rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

IARMM 3rd World Congress of Clinical Safety
10th – 12th Sep 2014, Ayre Gran Hotel Colon, Madrid, Spain- Clinical Risk Management -Program
Lecture hall: Meeting room (EUROPA).
Poster presentation space: Fouer near the lecture hall.
Onsite registration desk: Fouer near the lecture hall.
Lunch: Fouer near the lecture hall.
Staff room & business meeting room: Meeting room (LISBOA) next to EUROPA.

Each oral presentation (normal) should be performed within 10 minutes including 2 minutediscussion time. One PC with Windows 7 and MS-Office, and 1 screen are available for yourpresentation.
Visit the lecture hall 30 minutes before your presentation time with your micro stick of yourPowerPoint data.

Poster presentation(Poster presentation manner)
http://www.iarmm.org/3WCCS/(3WCCS)Poster_presentation_manner.pdf(Morning poster session) 9:00-13:00
Poster discussion: 12:00-13:00 by your poster.
(Afternoon poster session) 13:30-16:30
Poster discussion: 15:30-16:30 by your poster.

Dinner party : Since 18:00 (10th September) at the congress hotel.

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)【10 September 2014: Oral presentation】
Onsite registration desk open from 8:00 to 17:40.
Moring oral session launches at 9:00.

Morning on 10 September, Oral
Opening
9:00-9:05 Ryoji Sakai (Congress President. Presidents of IARMM, WHRMC, JPSCS & JSRMPM.
Hon. Prof. DMed SU, former Profs. TWU, EPFL, USM, etc., Tokyo, Japan)

Educational Lecture (1)9:05-9:35 (SP: NA068)

Cost-effectiveness of anticoagulation in patients with non-valvular atrial fibrillation withedoxaban compared to warfarin in Germany.
1

1

1

2

3

Harenberg J , Krejczy M , Wehling M , Obermann K , Lip GYHProf. MD. Department of Clinical Pharmacology, Medical Faculty Mannheim, University Heidelberg Hospital,
1
Maybachstrasse 1468169 Mannheim, Germany
Mannheim Institute of Public Health, Medical Faculty Mannheim, Ludolf-Krehl Strasse, 68167 Mannheim,
2
Germany ,3
University of Birmingham, Centre for Cardiovascular Sciences , City Hospital , Birmingham, B187QH, UK

Educational Lecture (2)9:35-10:05 (SP: NA172)

Understanding Intraoperative Patient Safety and Benchmarking the Quality of Intraoperative

Surgical Care.
Haytham M.A. Kaafarani (A. Prof. MD Surgery, Harvard Medical School, Director, Patient Safety & Quality
Division of Trauma, Emergency Surgery & Surgical Critical Care, Massachusetts General Hospital, Boston, USA)

Educational Lecture (3)10:05-10:35 (SP: NA173) New modules for clinical safety
Ryoji Sakai (Congress President. Presidents of IARMM, WHRMC, JPSCS & JSRMPM.
Hon. Prof. DMed SU, former Profs. TWU, EPFL, USM, etc., Tokyo, Japan)

Panel Discussion (1-A): 'Medication safety and drug safety’ (Part A)
10:35-10:50 (NA025)

The Clinical Input of Pharmacists in Veterinary PharmacyNoëlle H. O’Driscoll, Charles Juwah, Olga Labovitiadi and Andrew J. Lamb
(School of Pharmacy and Life Sciences, Robert Gordon University, UK)
10:50-11:05 (NA084)

Standards-based Healthcare Supply Chain Traceability -- Supporting Patient safety and quality

improvement.
Janice Kite (Traceability Director Healthcare, GS1 Global Office, Brussels, Belgium)rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Morning on 10 September, Oral
11:05-11:30 (NA114)

ASTRA - Algorithms for Seniors' Therapy Amelioration:
I. Patient-Centered Clinical Pharmacology in Traumatology.
Ursula Wolf *, Rudiger Neef #, Peter Presek **Department of Pharmacology and Toxicology, Division of Clinical Pharmacology and#University Hospital Halle, Department of Traumatology and Reconstructive Surgery,
Martin-Luther University Halle-Wittenberg, Germany

Educational Lecture (4)13:00-13:30 (SP: NA073)

In Pursuit of Professional Excellence – Training for Safety and Quality in Healthcare

Dean Ian Curren, BSc MBBS AKC FRCA Pg Dip Med Ed (Distinction) FFPMRCA FacadMEd
Clinical Advisor NHS Health Education England (KSS)
Director of Education, Cancer & Surgery Clinical Academic Group, Bart Health NHS Trust
Reader in Innovation & Excellence in Healthcare Education, Queen Mary University of London
Consultant Anaesthetist in Pain Medicine, St Bartholomew's Hospital, Barts Healthcare NHS Trust, UK

12:00-13:00

Lunch (Fouer near the lecture hall)Afternoon on 10 September, Oral
Afternoon oral session launches at 13:00.
Panel Discussion (2-A): 'Safety culture in clinical care' (Part A)
13:00-13:15 (NA009)

A review Model to measure Patient Safety and Occupational Safety and Health at Hospitals.
Background. Patient Safety and Occupational Safety and Health is a priority strategic line and a key success factor for
Hospitals governance.
1

2

3

4

Jiménez-Buñuales MT , González-Diego P , León-Sanz MP , González-Menorca L .
Preventive Medicine Unit. Calahorra Hospital Foundation. La Rioja Health and Social Services Council. Spain
2
Preventive Medicine and Quality Management. Reina Sofia Hospital. Navarre Health Service-Osasunbidea. Spain
3
School of Medicine. University of Navarra. Spain
4
Bussiness Economy Department. University of La Rioja. Spain
1

13:15-13:25 (NA140)RESEARCH CHALLENGES IN PATIENT SAFETY

Isabel Rodrigo-Rincon, Marta Martín-Vizcaino(Complejo Hospitalario de Navarra. Pamplona. Spain)
13:25-13:35 (NA026)

Critical Care Outreach – the Benefits

Carmel Gordon-Dark (Critical Care Outreach Lead, The London Clinic, UK)
13:35-13:50 (NA029)

Patient Safety: Prevention and Management of Protocol Violations in Clinical Trials.

1)Mohamed El Malt, MD, PhD, 2) Vijayanand Rajendran, MD
1) Chief Medical Consultant, Medical Consultancy division, Europital, Belgium2) Clinical Research Physician, Medical Consultancy division, Europital, Belgium

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Afternoon on 10 September, Oral
13:50-14:05 (NA033)

Person-centered manual handling of patients model.

Massimo Ragonesi*, Alessandro Perrone*, Adriano Papale**, Elisabetta Badellino*** IGIEA Association, Italy.
** INAIL Research Area, Italy
14:05-15:30 (NA038)

The Role of Family Nurse Practitioners in Clinical and Public Health Care Safety.

Helda Pinzon-Perez, Ph.D., RN, MCHES, FNP, MPH(Prof., Department of Public Health, California State University, Fresno, USA)

Symposium (1): ‘Clinical communication for clinical risk management’
15:30-15:50 (NA113)

1

It pays to talk: A multicentre study of verbal communication from the laboratory to the bedside.
1

2

1

2

2

2

1

Rutledge S* , Lambe G , Fitzpatrick S , Thanaseelan C , Hassan M , Anpalagan K , Haire G , Lunney G ,22Murphy D , Callanan I .
* = presenting author
1. St Michael's Hospital, Dun Laoghaire, Dublin, Ireland.
2. St Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
15:50-16:10 (NA137)

Calling for the doctor: using simulated patients to assess and improve the quality of GP advice onan out-of-hours telephone helpline.
1.
2.
3.

Rosemary McKenzie, Deputy Director, Centre for Health Policy, Melbourne School of Population and Global Health,
The University of Melbourne
Professor David Dunt, Founding Director, Centre for Health Policy, Melbourne School of Population and Global
Health, The University of Melbourne, Victoria, Australia,
Maureen Robinson, General Manager Clinical Governance, Healthdirect Australia, Level 19, 133 Castlereagh
Street, Sydney, NSW, Australia

16:10-16:30 (NA147)

Patient safety in middle income societies attacked by conflict situations or natural disasters.

Prof. Dr. Smilja Tudzarova Gjorgova, Dr.Idriz Orana(University Clinic for Plastic and Reconstructive Surgery,
Medical University<St. Cyril and Methodius> bul. Mother Teresa,-Skopje, R. Macedonia)

Panel Discussion (3): 'Survey and reporting of clinical errors'
Analysis on the Similarities and Dissimilarities between the Aviation and Medical
Accidents: How can we learn safety system from the avian society ?
16:30-16:45 (NA142)

Yasunari Tsuchihashi, M.D., PhD(Department of Clinical Pathology, Louis Pasteur Centre for Medical Research, Kyoto, Japan)

Panel Discussion (4): 'Emergency healthcare system'
16:45-17:05 (NA034)

Changing hospital culture to improve care and reduce risk for patients with cognitive impairment

in the acute sector
Mark Yates, Meredith Theobald, Michelle Morvell(Ballarat Health Services, Deakin University, Australia)
17:05-17:20 (NA108)

A model of prioritization between risk management and clinical care pathways.
Bartoccioni F, Convertini P, Talanas G, Landi F, Borreca F, Molinaro M, Fiorillo C, Dubinski M, Cenci F(Dirigente medico presso: Azienda Ospedaliera S. Camillo - Forlanini, U.O. Formazione e Governo Clinico, Italy)

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Afternoon on 10 September, Oral
17:20-17:35 min (NA105)

Saving a life – The effect of the Medical Emergency Team in preventing the deterioration of

inpatients.
Takamitsu Kodama: St. Marianna University School of Medicine, Department of Emergency and Critical Care Medicine, Japan
Shigeki Fujitani: St. Marianna University School of Medicine, Department of Emergency and Critical Care Medicine, Japan
Yasuhiko Taira: St. Marianna University School of Medicine, Department of Emergency and Critical Care Medicine, Japan

Dinner party : Since 18:00 at the congress hotel.
---- The end of the 1st day ----

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)【11 September 2014: Oral presentation】
Onsite registration desk open from 8:00 to 17:30.
Moring oral session launches at 9:00.

Morning on 11 September, Oral

Panel Discussion (2-B): 'Safety culture in clinical care' (Part B)
9:00-9:15 (NA112)

Leading a horse to water or helping him drink? An audit of audits in a university hospital group.

Ian Callanan, Ailís ní Riain and Nora Ellard(St Vincents University Hospital, Dublin Ireland )9:15-9:30 (NA130)

Improving Safety Culture Starts with Leadership.
Stephen M. Powell, MS, Daniel Baily, MS, Jeffrey Box, MS, MBA, and Spencer King, BS(Synensis, LLC , GA, USA)

9:30-9:45 (NA134)

A Retrospective Analysis of Negative Appendicectomy Rate in a Large District General Hospital in

North-West London.
S. Bokhari, R. Folwell, A. Baheerathan, N. Zaffar, K. Qurashi(Northwick Park Hospital, Northwest London Hospitals NHS Trust, Harrow, Middlesex, UK)
9:45-9:55 (NA139)

Balanced Scorecards as discussion stimulator in OR.

Yasuhiko SUEMORI M.D, MBA (Graduate school of economics Kyushu University, Japan)
9:55-10:15 (NA148)

Safety on the line - developing a quality improvement system for an out-of-hours GP telephone
helpline using simulated patients.
1.
2.

Rosemary McKenzie, Deputy Director, Centre for Health Policy, Melbourne School of Population and Global Health,
The University of Melbourne, Victoria, Australia
Maureen Robinson, General Manager Clinical Governance, Healthdirect Australia, Sydney, Australia.

10:15-10:30 (NA149)

Risk Management and ICT-enabled approaches to clinical process innovation.
1

2

2

2

1

Michele Torresani , Paolo Locatelli , Roberta Facchini , Roberto Moser , Dr. Vittorio Montefusco ,
1
1
1
1
3
Paolo Longoni , Dr. Flavio Arienti , Dr. Michele Magni , Giuseppe Rosito , Elena Sini
1
Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
2
Fondazione Politecnico di Milano, Milan, Italy
3
IRCCS Istituto Clinico Humanitas, Rozzano (Milan), Italy
10:30-10:45 (NA152)

Changing Human Behaviors to Create a Stronger Safety Culture.

Howard W. Bergendahl, JD, MS, CPPS (President of the Bergendahl Institute, LLC, Ohio, USA)10:45-10:55 (NA052)

Reducing Harm to Patients from Healthcare Associated Infections–Risk Based Approach in HAI.

Dr. Nellie S Boma, Chief Medical Officer / Ms. Sreevidya P.N, Infection Control Nurse /Ms. Maisa Saaban, Infection Control Nurse / Dr. Ritu Nambiar, Chief of Service – Obstetrics & Gynecology /Ms. Norma Abu Nassif, Clinical Pharmacist / Dr. Faraj Massouh, Specialist – Anesthesia /Dr. Julia Abu Asbeh, Consultant – NICU / Mr. Salih Abdulla, Microbiologist /Mr. Ahmed Qaissiah, Unit Manager – OR, Abu Dhabi, UAE
0:45-10:55

Break

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Morning on 11 September, Oral
Panel Discussion (5): ‘Clinical risk management before/after surgical operation and the guidelines’(Chairperson) Haytham M.A. Kaafarani , Harvard University, USA

Educational Lecture (5)11:00-11:30 (SP: NA078)

Björn Brücher (Prof.of Surgery, Bon Secours Cancer Institute, VA, USA.
Prof.of Ethical Leadership, New Westminster College, Canada)
11:30-11:40 (NA050)

Cesarean Section Surgical Site Infection Prevention–A Risk Based Approach in HAI.

Dr. Nellie S Boma, Chief Medical Officer / Ms. Sreevidya P.N, Infection Control Nurse /Ms. Maisa Saaban, Infection Control Nurse / Dr. Ritu Nambiar, Chief of Service – Obstetrics & Gynecology /Ms. Norma Abu Nassif, Clinical Pharmacist / Dr. Faraj Massouh, Specialist – Anesthesia /Dr. Julia Abu Asbeh, Consultant – NICU / Mr. Salih Abdulla, Microbiologist /Mr. Ahmed Qaissiah, Unit Manager – OR. Abu Dhabi, UAE

Dexmedetomidine versus fentanyl in microdiscectomy surgery – a double blind study.

11:40-11:50 (NA063)

1. Bushra Abdul Hadi * PhD, 2. Saleh M Sbeitan, Md
1. Faculty of Pharmacy, Philadelphia University, Jordan,
2. Specialist Internal Medicine & Cardiology. Head of ICU/ Specialty Hospital, Amman, Jordan
11:50-12:00 (NA128)

NURSING and IT: - SURGICAL INSTRUMENTS REVIEW. INNOVATIVE PROJECT TO ENSURE PATIENT
SAFETY IN THE SURGICAL AREA.
Garcia Gonzalez Veronica, Alberdi Aramendi Amaia, Berasategui Orbegozo Miren, Beristain Echave Arantxa,
Encinas Rivero Ana, Garmendia Urquizu Elixabet, Larrañaga Garaikoetxea Aintzane,(Mendaro’s hospital, Spain)
12:00-12:10(NA141)

Mirror assessment of improvement areas in patient safety: Surgeons vs. Anaesthesiologists.

Marta Martin-Vizcaino, Isabel Rodrigo-Rincon(Complejo Hospitalario de Navarra. Pamplona. Spain)

Lunch (Fouer near the lecture hall)

12:10-13:00

Afternoon on 11 September, Oral
Afternoon oral session launches at 13:00.
Panel Discussion (6): ‘Simulation and human factor for clinical safety culture'
13:00-13:30 (SP: NA077)

Educational Lecture (6)Interdisciplinary health team, focusing on Patient safety. How must we train?

Enric Macarulla (Director of 4DHealth innovation health center, Igualada, Barcelona, Spain. Prof. MD.
Autonomous University of Barcelona, Medical School, Barcelona, Spain.)
13:30-13:45 (NA008)

Usability of Ventricular Assist Devices in Daily Experience: A Multicenter Study.

Thomas Schlöglhofer (Center for Medical Physics and Biomedical Engineering, Department of Cardiac Surgery,
Medical University Vienna, Austria)
13:45-14:00 (NA133)

Audit of Compliance with the World Health Organisation Surgical Safety Checklist (SSC) – Are we

missing the point?
S. Bokhari, K. Qurashi(Northwick Park & St Mark’s Hospitals, Northwest London Hospitals NHS Trust, Harrow, Middlesex, UK.)rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Afternoon on 11 September, Oral
14:00-14:10 (NA143)

The medical safety of treating prescriptions in the dispensing pharmacy.
Shino Shiosaka1), Nobumi Matsuda2)
1)Pack knowledge Co.,Ltd (Mental health and human error researching company), Japan
2)Matsuda Eye Clinic, Japan

14:10-14:20 (NA144)

About the influence that oblivion of the memory gives to human error.

Nobumi Matsuda1) M.D, Shiosaka Shino2) Medical counselor
1)Matsuda Eye Clinic, 2)Packnowledge co.ltd (mental hearth and human error reseaching company), Japan
14:20- 14:35 (NA145)

Addressing Patient Safety through Human Factors training: A Training Tool to empower JuniorDoctors.
Vincent L, Van Manen A, Edwards R, Cooney A(Department of Anaesthetics, Milton Keynes Hospital NHS Foundation Trust, UK)
14:35-14:50 (NA164)

The human factor in adverse events related to nursing practice: analysis of predictive models.
Amélia Filomena Oliveira Mendes Castilho(Nurse School of Coimbra, Portugal)

Panel Discussion (7): 'Medical device risk'
14:50-15:05 (NA120)

The Checklist Manifesto as a basis for prospective risk inventories.

Maurice Janssen, Miriam Schiltmans, Renate Schuttelaar(Orbis Medical Centre, School of Medical Physics and Engineering, Netherlands)
15:05-15:20 (NA160)

Best practices and principles in medical technology education.

Job Gutteling MSc, medical physicist(Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands)

Panel Discussion (1-B): 'Medication safety and drug safety’ (Part B)
15:20-15:50 (SP: NA080)

Educational Lecture (7)Safe and sound: the evidence on how to prevent medication errors.
Katja Taxis (Prof. PhD. Faculty of Pharmacy, Rijksuniversiteit Groningen, The Netherland)
15:50-16:05 (NA115)

ASTRA - Algorithms for Seniors' Therapy Amelioration:
II. Analysing Risk of Polypharmacy for Development of Cognitive Dysfunctions and Dementia.

Ursula Wolf
Department of Pharmacology and Toxicology, Division of Clinical Pharmacology andUniversity Hospital Halle, Martin-Luther University Halle-Wittenberg, Germany
16:05-16:20 (NA146)

Pharmacist services in a transitional care program to reduce 30-day readmissions.
1,2

Timothy Reilly, PharmD, BCPS, CGP, FASCP
Kathleen H. Seneca APN-BC, MSN, CNL
1. Princeton HealthCare Systems, Plainsboro, NJ, USA
2. Rutgers, The State University of New Jersey
16:20-16:35 (NA154)

1

DART: On Target for Safe Prescribing. A Multidisciplinary Simulation-based Quality Improvement
Project to improve prescribing safety.
Karin Purshouse, Thomas Oakley, Judith Bailey, Neha Shah, Triss Clark, Jane Hough(John Radcliffe Hospital, Oxford University Hospitals Trust. Oxford, UK)rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Afternoon on 11 September, Oral
Panel Discussion (8): 'IT and medical informatics in clinical risk management’
The quality of patient record keeping in the surgical department of a London District General
Hospital and its association with patient safety.
16:35-16:50 (NA018)

Manousos-Georgios Pramateftakis, Faddy Kamel, Sheridan Brown, Idan Bokobza, Ahmad Moinie, Abhay Chopada.
(Ealing Hospital NHS Trust, London, UK)
16:50-17:00 (NA088)

The use of IT to optimise patient safety in the peri-operative period.

Dr Nav-Preet Kaur, Dr Sugam Kale. (Anaesthesia Department, Alexandra Hospital, Singapore)
17:10-17:10 (NA121)

Disciplined Instant Messaging to Enhance Patient Safety
Dr. Somnath Chatterjee, Consultant Intensivist, Jurong Health, Singapore
Dr. Tan Chee Keat, Consultant Intensivist, Jurong Health, Singapore
Dr. Chaitra Holla, Medical Officer, Jurong Health, Singapore
Dr. Richa Agarwal, Medical officer, Jurong Health, Singapore
Dr. Sugam Kale, Consultant Anaesthesiologist, Jurong Health, Singapore---- The end of the 2nd day ----

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)【12 September 2014: Oral presentation】
Onsite registration desk open from 8:00 to 17:00.
Moring oral session launches at 9:00.

Morning on 12 September 2014, Oral

'Oral presentation (General)'
9:00-9:10 (NA043)

Medicalization risk. Bases of discussion for a non-pharmacological care of life.

Norma González González; Alfredo García Rosas; Laura Elizabeth Benhumea González;Aristeo Santos López; Epigmenio López Martínez.
(Profesores investigadores de la Universidad Autónoma del Estado de México UAEMEX. Mexico)
9:10-9:20 (NA051)

Providing A Safer Environment for Healthcare Personnel & Patients Through Influenza
Vaccination: Strategies from Research and Practice.
Dr. Nellie S Boma, Chief Medical Officer / Ms. Sreevidya P.N, Infection Control Nurse /Ms. Maisa Saaban, Infection Control Nurse / Dr. Ritu Nambiar, Chief of Service – Obstetrics & Gynecology /Ms. Norma Abu Nassif, Clinical Pharmacist / Dr. Faraj Massouh, Specialist – Anesthesia /Dr. Julia Abu Asbeh, Consultant – NICU / Mr. Salih Abdulla, Microbiologist /Mr. Ahmed Qaissiah, Unit Manager – OR, Abu Dhabi, UAE
9:20-9:30 (NA100)

Ensuring patient safety in patients with cardiac pacemaker presenting for anesthesia.

Dr. SUGAM S. KALE (Alexandra Hospital, Jurong Health, Singapore)
Dr HEMANT SHINDE (Hinduja Healthcare Surgical Hospital, India)
9:30-9:40 (NA127)

A NEW METHOD FOR THE ASSESSMENT OF PERCUTANEOUS CRYOABLATION.

Riccardo Dodia*, Alberto Sannaa(aFondazione Centro San Raffaele, eServices for Life and Health, via Olgettina 60, 20132 Milano, Italy)
9:40-10:00 (NA095)

Medication safety and drug safety.

Dr. Vlasta Molak, Gaia Foundation, Cincinnati, Ohio, USA

Panel Discussion (9): 'Clinical safety technology'
10:00-10:10 (NA006)

Bridging the Gap.

Andrea Croft (Anticoagulation Advanced Nurse Practitioner / Hospital Acquired Thrombosis Project Lead, UK)
10 :10-10:20 (NA007)

Reticlocytes, new or old red blood cells? Reticulocytes and the risk of thrombosis.

Dr. Louis Van Hecken (General Practitioner, BELGIUM)
10:20-10:30 (NA014)

Effects of exogenous and endogenous alcohol on liver functions.

Dr. Aurelian Udristioiu (City Targu Jiu. Romania)

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Morning on 12 September 2014, Oral

10:30-10:40 (NA021)

The Development of a Nurse Led Thromboprophylaxis Re-Assessment Tool to Aid the Uptake ofhromboprophylaxis Risk Assessment and Improve Patient Safety.
Andrea Croft (Anticoagulation Advanced Nurse Practitioner / Hospital Acquired Thrombosis Project Lead, UK)
10:40-10:55 min (NA124)

Aseptic method of infection safety of gastro- and colonoscopy.

S.A.Matasov (Public R&D Center “Contra Cancrum Coli”, Riga, Latvia)

Workshop (1)

10:55-11:25 (SP: NA069)

Safer Sign Out: A High Reliability Tool for Emergency Physician Handoffs and Team
Communication and Model for International Collaboration.
Drew Fuller, MD, MPH, FACEP, Martin Brown, MD, FACEP,
Emergency Medicine Associates, MD. USA
Christopher Beach, MD, FACEP
Vice Chairman and Associate Professor of Emergency Medicine, USA
Northwestern University Feinberg School of Medicine ? Department of Emergency Medicine, USA
Chief, Northwestern Lake Forest Hospital - Department of Emergency Medicine, USA
Safer Sign Out is a handoff communication process develop by physicians and is getting wide attention and growth in the US andinternationally. It is an innovative approach that can decrease risk, increase the safety and satisfaction with ER to ER doctor
handoffs.
The Emergency Medicine Patient Safety Foundation (EMPSF) reports that the tool kit has been download by by nearly 300
hospitals in 10 counties.

11:25-11:55 (SP: NA070)

Safer Admit: An Interservice Communication Tool for Patient Handoff’s in Hospitals.

Christopher Beach, MD, FACEP
Vice Chairman and Associate Professor of Emergency Medicine, USA
Northwestern University Feinberg School of Medicine ? Department of Emergency Medicine, USA
Chief, Northwestern Lake Forest Hospital - Department of Emergency Medicine, USA
Drew Fuller, MD, MPH, FACEP, Martin Brown, MD, FACEP,
Emergency Medicine Associates, MD. USA
11:55-12:00 Discussion

12:00-13:30

Lunch (Fouer near the lecture hall)

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Afternoon on 12 September 2014, Oral
Afternoon oral session launches at 13:30.
Panel Discussion (10): ‘Medical education in Patient Safety Culture: New Challenges’
13:30-13:45 (NA032)

Results of a multicentre audit to improve doctors awareness of DVLA guidelines.
1,2,3

2

4

2,5

5

5

Mahiben Maruthappu , Mark Sykes , Nicholas D Gollop , Robert A Watson , Justin CR Wormald , Mirae Park ,
6
6
6
2,3
James Diviney , Amy Taylor , Joseph Shalhoub , Ka Ying Bonnie Ng
1 Scholar, National Institute for Health and Care Excellence
2 Imperial College London . UK
3 Ealing Hospital NHS Trust. UK
4 Norfolk and Norwich University Hospital . UK
5 North West London Hospitals NHS Trust. UK
6 Watford General Hospital. UK
13:45-13:55 (NA101)

The trial of patient safety education made to prevent rule oblivion.

Yukiko Kai *1, Taisuke Ogawa *2, Muneou Suzuki *3, Kenji Araki *3
Katsuhiro Hayashi *1, Takahiro Miyoshi*1, Ryo Sai*2, Mitsuru Ikeda*2
1: Faculty of Medicine, University of Miyazaki , Japan
2: School of Knowledge Science, Japan Advanced Institute of Science and Technology, Japan
3: University of Miyazaki Hospital, Medical Informatics, Japan
13:55-14:10 (NA010)

Implementation of “Medication Reconciliation” for Patient Safety in the hospital setting.
1

2

3

4

5

Jiménez-Buñuales MT , González-Diego P , Vallejo-García M , Gallardo Anciano J , Sola-Lapeña C ,
6
7
8
9
10
Martínez-Hernández A , León-Sanz MP , González-Menorca L , Cestafe-Martínez A , López del Val JA .
Calahorra Hospital Foundation. Health and Social Services Council. La Rioja.
1
3,5
6
10
Preventive Medicine Unit. Internal Medicine Unit. Emergency Unit.
Director.
2
Preventive Medicine and Quality Management Service. Reina Sofia Hospital. Navarre Health Service-Osasunbidea.
7
School of Medicine. University of Navarra.
8
Bussiness Economy Department. University of La Rioja.
4
9
Health and Social Services Council. La Rioja. Planning Pharmaceutical Service. Planning, Evaluation and Quality Service.
Spain

Workshop (2)--- Patient safety education --CHAIRMAN: Jose Antonio de Pedro Moro. MD PhD. (Prof. Surgery. Department Surgery. University of Salamanca, Spain),
Luis Collado Yurrita MD, PhD (Director of Department of Medicine. Complutense University of Madrid, Spain)
SUMMARY
Patient safety is one of the new challenges in medical education. The patient safety has emerged as a discipline teaching degree
program, being introduced as an area of knowledge within medical schools around the world, with the goal of creating a cultureof patient safety in students and as a strategy for risk reduction.
Patient safety is thus a new discipline within the medical education, being necessary to know the concepts and principles.
Moreover, we note that it is not only the acquisition of knowledge and skills, but also an invitation to reflect on attitudes. The
alarming number of patients who have suffered adverse events or death (Article err is human) have made awareness of the
problem is taken and strategies to improve patient safety arise. Medical and Nurse students as potential medical and nurse
professionals and clinical leaders must be prepared to carry out their daily clinical practice within a framework of quality andsafety.
14:10-14:40 (SP: NA074)

Patient safety in Health Sciences: relevance and students’ perception

Maria Angeles Cuadrado Cenzual MD, PhD (Prof. Department of Medicine. Complutense University of Madrid, Spain)
14:40-15:10 (SP: NA075)

Patient Safety: Knowledge and Attitude in Undergraduate Medical Students

Maria Jose Ciudad Cabañas MD, PhD (Prof. Department of Medicine. Complutense University of Madrid, Spain)
15;10-15:20 Discussion

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3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Afternoon on 12 September 2014, Oral
Symposium (2): ‘Patient safety goals. Universal Protocols for risk prevention’
15:20-15:40 (NA094)

Philosophy and strategy of clinical risk management.

Dr. Vlasta Molak (Gaia Foundation, Cincinnati, Ohio, USA)
15:40-16:00 (NA126)

A Different Approach to Improving Patient Safety and Quality.

Lyn Astle, Anil Agarwal, Jean MacLeod, Janet Alderton, Cath Siddle, Barbara Carr, Lesley Wharton,
Pam Nicholls, Syd Pinkney, David Emerton(University Hospital of North Tees, UK)
16:00-16:20 (NA166)

Tips and tools to improve medication management systems.

Dr Rola Hammoud (Anesthesiologist, Medical Quality Director, Clemenceau Medical Center, Beirut, Lebanon)---- Closing remarks ----

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)【Morning, 10 September 2014
Poster presentation】(Poster presentation manner)
http://www.iarmm.org/3WCCS/(3WCCS)Poster_presentation_manner.pdf(Morning poster session) 9:00-13:00
Poster discussion: 12:00-13:00 by your poster.

(NA001)

An audit of medication administration records in the paediatric ward in Gondar University Hospital, Ethiopia.
Vicky Wilson (MSc,MN,PG Cert TLTM,RNT,BA, Dip DN,Neuro Cert,RGN. Lecturer, University of the West of Scotland
School of Health Nursing and Midwifery, UK)(NA011)
surgery.

Bridging the GAP – An Innovation to improve the care of patients taking warfarin undertaking elective
Andrea Croft Anticoagulation Advanced Nurse Practitioner & Dr Jon Hughes Consultant Anaesthetist, UK(NA023) FITISPos-UAH Group Research Aimed at the Improvement of the Communication between Foreign
Population and the Medical Staff.
Carmen Valero-Garcés (FITISPos-UAH Coordinator and FITISPos members,
University of Alcalá, Madrid, Spain)(NA041)

Reduction of Catheter-related Incidence with Multidisciplinary Approach in Surgical Wards.

Hui-Ju Chung (RN, Head Nurse, Nursing Department, Chi-Mei Medical Center, Taiwan)(NA042)The Project of Reducing Falls Incidence in ER of A Medical Center in the South.

Hui-Ching Hsu (RN, Leader, Nursing Department, Chi-Mei Medical Center, Taiwan)(NA044)Development and implementation of Structured Oral Examinations (SOE) to prepare infection control ingraduate students to Quebec certification exam leading to clinical nurse specialist title.
Andréanne Tanguay1) Francis Brière2)
1) Assistant Professor, and Infection Prevention and Control Graduate Program Director,
School of Nursing-Continuing Education Centre-School of Medecine and Health Care
Université de Sherbrooke, Québec, Canada
2) Graduate Program Coordinator, Continuing Education Centre-School of Medecine and Health CareUniversité de Sherbrooke, Québec, Canada(NA045)Development of a management system using radio-frequency identification tags on surgical instruments forpatient safety.
1

2

3

4

2

Kaori KUSUDA , Kazuhiko YAMASHITA , Shinichi TANAKA , Kiyohito TANAKA , Takashi OKUBO , Yuji OHTA
1) Ochanomizu University, Tokyo, Japan.
2) Tokyo Healthcare University, Tokyo, Japan
3) St. Marianna University School of Medicine, Tokyo, Japan4) Kyoto Second Red Cross Hospital, Kyoto, Japan1

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3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Morning on 10 September 2014, Poster(NA054)The Effects of Music Therapy on Improve ICU Patients Vital Signs.

Yu-Chi Li‚MS 1)＊ Szu-Hui Su‚RN 2)
1) MSN, RN, Nursing, Chi Mei Medical Center, Tainan, Taiwan and Doctoral Student,
College of Nursing, Kaohsiung Medical University. Taiwan.
2) Nursing, Chi Mei Medical Center, Tainan, Taiwan.

(NA093)National recommendation for patient safety and quality improvement in radiotherapy in the Czech Republic.

V. Dufek, I. Horakova, I. Koniarova(NA102)-(National Radiation Protection Institute (NRPI), Prague, Czech Republic)

Relationship between the anesthetic risk and postoperative glycemia.
María Fernández Prada. Preventive Medicine and Public Health Department. University Hospital Central de Asturias.
Spain.
Carmen Martínez Ortega. Preventive Medicine and Public Health Department. University Hospital Central de Asturias.
Spain.
Marta Mateos Mazón. Preventive Medicine and Public Health Department. University Hospital Central de Asturias.
Spain.
Mª José González Garrido. Preventive Medicine and Public Health Department. University Hospital Central de Asturias.
Spain.
Félix Ezequiel Fernández Suárez. Anesthesiology Department. University Hospital Central de Asturias. Spain.
Raquel García Pelaz. Anesthesiology Department. University Hospital Central de Asturias. Spain.
David Fernández del Valle. Anesthesiology Department. University Hospital Central de Asturias. Spain.
Juan Carlos Gutiérrez del Valle. Anesthesiology Department. University Hospital Central de Asturias. Spain.
Juan Sánchez Lasheras. Anesthesiology Department. University Hospital Central de Asturias. Spain.

(NA119)Reduction of Adverse Incidents for patients receiving procedural sedation, through the introduction of a
uniform competency tool.
Anne Marie Woods (St Vincent's University Hospital, Dublin, Ireland)(NA131)

Improving Safety Culture Starts with Leadership.
Stephen M. Powell, MS, Daniel Baily, MS, Jeffrey Box, MS, MBA, and Spencer King, BS(Synensis, LLC , GA, USA)

(NA161)

Newspaper reports on BSE in the UK: Content analysis of newspaper articles between 1985 and 2008.
Hajime SATO, Satomi NOGUCHI(National Institute of Public Health, Department of Health Policy and Technology Assessment, Japan)
Andrew WEBSTER(University of York, Department of Sociology, UK)(NA167)

PATIENT IDENTIFICATION ERROS IN EMERGENCY OF THE HOSPITAL AND ITS IMPACT ON PATIENT SAFETY.
Cuadrado-Cenzual MA1, Guessous A1, Palazón I1, de Gracia Y1, Collado L2, de Pedro JA3.
Hospital Clínico San Carlos1. Facultad Medicina. UCM 2. Madrid . Facultad de Medicina USAL. Salamanca3. Spain

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)【Afternoon, 10 September 2014
Poster presentation, Fouer】(Poster presentation manner)
http://www.iarmm.org/3WCCS/(3WCCS)Poster_presentation_manner.pdf(Afternoon poster session) 13:30-16:30
Poster discussion: 15:30-16:30 by your poster.

(NA019)Safe use of high alert medications (1).
Asli OZYILDIRIM, MSc Pharmacist, Chief of Pharmacy, Turkey
Ismail BOZKURT, MD, Chief of Continuous Quality Improvement Department, Turkey
Fatma KUCUKERENKOY – Patient Safety Manager, Turkey
Gulden ARSLAN – Pharmacist, Turkey
Ulku Burgess – Nurse Manager, Turkey(NA099)
Patient safety and quality improvement in the form of an audit on the Clinical Decision Unit of a tertiarycare hospital in the United Kingdom.
Ceri Spencer, Omar Khan, Israr Haq (New Cross Hospital, Royal Wolverhampton NHS Trust, England, UK)(NA106)

Incidents of postoperative retained foreign objects at a Japanese university hospital.

Ayuko Yasuda MD, PhD, Yoshimasa Nagao MD, PhD, Hiromi Noda RN, Rieko Sakai RN, Fumimasa Kitano JD(Department of Quality and Patient Safety, Nagoya University Hospital in Nagoya, JAPAN)(NA125)Use and safety of new oral anticoagulants in clinical practice. Novel prescriptions from a University Hospital.

Marta Duero, Laura Domenech,, Pilar Lalueza, Leticia Mestre, Emma Movilla, Julio Martínez(Servei de Farmàcia, Hospital Universitari Vall d’Hebron, Barcelona, Spain)(NA129)Simulation education in patient safety: Improvement of nurses’ patient and medication identification errors.
1)

2)

2)

2)

2)

3

1

2)

Yukie abe , Yorie Kajiki , Kazufumi Nagahama , Sadayuki Murayama , Ichiro Kukita , Takako Simoji .
Tokyo Medical University Hospital, Okinawa clinical simulation center, Japan.
University of the Ryukyus Hospital, Japan

1)
2)(NA150)Pre-Hospital/Emergency Department Handover in Italy.
1*2Francesco Dojmi Di Delupis ; Niccolò Mancini ; Tommasina di Nota ; Paolo Pisanelli
1
MD. Inter-institutional Integrated Department, University of Florence and Careggi University Hospital,
Largo Brambilla 3, 50134 Florence, Italy2
Human Geography; Executive director ‘Fratellanza Militare’ Educational and Training Department, Florence
3
RN Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy(NA153)
Optimizing drug prescribing and dispensing habits in a surgical department: risk analysis, observational
study and patient involvement.
1, 2

3

1

Sendlhofer G , BA, Brunner G ,MD, PhD., Kamolz L P , MD, PhD
Department of Quality and Risk Management, University Hospital Graz, Graz, Styria, Austria
2
Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University Graz,
Graz, Styria, Austria
3
Chief Medical Director, University Hospital Graz, Graz, Styria, Austria
1(NA155)

Pharmacist services in a transitional care program to reduce 30-day readmissions.
1,2

Timothy Reilly, PharmD, BCPS, CGP, FASCP
Kathleen H. Seneca APN-BC, MSN, CNL
1. Princeton HealthCare Systems, Plainsboro, NJ, USA
2. Rutgers, The State University of New Jersey, NJ, USA1

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Afternoon on 10 September 2014, Poster(NA156)

Pharmacy Medication Safety Initiatives: KK Women’s & Children’s Hospital Experience, Singapore.

Mr Mohammed Nazri Bin Abdul Ghani(BSc (Pharmacy) Honours, GradDip (Clinical Pharmacy), Medication Safety Officer, Pharmacy Department,
KK Women’s & Children’s Hospital, Singapore)(NA162)

Newspaper reports on BSE in Korea: Content analysis of newspaper articles from 2002 to 2009.
Satomi NOGUCHI, Hajime SATO
(National Institute of Public Health, Department of Health Policy and Technology Assessment, Japan)(NA163)101 incidents in the emergency department (ED)
Alcaraz Martínez J, Marin Martínez J M, Lozano Pastor V E, Ortiz González O, Conesa Hernández A,
Melgares de Aguilar Mata J M, Escudero Sánchez C. Trigueros Ruiz N, Rojo Cánovas M, Reina Nicolás I M,
Contreras Garcia C.
(Hospital Morales Meseguer. Area VI, MURCIA, Spain)(NA165)

The Project of Reducing Restraint Numbers in a Surgical Ward.
Lee I-Ping(NA168)(Chi Mei Medical Center, Tainan, Taiwan)

MEDICINE LABORATORY AND PATIENT SAFETY: ANALYSIS OF PATIENT/SPECIMEN IDENTIFICATION ERRORS.
de Gracia Y1, Cuadrado-Cenzual MA1, Guessous A1, Arroyo M1, Collado L2, de Pedro JA3.
Hospital Clínico San Carlos1. Facultad Medicina. UCM 2. Madrid . Facultad de Medicina USAL. Salamanca3. Spain

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)【Morning, 11 September 2014
Poster presentation, Fouer】(Poster presentation manner)
http://www.iarmm.org/3WCCS/(3WCCS)Poster_presentation_manner.pdf(Morning poster session) 9:00-13:00
Poster discussion: 12:00-13:00 by your poster.
(NA003)

Phenol Safety during toenail matrixectomies procedure performance.

*Sánchez Gómez R., Becerro de Bengoa Vallejo R., Losa, Iglesias ME., González Gutiérrez MR., Rico Teixeira R.
* Prof. UEM. Madrid, Spain(NA022)

Paradoxical Response Protocol for Improving Safety of Endoscopy.
Hui-Jeong Hwang, Mi-Hyun Yun, Min-Sun Lee, Ji-Young Park
(Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea)(NA040) A Project of Applying Integrated multidisciplinary team model to Reduce delay bed with lower limb
Fractures.
Li-Yun Chung (RN, Team leader Nurse, Nursing Department, Chi-Mei Medical Center, Taiwan)(NA047) A Project of Applying Team Resource Management (TRM) Based on PDCA to Improve The Effectiveness of
Cardiac Catheter Puncture Site Complications.
Ching-Yun Liu, Huang-Tsai Su, The third author : Shu-Hui Hu
Nursing Department, Chi-Mei Medical Center, Taiwan(NA048)Using Mind Map as education of medication errors for novice nurse.
1)2)

3)

1)3)

3)

3)

3)

Muneto Tatsumoto , Miki Ohshima , Miyuki Hashimoto , Yoshiko Ogura , Yoko Fujii , Keiko Ohzeki ,
1)
2)
4)
1)5)
Hajime Kaneko , Koichi Hirata , Hideyuki Hiraishi , Keiichi Kubota
1) Medical Safety Management Center, Dokkyo Medical University Hospital, Tochigi, Japan
2) Department of Neurology, Dokkyo Medical University, Tochigi, Japan
3) Nursing Department, Dokkyo Medical University Hospital, Tochigi, Japan
4) Department of Gastroenterology, Dokkyo Medical University, Tochigi, Japan
5) Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan(NA098)-Compliance with the use and application of an antiseptic for surgical skin preparation.
María Fernández Prada. Preventive Medicine and Public Health Department. University Hospital Central de Asturias.
Spain.
Carmen Martínez Ortega. Preventive Medicine and Public Health Department. University Hospital Central de Asturias.
Spain.
Marta Mateos Mazón. Preventive Medicine and Public Health Department. University Hospital Central de Asturias.
Spain.
Mª José González Garrido. Preventive Medicine and Public Health Department. University Hospital Central de Asturias.
Spain.
Juan Navarro Gracia. Preventive Medicine and Public Health Department. University Hospital of Elche. Spain.
César Morís. Cardiology Department. University Hospital Central de Asturias. Spain.
Carlos Morales. Cardiology Department. University Hospital Central de Asturias. Spain.
Lino Vázquez Velasco. Surgery Department. University Hospital Central de Asturias. Spain.
Juan Carlos De Vicente. Maxillofacial Surgery Department. University Hospital Central de Asturias. Spain.

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Morning on 11 September 2014, Poster(NA103)

DNA Outpatient Appointment Rates Can We Make Them Better?
Nolan G

(NA103)

DNA Outpatient Appointment Rates Can We Make Them Better?
Nolan G

(NA107)-(Chief Respiratory Scientist, Pulmonary Laboratory, St Vincent’s University Hospital, Dublin, Ireland)(Chief Respiratory Scientist, Pulmonary Laboratory, St Vincent’s University Hospital, Dublin, Ireland)Management of pre and postoperative glycemia in diabetic patients undergoing elective surgery.
María Fernández Prada. Preventive Medicine and Public Health Department. University Hospital Central de Asturias.
Spain.
Carmen Martínez Ortega. Preventive Medicine and Public Health Department. University Hospital Central de Asturias.
Spain.
Marta Mateos Mazón. Preventive Medicine and Public Health Department. University Hospital Central de Asturias.
Spain.
Mª José González Garrido. Preventive Medicine and Public Health Department. University Hospital Central de Asturias.
Spain.
Mª Luisa González Ruiz. Anesthesiology Department. University Hospital Central de Asturias. Spain.
Mercedes Casaprima González. Anesthesiology Department. University Hospital Central de Asturias. Spain.
Ana Menéndez Miranda. Anesthesiology Department. University Hospital Central de Asturias. Spain.
Isabel Santín Piñán. Critical Care Service. University Hospital Central de Asturias. Spain.
Pedro Fernández Álvarez. Critical Care Service. University Hospital Central de Asturias. Spain.
Asunta Martínez González. Critical Care Service. University Hospital Central de Asturias. Spain.

-(NA116)

Innovative Consequences for Clinical Pharmacological Approach:
HELP – Hierarchical Elements for Long-term Transplant Preveillance.

Ursula Wolf (Department of Pharmacology and Toxicology, Division of Clinical Pharmacology andUniversity Hospital Halle, Martin-Luther University Halle-Wittenberg, Germany)(NA158)

Fall Risk Factors among Inpatients in a Japanese University Hospital.
1

2

1

1

Toshihide Saga , Taku Obara , Chiyo Oikawa , Keisei Fujimori ,and on behalf of the Working Group of Prevention from Fall
1
Medical Safety Management Office, Tohoku University Hospital, Sendai, Japan.
2
Department of Pharmacy, Tohoku University Hospital, Sendai, Japan.

(NA169)Appliyng Failure Models and Effects (FMEA) Analysis of Identification Patient Errors in Medicine Laboratory.

Cuadrado-Cenzual MA1, Guessous A1, de Gracia Y1, Collado L2, de Pedro JA3.
Hospital Clínico San Carlos1. Facultad Medicina. UCM 2. Madrid . Facultad de Medicina USAL. Salamanca3. Spain

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)【Afternoon, 11 September 2014
Poster presentation, Fouer】(Poster presentation manner)
http://www.iarmm.org/3WCCS/(3WCCS)Poster_presentation_manner.pdf(Afternoon poster session) 13:30-16:30
Poster discussion: 15:30-16:30 by your poster.

(NA020)

Safe use of high alert medications (2).
Asli OZYILDIRIM, MSc Pharmacist, Chief of Pharmacy, Turkey
Ismail BOZKURT, MD, Chief of Continuous Quality Improvement Department, Turkey
Fatma KUCUKERENKOY – Patient Safety Manager, Turkey
Gulden ARSLAN – Pharmacist, Turkey
Ulku Burgess – Nurse Manager, Turkey(NA055)Creation of pilot protocol for sudden changes in home care patient conditions Judgment and Support by
Visiting Nurses- In association with the symptoms of Dyspnea and cooperation between visiting nurses and physicians－
Yayoi Sato and Miho Tonai(NA056)(Oita University of Nursing and Health Sciences, Oita, Japan)

Effective Analysis of Electronic Handover System by Registered Nurses.

Li-Chien Yang RN, Head Nurse, Yi Liu PhD Assistant Professor(Nursing Department, Chi-Mei Medical Center, Tainan, Taiwan)(NA058)Introduction of Team Resource Management to Reduce Medication Error Rate in Emergency Department.

I-Ching Yang, Hui-Ju Chung(Nursing Department, Chi-Mei Medical Center, Tsainan, Taiwan)(NA060)Patient safety incident prevention among Korean dentists.
Ho-Joon Choi, Hye-Ju Lee, Dong-Hun Han(Department of Preventive and Social Dentistry, Seoul National University School of Dentistry, Korea)(NA082) 「 Time Out 」Verification Right - A Study of New Nurses Medication Administration Errors Process Analysis.
Yu-Mei Lee, MSN, RN (Department of Nursing, Chi Mei Medical Center, Tainan City, Taiwan)(NA090)Care Unit.

Investigation of Complications Arising from Perimeter Vein Injection in the Heart Afferent Surgery Intensive

Li Chuan CHANG，RN: Nursing department，Chi Mei Medical Center, Taiwan
Hui-Ting Kuo ，HN: Nursing department，Chi Mei Medical Center, Taiwan(NA096)

Leadership of the Head Nurse in Fostering of a Culture that Prioritizes Safety.

Toshiko Kobayashi
Ruriko Nakahara
Junko Ito
Chieko Takeuchi: Toho University, Ohashi Medical Center, Tokyo, Japan: Toho University, Nurse College, Tokyo, Japan: Funabashi Municipal Medical Center, Chiba, Japan: Tokyo Medical University, Tokyo, Japanrd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Afternoon on 11 September 2014, Poster(NA104) Informed consent- Fact or fiction?
--- An audit of 1) compliance with Joint Commission International standards of informed consent and 2) intern,
consultant and patient satisfaction with the informed consent process in St. Michael’s Hospital.
Dr. Gerard Lambe, Dr. Stephanie Rutledge, Dr. Geoff Watson, Dr. Ian Callinan, Ms. Bernie Farrelly,
Ms. Fran Campbell. (St. Michael’s Hospital, Ireland)(NA117)

Prevalence of Needlestick Injuries among Nurses and Prevention Interventions: A Literature Review.

Yuka Kanoya1), Noriko Kubo2), Akiyo Sasaki-Otomaru3), Mana Kanno4), Yuko Morikagi5), Takiko Hosoya6)1),3),4) Nursing Course, School of Medicine, Yokohama City University, Japan
2)
Tokai University Junior College of Nursing Technology, Japan5), 6)
School of Nursing, Yamagata University Faculty of Medicine, Japan(NA123)
Risk Management by Nurses at Mealtimes to Prevent Postoperative Aspiration Pneumonitis in Patientswith Thoracic Esophageal Cancer.
T. Shimoda, S. Yoshimura (Faculty of Health Sciences, Hokkaido University, Japan)(NA135)The significance of good communication in disclosure conversations with patients after the adverse event as
a risk management: A Case of the Foodborne Norovirus Outbreak in general hospital.
*1*2,

*1

*1

*1

Hiroyuki Kojin
Nobuko Sakai , Sanae Kubota , Takahiro Kudo
*1 Infection Control Team, Kohsei Chuo General Hospital, Japan*2 Department of Preventive Medicine and Public health, Tokyo Medical University, Japan(NA136)

Use and application of Surgical Safety guidelines in Abruzzo: results of first the year monitoring.
a

b

c

a

Di Filippo Maria Carmina , Muraglia Angelo , Tozzi Quinto , Fabiani Leila
Università degli Studi dell’Aquila, Scuola di Specializzazione in Igiene e Medicina Preventiva, L’Aquila, Italyb
Regione Abruzzo, Direzione Politiche della Salute, Pescara, Italyc
AGE.NA.S. Agenzia Nazionale Servizi Sanitari Regionali, Roma, Italya(NA170)

Root Cause Analysis of Patient and Specimen Identification Errors in Laboratory Medicine.

Guessous A1,Cuadrado-Cenzual MA1,, de Gracia Y1, Arroyo M1, Collado L2, de Pedro JA3.
Hospital Clínico San Carlos1. Facultad Medicina. UCM 2. Madrid . Facultad de Medicina USAL. Salamanca3. Spain

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)【Morning, 12 September 2014
Poster presentation, Fouer】(Poster presentation manner)
http://www.iarmm.org/3WCCS/(3WCCS)Poster_presentation_manner.pdf(Morning poster session) 9:00-13:00
Poster discussion: 12:00-13:00 by your poster.

(NA036)

Impact of Multifaceted Campaign to Improve Culture of Medication Errors Reporting.
S. Owais, A. Alamry,(Ministry of National Guard Health Affairs, King Abdulaziz Medical City-Riyadh.
King Saud bin Abdulaziz University for Health Sciences, Saudi Arabia)(NA039)Safety management of tracheostomy: analyze complications on the early period.
1)

1)

1)

2)

2)

Keisuke Kumada 、Sayuri Tamai 、Nobuo Murakami 、Izumi Toyoda 、Shinji Ogura(Patient Safety Division, Gifu University Hospital1), Department of Emergency & Disaster Medicine
2)
Gifu University Scholl of Medicine , Japan)(NA046)

Workplace Safety Culture and Human Environment Influencing Nurses’ Violation Behavior.
Junko Ito,
Funabashi Municipal Medical Center, Chiba, Japan
Ruriko Nakahara, Toho Univercity , Doctor of Science in Nursing Major, Japan
Toshiko Kobayashi, Toho Univercity Ohashi medical center, Master of Science in Nursing Major, Japan
Chieko Takeuchi,
Tokyo Medical Univercity , Doctor of Science in Nursing Major, Japan(NA057)

Case Study regarding Judgment and Risk Prediction of Visiting Nurses in Japan.
121

Miho Tonai ）, Sayaka Seike ）, Yayoi Sato ）1)
2)
Oita University of Nursing Health Sciences Oita University Hospital, Japan(NA089)Confirming the insertion of nasoesophageal feeding tubes using X-ray and pH measurement throughgastric fluid.
Keiko YAMAMOTO, Ryo TANAKA & Noboru FUJITANI (Chiba Institute of Science, Japan)(NA097)

Applying Team Cooperation to Elevate Postoperative patients’ Rate on Early Ambulation.

Chiu-Yen Li (RN, Nursing Department, Chi-Mei Medical Center, Taiwan)(NA110)Application of PRECEDE Model for diagnosis of behaviors related to patient safety: young doctors’
participation in SPNIS.
-

María Fernández Prada. Preventive Medicine and Public Health Department. University Hospital Central de Asturias.
Spain.
Blanca Meana Fernández. Cardiology Department. University Hospital Central de Asturias. Spain.
Laura del Río García. Nephrology Department. University Hospital Central de Asturias. Spain.
María Argüello Junquera. Hematology Department. University Hospital Central de Asturias. Spain.
Lucía Junquera Vega. Cardiology Department. University Hospital Central de Asturias. Spain.
Helena Gómez Rodríguez. Internal Medicine Department. University Hospital Central de Asturias. Spain.
Elena Díaz Peláez. Cardiology Department. University Hospital Central de Asturias. Spain.
Daniel García Iglesias. Cardiology Department. University Hospital Central de Asturias. Spain.
Pedro Fernández Díaz-Villabella. Angiology Department. University Hospital Central de Asturias. Spain.
Daniel Martínez Carballeira. Hematology Department. University Hospital Central de Asturias. Spain.

rd

3 World Congress of Clinical Safety

10-12 Sep 2014 Madrid, Spain
by International Association of Risk Management in Medicine (IARMM)

Morning on 12 September 2014, Poster(NA122)Analysis of Nurse-Related Adverse Drug Events Based on Publicly Available Data.
1)

2)

1)

3)

4)

Taiko TERASHIMA ，Sadako YOSHIMURA ，Junichi TANEMOTO ，Kayo MITSUNO ，Hiromi TAKESHIMA ，
4)
Reiko KIKUCHI
1）Department of Nursing，Japanese Red Cross Hokkaido College of Nursing，Kitami，Japan
2）Faculty of Health Sciences，Hokkaido University，Sapporo，Japan
3）Nursing Department，Sapporo Minamiseisyu Hospital，Sapporo，Japan
4）Nursing Department，Sapporo Tokusyukai Hospital，Sapporo，Japan(NA118)The role of patient safety culture toward incident reporting as a mediator of nursing work environment to
the nurse’s safety performance in Taiwan.
Chiang, Hui-Ying, PhD, RN (Deputy Director of Nursing Department, Chi Mei Medical Center, Tainan Taiwan, R.O.C.)(NA171)
PATIENT SAGETY: EXPLORING 1 YEAR MEDICAL STUDENTS KNOWLEDGE AND ATTITUDES.
Cuadrado-Cenzual MA1, Ciudad MJ1, de Pedro JA2, Collado L1,
Facultad Medicina. UCM 1. Madrid . Facultad de Medicina USAL. Salamanca2. Spain--- Program End ---