and Consults in a Multi-Disciplinary Resident Clinic: Role of a Tracking Log – Presenter: Mukta Panda, MD, University of Tennessee
Co-Authors: Ann Rybolt, MD, Margaret Calloway, RN, Roger Jones, MD
Three Years of Experience in Teaching about Medical Errors: A Problem-Based Learning Approach – Presenter: Anne E. Caffee, PharmD, BCPS, Shenandoah University Dunn School of Pharmacy
Moderator: Nancy C. Elder, MD – Sheraton II
Straight From the User: Error Reporting System Guidelines – Presenter: Kamisha Hamilton Escoto, MSIE
Co-Authors: Ben-Tzion Karsh, PhD, John Beasley, MD
Use of an Electronic Adverse Event Reporting System in the Ambulatory Clinic Setting – Presenters: Kathryn J. Nelson, MHA and Karen R. Cox, RN, PhD, University of Missouri Health Care
Applied Strategies for Improving Patient Safety (ASIPS) – Presenter: Wilson D. Pace, MD, University of Colorado
Developing a Patient Safety Taxonomy for Ambulatory Primary Care Settings – Presenter: Deborah Graham, MSPH for Susan Dovey, PhD, Co-Authors: Bob Phillips, MD, MSPH, Larry Green, MD, John Hickner, MD, MS
10:20–10:40 a.m.
Refreshment Break – Sheraton Ballroom Foyer
Moderator: Deborah Cummins, PhD – Chicago
Teaching Tools to Enhance Patient Safety in Ambulatory Care Practice – Presenter: Sharon Muret-Wagstaff, PhD, MPA, Childrens Hospital Boston
Teaching Patient Safety: A Curriculum for Residents in Training – Presenter: Stasia Miaskiewicz, MD, FACP, UPMC McKeesport
Co-Author: T. Michael White, MD
Appropriate Tracking of Diagnostic Tests and Consults in a Multi-Disciplinary Resident Clinic: Role of a Tracking Log – Presenter: Mukta Panda, MD, University of Tennessee
Co-Authors: Ann Rybolt, MD, Margaret Calloway, RN, Roger Jones, MD
Three Years of Experience in Teaching about Medical Errors: A Problem-Based Learning Approach – Presenter: Anne E. Caffee, PharmD, BCPS, Shenandoah University Dunn School of Pharmacy
Moderator: Nancy C. Elder, MD – Sheraton II
Straight From the User: Error Reporting System Guidelines – Presenter: Kamisha Hamilton Escoto, MSIE
Co-Authors: Ben-Tzion Karsh, PhD, John Beasley, MD
Use of an Electronic Adverse Event Reporting System in the Ambulatory Clinic Setting – Presenters: Kathryn J. Nelson, MHA and Karen R. Cox, RN, PhD, University of Missouri Health Care
Applied Strategies for Improving Patient Safety (ASIPS) – Presenter: Wilson D. Pace, MD, University of Colorado
Developing a Patient Safety Taxonomy for Ambulatory Primary Care Settings – Presenter: Deborah Graham, MSPH for Susan Dovey, PhD, Co-Authors: Bob Phillips, MD, MSPH, Larry Green, MD, John Hickner, MD, MS
10:20–10:40 a.m.
Refreshment Break – Sheraton Ballroom Foyer
Concurrent Sessions #5
10:40–Noon
Facilitator: Deborah Cummins, PhD
Recorder: Stacy Singleton
Education Brainstorming Session – To identify major issues and action plans – Chicago
Facilitator: Nancy C. Elder, MD
Recorder: Deborah Graham, MSPH
Research Brainstorming Session – To identify major issues and action plans – Sheraton II
Noon–12:30 p.m.
Plenary Session – Sheraton Ballroom
Final Wrap-Up and Closing Comments:
Jack Ende, MD, Presbyterian Medical Center Chief of Medicine, Philadelphia, PA
This activity has been reviewed and is acceptable for up to 12.25 prescribed credit hours by the American Academy of Family Physicians.
Facilitator: Deborah Cummins, PhD
Recorder: Stacy Singleton
Education Brainstorming Session – To identify major issues and action plans – Chicago
Facilitator: Nancy C. Elder, MD
Recorder: Deborah Graham, MSPH
Research Brainstorming Session – To identify major issues and action plans – Sheraton II
Noon–12:30 p.m.
Plenary Session – Sheraton Ballroom
Final Wrap-Up and Closing Comments:
Jack Ende, MD, Presbyterian Medical Center Chief of Medicine, Philadelphia, PA
This activity has been reviewed and is acceptable for up to 12.25 prescribed credit hours by the American Academy of Family Physicians.
