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2 World Congress of Clinical Safety (2 tentative Draft)

12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)

IARMM 2nd World Congress of Clinical Safety
12th – 13th Sep 2013, Heidelberg University, Germany- Risk in Clinical Care -Congress President: Ryoji Sakai (IARMM President. Profs. Dr. (retired), EPFL. etc. Honor Prof. SU, Tokyo)
Congress vice-President: Job Harenberg (Prof. Dr. med University of Heidelberg)
Co-organizer: Günther Jonitz (Dr. President of Berlin Chamber of Physicians. Founder of German Coalition for Patient
Safety. Patient safety consultant of German Federal Ministry of Health, Germany)
Co-organizer: Mark Weinert (Dr. Krankenhaus München Pasing, München)

Program(Final version)

Conference venue: Neuen Universitat in University of Heidelberg
Universitatsplatz, 69117 Heidelberg
http://www.uni-heidelberg.de/universitaet/besucher/karten/2170a.html(Utility space)
Oral session: Hall 4a (1st floor) & Hall 14 (2nd floor)
Poster presentation: Foyer (1st floor)
Business meeting: Hall 3 (1st floor)(Onsite registration desk)
Opening hour of the onsite registration desk: from 8:00 to 17:30, 12 Sep. 2013
Opening hour of the onsite registration desk: from 8:00 to 17:30, 13 Sep. 2013
(Poster)
12 Sep 9:00 – 17:00 (Poster discussion time: 12:00-13:00 and 15:00-16:00)
13 Sep 9:00 – 13:00 (Poster discussion time: 12:00-13:00 )Each poster should be displayed at 4 hours in the morning (9:00 - 13:00) or in the afternoon (13:00-17:00) on Sep 12 or
Sep 13.
(Live broadcasting)Internet live broadcast releases at Hall 14, only. The other halls don’t release any broadcasting.

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2 World Congress of Clinical Safety (2 tentative Draft)

12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)(Dinner party)

Time: From 6 pm to 10 pm, 12th September 2013
Place: Kulturbrauerei Heidelberg AG
Leyergasse 6, 69117 Heidelberg
Phone +496221-502 980

Route guide: The walking time form the University is about 5 - 10 minutes. You just walk down
Hauptstrasse (right at the University). Then, after a square right underneath the castle (Kornmarkt)
you turn left down the alley Leyergasse.

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2 World Congress of Clinical Safety (2 tentative Draft)

12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)【12 SEPTEMBER 2013: HALL 14, 2ND FLOOR:ORAL: LIVE BROADCASTING】

OPENING REMARKRYOJI SAKAI (PRESIDENT OF IARMM & WHRMC. HON. PROF. SU. PROFS (RETIRED). DR., TWU, EPF, USM, ETC.,JAPAN)(9:00 - 9:05, 12 SEP. 2013)

MEMORIAL ADDRESS (1)(ML01) ”IMPROVEMENT OF SAFETY OF TREATMENT WITH NEW ORAL DIRECT ANTICOAGULANTS BY AQUALITATIVE POINT OF CARE TEST USING URINE SAMPLES”
PROF. DR. MED. JOB HARENBERG (1), SHANSHAN DU (1), SANDRA KRÄMER (1), CHRISTINA GIESE (1), ASTRIDSCHULZE (2), ROLAND KRÄMER (3)(DEPARTMENT OF CLINICAL PHARMACOLOGY (1), ORTHOPEDIC CENTER (2), MEDICAL FACULTY MANNHEIM, INSTITUTEINORGANIC CHEMISTRY (3), UNIVERSITY OF HEIDELBERG, MANNHEIM, GERMANY)(9:05 - 9:30, 12 SEP. 2013)

MEMORIAL ADDRESS (2)(ML02) “HOW TO CHANGE SAFETY CULTURE ON NATIONAL LEVEL – THE PATIENT SAFETY STORY IN GERMANY”
GÜNTHER JONITZ(DR. MED. PRESIDENT OF BERLIN CHAMBER OF PHYSICIANS. FOUNDER OF GERMAN COALITION
FOR PATIENT SAFETY.
PATIENT SAFETY CONSULTANT OF GERMAN FEDERAL MINISTRY OF HEALTH, GERMANY)(9:30 - 9:55, 12 SEP. 2013)

SPECIAL LECTURE (1)(SL01) “THE TOP TEN ISMP MEDICATION SAFETY ISSUES”
ALLEN J VAIDA(DR. EXECUTIVE VICE PRESIDENT, THE INSTITUTE FOR SAFE MEDICATION PRACTICE , USA)
(9:55 - 10:20, 12 SEP. 2013)(10:20 - 11:00, 12 SEP. 2013)
SPECIAL LECTURE (2)(SL02) “FUTURE OF RISK SCIENCES IN EUROPE”
ORTWIN RENN
(PROF. DR. UNIVERSITY OF STUTTGART, GERMANY)(11:00 – 12:00, 12 SEP. 2013)

PANEL (1): ‘INTERNATIONAL PERSPECTIVES FOR CLINICAL SAFETY’(11:00 – 11:15, 12 SEP. 2013)(SL03) “HELSINKI DECLARATION ON PATIENT SAFETY IN ANAESTHESIOLOGY”
DR. SVEN STAENDER(CHAIRMAN, PATIENT SAFETY TASK FORCE IN “EUROPEAN SOCIETY OF ANAESTHETISTS”,
REGIONAL HOSPITAL MÄNNEDORF/ZUERICH, SWITZERLAND)(11:15 – 11:30, 12 SEP. 2013) INCLUDING 3 MIN OF DISCUSSION(NA085) “EXCHANGING KNOWLEDGE ABOUT PATIENT SAFETY PRACTICES AMONG EU MEMBER STATES: A
PROGRESS REPORT ABOUT SELECTED GOOD PRACTICES AND EXCHANGE MECHANISMS BY THE JOINT ACTION
PROJECT OF THE EUROPEAN UNION NETWORK FOR PATIENT SAFETY AND QUALITY OF CARE (PASQ JA)”
DR. LIETZ, MARTINA. DR. LESSING, CONSTANZE(INSTITUTE FOR PATIENT SAFETY (IFPS), UNIVERSITY OF BONN BY ORDER OF THE GERMAN COALITION FOR PATIENT
SAFETY (APS), BONN, GERMANY)

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2 World Congress of Clinical Safety (2 tentative Draft)

12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)(11:30 – 11:45, 12 SEP. 2013) INCLUDING 3 MIN OF DISCUSSION(NA064) “IMPLEMENTATION OF SAFE CLINICAL PRACTICES IN THE PROJECT “EUROPEAN UNION NETWORK FOR
PATIENT SAFETY AND QUALITY OF CARE”
LENA MEHRMANN, LIAT FISHMAN, CHRISTIAN THOMECZEK(AGENCY FOR QUALITY IN MEDICINE (AQUMED / AEZQ) – JOINT INSTITUTION OF THE GERMAN MEDICALASSOCIATION AND THE NATIONAL ASSOCIATION OF THE STATUTORY HEALTH INSURANCE PHYSICIANS, BERLIN,GERMANY)(11:45 – 12:00, 12 SEP. 2013) INCLUDING 3 MIN OF DISCUSSION(NA147) “GLOBAL COMPARATORS PROJECT; INTERNATIONAL COMPARISON OF HOSPITAL OUTCOMES USINGADMINISTRATIVE DATA”
RICHARD AYRES (DR. FOSTER INTELLIGENCE, UK)

Invitation note:“Introduction to the 3rd World Congress of Clinical Safety, 2014 in Spain”(12:00 - 12:05, 12 Sep. 2013)(12:05 - 13:00, 12 Sep. 2013)

Lunch(13:00 - 13:45, 12 Sep. 2013)

Panel (2): ‘Clinical communication for risk and safety’(13:00 - 13:15, 12 Sep. 2013)

including 3 min of discussion(SL04) “Team communication strategies for safe handover”
Tanja Manser (Prof. Dr. Universite de Fribourg, Switzerland)(13:15 - 13:30, 12 Sep. 2013)

including 3 min of discussion(NA002) “Communication for medical professionals to improve patient safety”
Mark Weinert(Dr. Krankenhaus München Pasing, Germany)(13:30 - 13:45, 12 Sep. 2013)

including 3 min of discussion(NA058) “Interpersonal Communication Skills and Patient Safety:
Expanding Patient-Caregiver Communication Studies for Nursing Students at the Tel Aviv-Yaffo Academic College”
Dr. Pazit Azur*i, Dr. Yafa Haron(*Dean, School Of Nursing Science, Tel Aviv-Yaffo Academic College, Israel)

Panel (3): Simulation and human factor for clinical safety'
Chairperson: Gesine Hofinger (Germany)(13:45 - 15:00, 12 Sep. 2013)(13:45 - 14:15, 12 Sep. 2013)(SL05) “Design of Crisis Resource Management scenarios for full scale simulators – what is needed to improve theoverall clinical safety?”
Wolfgang Heinrichs (Prof. Dr. Applied quality assurance in anesthesia and intensive care. Simulation Centre Mainz,
Germany)

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2 World Congress of Clinical Safety (2 tentative Draft)

12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)(14:15 - 14:40, 12 Sep. 2013)(SL06) “Human error and safety in health care organizations”
Gesine Hofinger(Dr. President of the platform “People in complex work environments", Germany)(14:40 - 15:00, 12 Sep. 2013)

including 3 min of discussion(NA119) “Education in Technical Safety at the Medical University of Graz”
Dr. Puchinger M., Rehak, P. H.
(Medical University of Graz, Department of Surgery, Research Unit of Medical Engineering and Computing, Graz, Austria)(15:00 - 16:00, 12 Sep. 2013)

Break(15:00 – 16:55, 12 Sep. 2013)

Panel (4): 'Clinical safety culture'(15:00 - 15:25, 12 Sep. 2013)(SL07) “NEOCONTROL: Pelvic Floor Therapy System - How does a new technological development eliminate
any patients risk in pelvic floor therapy”.
Michael Jordan(Praxis Prof. Dr. for Urology. Kitalpha Med. München, Germany)(15:25 - 15:40, 12 Sep. 2013)

including 3 min of discussion(NA015) “Balancing Risk with Experience? International Placements in Developing Countries”
Prof. Louise Ackers, Mr James Ackers-Johnson, Dr. Emilie Lewis(School of Law and Social Justice, Faculty of Humanities and Social Sciences University of Liverpool, UK)(15:40 - 15:55, 12 Sep. 2013)

including 3 min of discussion(NA105) “INVOLVEMENT IN HEALTHCARE IMPROVEMENT INTERVENTIONS: PERCEPTIONS OF A FRONT LINEHEALTHCARE TEAM”
Lorna Flynn1, Peter McCulloch1, Graham Martin2, Francesca Castillo1, Lauren Morgan1(1Nuffield Department of Surgical Sciences, University of Oxford, 2Department of Health Sciences, University ofLeicester)(15:55 – 16:10, 12 Sep. 2013)

including 3 min of discussion(NA129) “Driving clinical safety initiatives through innovative technological feedback systems in an Australianacademic health service.”
Bain C1, Weir-Phyland J1, Metcalf S1, Ingram P1 and Prof. Bucknall T 1&2(1Alfred Health, Melbourne, Australia; 2Deakin University Melbourne, Australia)(16:10 - 16:25, 12 Sep. 2013)

including 3 min of discussion(NA120) “Quality improvement Audit: The Hunger Games - Our fight to reduce nil by mouth times for
gastroscopy. “Dr Simon Huf, Dr Sorayya Alam, Dr Ariadne Strong, Dr Dineth Sumathipala, Dr James Robinson(North Bristol trust, Bristol, England)

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2 World Congress of Clinical Safety (2 tentative Draft)(16:25 - 16:40, 12 Sep. 2013)

including 3 min of discussion.

12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)

Remote presentation(NA057) “Knowledge of Student Nurses on Quality Assurance in Clinical Practice”
Ms. Manisha Kammar (Asst. Prof. Symbiosis College of Nursing, Pune, Maharashtra, India)(16:40 - 16:55, 12 Sep. 2013)

including 3 min of discussion(NA035) “Designing and Validating an Egyptian Assessment Tool for Environmental Risk Factors Affecting
Intensive Care Patients “Elham Youssef Elhanafy, DrNSc, RNa,*, Reem Mabrouk Abd El Rahman, DrNSc, RNa,**(*Nursing Administration Department, Faculty of Nursing, University of Damanhour, El-Beheira, Egypt, A.R.E., Egypt)

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2 World Congress of Clinical Safety (2 tentative Draft)

12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)【13 September 2013: Hall 14, 2nd floor: Oral: Live broadcasting】

Special Lecture (3)(NA042) “Global Risk Due To Medical Product Globalization”
Bilha Cahana(Judge (Retired) Dr. Jerusalem 91451 Israel)(9:00 – 9:30, 13 Sep. 2013)

Special Lecture (4)(SL08) “Patient Safety and Medical Devices”
Uvo M Hölscher(Prof. Dr.-Ing. MT-E: Medical Technology and Ergonomics, Münster University of Applied
Sciences, Germany)(9:30 - 10:10, 13 Sep. 2013)

Panel (5): 'Medication safety and drug safety’
Chairpersons: Prof. Job Harenberg (Heidelbeg University, Germany) & Dr. Allen J Vaida (ISMP, USA)
(10:10 – 11:50, 13 Sep. 2013)(10:10 – 10:40, 13 Sep. 2013)(SL09) “An overview of real-world data mining approaches in the context of pharmacovigilance”
Martin Hofmann-Apitius (Prof. Dr. Bioinformatics, University of Bonn, Germany)(10:40 – 10:55, 13 Sep. 2013)

including 3 min of discussion(NA078) “Medication Reconciliation in High 5s: Germany’s approach to implement a standardized clinicalprocedure”
Daniela Renner1, Liat Fishman1, Katharina Bayer2, Daniel Berning3, Constanze Lessing3, Christian Thomeczek1
1
German Agency for Quality in Medicine (AQuMed), Berlin, Germany
2
Hospital Pharmacy oft Klinikum Coburg, Coburg, Germany
3Institute for Patient Safety (IfPS), University of Bonn by order of the German Coalition for Patient Safety (APS),
Bonn, Germany(10:55 – 11:10, 13 Sep. 2013)

including 3 min of discussion(NA011) “Potentially Inappropriate Medication and in-Hospital Falls”
Lilli Neumann, Dipl. Health Economist1; Verena Hoffmann, M.A.2; Björn Klugmann1; Stefan Golgert1; Joerg Hasford,
MD2; Wolfgang von Renteln-Kruse, MD1
1 Albertinen-Haus, Geriatrics Centre, University of Hamburg, Germany
2 Institute of Medical Information Sciences, Biometry and Epidemiology (IBE), Ludwig-Maximilians-University Munich,Germany(11:10 – 11:40, 13 Sep. 2013)(SL10) “Preventing Vaccine-Related Medication Errors”
Allen J Vaida (Dr. Executive Vice President, The Institute for Safe Medication Practice , USA)

(12:00 - 13:00, 13 Sep. 2013)

Lunch

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2 World Congress of Clinical Safety (2 tentative Draft)

12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)

Special Lecture (5)(SL12) “Results of 5 years crisis resource management training in a large private hospital chain in Germany –Helios clinical group”
Wolfgang Heinrichs(Prof. Dr. Applied quality assurance in anesthesia and intensive care. Simulation Centre
Mainz, Germany)(13:00 – 13:30, 13 Sep. 2013)

Special Lecture (6)(SL13) “Overview of German activities in patient safety”
Constanze Lessing (executive manager of the Institute for Patient Safety, University of Bonn, Germany)(13:30 – 14:00, 13 Sep. 2013)(14:00 – 15:30, 13 Sep. 2013)

Panel (6): ‘Surgical safety, preoperative risk management and Checklist’(14:00 – 14:30, 13 Sep. 2013)(SL14) “Safety management principle of surgery - Principal and major procedures toward safe surgery
operation”
Björn LDM Brücher (Prof. of Surgery, Bon Secours Cancer Institute, Richmond, USA)

(14:30 – 14:45, 13 Sep. 2013)

including 3 min of discussion(NA059) “A new bar code technology for managing the use of surgical endoscopes---Ultra-fine direct part marking of unique device identification (UDI)---“
CEO, Dr. OCHIAI, Chikayuki and UGAJIN, Mitsuru (NTT Medical Center Tokyo, Japan)(14:45 – 15:00, 13 Sep. 2013)
including 3 min of discussion(SL15) “SAFE SURGERY SAFE LIFE CHECKLIST IMPLEMENTATION , OBSTACLES AND SUCCSESS - M.S.BASHARAHIL HOSPITALMAKKAH SAUDI ARABIA”

Dina Baroudi (Dr. WHO external patient safety expert, Saudi Arabia(15:00 – 15:15, 13 Sep. 2013)

including 3 min of discussion(SL16)“Development of patient safety indicator in anesthesia - Does it matter?”Dina Baroudi (Dr. WHO external patient safety expert, Saudi Arabia) & WEINERT, M(15:15 – 15:30, 13 Sep. 2013)

including 3 min of discussion(NA023) “The nurse’s view: counting as a procedure to prevent the inadvertent retention of surgicalitems”
Lex, Katharina; Dr. Lux, Richard (Research Fellows at the German Institute for Patient Safety, RheinischeFriedrichs-Wilhelms-Universität Bonn (D), Germany)(15:30– 15:40, 13 Sep. 2013)

Break

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2 World Congress of Clinical Safety (2 tentative Draft)(15:40 - 16:25, 13 Sep. 2013)12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)

Panel (7): 'Safety with healthcare team and communication'(15:40 - 15:55, 13 Sep. 2013) including 3 min of discussion(NA127) “COMMUNICATION OF PATIENTS WITH BREAST CANCER WITH HEALTHCARE PROFESSIONALS”
Patouras Grigorios1, Stamatopoulou Eleni2, Stamatopoulou Athanasia3, Chrysomallis Marios4, Heras Panagiotis5
1.RN, Nafplion Nursing Unit, General Hospital of Argolida, Greece / 2. RN, BSC, MSc Notional school of Public Health.
Greece / 3. Bachelor Degree on Account Management & MSc on International Business Management- Expert in
Human Resource Management. Greece / 4. Nursing Student of Alexander Technological Educational Institute of
Thessaloniki.Greece / 5. Doctor, Coordinator Director of Pathology, Nafplion Nursing Unit, General Hospital of
Argolida. Greece(15:55 - 16:10, 13 Sep. 2013)

including 3 min of discussion(NA095) “German Version of Observational Teamwork Assessment for Surgery (OTAS-D): Adaption, Refinement andfirst results from German ORs”
Stefanie Passauer-Baierl*, Nick Sevdalis+, Louise Hull+ & Matthias Weigl**Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine; University Hospital LMU Munich;Germany+ Department of Surgery and Cancer, Imperial College London, UK(16:10 - 16:25, 13 Sep. 2013)

including 3 min of discussion(NA104) “THE INFLUENCE OF TEAM EXPERIENCE ON TEAMWORK AND PERFORMANCE IN EMERGENCY CARE”
Jan Schmutz1, Florian Hoffmann2, Ellen Heimberg3, & Tanja Manser1
1
Department of Psychology, University of Fribourg, Switzerland
2
Dr. von Hauner University Children‘s Hospital, Munich, Germany
3
University Children‘s Hospital, Tübingen, Germany

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2 World Congress of Clinical Safety (2 tentative Draft)

12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)(Session) Oral presentation
Presentation core time: 10 min talking + 3 discussion
The invited speaker has the different presentation period.

【12 September 2013: Ｈall 4a, 1st floor: Oral session, No live broadcasting】(10:25 – 12:00, 12 Sep. 2013)

Oral Session (1): ‘Philosophy of managing risk and error’(10:25 – 10:45, 12 Sep. 2013)(SL17) “Preventing health risks through participation – the citizen forum in health care conception"
Gisela Wachinger (Dr. ZIRIUS, Stuttgart , Germany)(10:45 – 11:00, 12 Sep. 2013)(NA012)

including 3 min of discussion“Developing an All Ireland Approach to Patient Safety”

Levette Lamb – Regional Patient Safety Advisor Northern Ireland
Gavin Lavery – Clinical Director HSC Safety Forum Northern IrelandDavid Vaughan – Director of Leadership and Quality, Royal College of Physicians Ireland.

(11:00 – 11:15, 12 Sep. 2013)

including 3 min of discussion(NA014) The Risks of Safety in Health Care
Franz Porzsolt1, Hardy Müller2, Hedwig François-Kettner3
1
MD, PhD. Health Care Research and Clinical Economics at Dept. General and Visceral Surgery, University Hospital2
Ulm, 89073 Ulm, Germany
WINEG Hamburg, 22305 Hamburg, Germany
3
Direction Nursing, Charité University Medicine, 10117 Berlin, Germany(11:15 – 11:30, 12 Sep. 2013)

including 3 min of discussion(NA063) “Requests for Allowance about Supposed Harmful Events”
Dr. Paola Costanzo°,P.Zanino*, M.T. Nicola*, G.Gennaro*°Risk Manage - Local Health Trust - Alexania – Piedmont, Italy.
*Risk Management Unit – Local Health Trust of Alexania, Italy.

(11:30 – 11:45, 12 Sep. 2013)

including 3 min of discussion(NA118) “A marriage of convenience – In patient experience of urinary catheterisation”
Daniel Darbyshire MBBS MRCS FHEA
(Clinical Fellow in Urology, Salford Royal Hospital, UK)

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2 World Congress of Clinical Safety (2 tentative Draft)(11:45 – 12:00, 12 Sep. 2013)12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)

including 3 min of discussion(NA052) “The Educational Effectiveness of Rapiesponse System by Fundamental Critical Care Support”
1) Takamitsu Kodama, MD
The University of Texas Southwestern Medical Center at Dallas, USA.
Section on EMS, Disaster Medicine and Homeland Security, Division of Emergency Medicine, Department of Surgery,Japan2) Masashi Nakagawa, MD Social Insurance Kinan Hospital, Department of Anesthesiology, Japan3) Eiji Kawamoto, MD
Mie University Hospital, Emergency Critical Care Center, Japan4) Jun-ya Ishikawa, MD
Yokohama City University School of Medicine, Department of Emergency Medicine,Japan5) Shigeki Fujitani, MD
Tokyo Bay Urayasu/Ichikawa Medical Center, Japan
6) Kazuaki Atagi, MD
Osaka City General Hospital, Department of Critical Care Medicine, Japan(12:00 - 13:00, 12 Sep. 2013)

Lunch(13:00 – 14:45, 12 Sep. 2013)

Oral Session (2): Risk factor in clinical safety(13:00 – 13:15, 12 Sep. 2013)

including 3 min of discussion(NA019) “Orthodontic Objects as Risk Factors in Treatment”
Dr. Reeta Varho1, H Oksala2 , A-L Svedström-Oristo1
1
Department of Oral Development and Orthodontics, Finland2
Department of Community Dentistry, Institute of Dentistry, University of Turku, Turku, Finland(13:15 – 13:30, 12 Sep. 2013)

including 3 min of discussion(NA032)“The Influence that Stress Gives in Human Error Factor”
Shino Shiosaka1), Nobumi Matsuda MD2)
1) Pack knowledge Co.,Ltd (Mental health researching company), Japan2) Matsuda Eye Clinic, Japan(13:30 – 13:45, 12 Sep. 2013)

including 3 min of discussion(NA096) “The influence that stress, sub-consciousness give in human error factor”
Nobumi Matsuda MD (Matsuda Eye Clinic, Japan)(13:45 – 14:00, 12 Sep. 2013)

including 3 min of discussion(NA098) “Factors responsible for the complications associated to patients with peripheral venous catheters: anempirical study conducted with nurses”
Salgueiro-Oliveira, Anabela Salgueiro-Oliveira(Nursing School of Coimbra, Portugal)(14:00 – 14:15, 12 Sep. 2013)

including 3 min of discussion(NA133) “Adverse events reported during Mortality and Morbidity Conferences in wards with risky clinical carein a university hospital network”
Kamran S. 1, Randriamanana D. 1, Pibarot M.L. 2, Hartmann J.F. 3, Benhamou D.4, Lienhart A.5, Vidal-Trécan G.1(1Public Health Service, Paris Center Hospital Group; 2 Medico Administrative Department of Paris Hospital Network(AP-HP) Headquarter / Quality of care and Patient safety unit; 3Robert Debré Hospital; 4 Anesthesia and critical careward, Paris South Hospital Group; 5 Anesthesia and critical care ward, Paris East Hospital Group., France)

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2 World Congress of Clinical Safety (2 tentative Draft)(14:15 – 14:30, 12 Sep. 2013)12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)

including 3 min of discussion(NA130) “Examining barriers to escalation of care for deteriorating patients in an Australian academic healthservice.”
M.Sandford1, G.Bingham1, C.Kelly1, & Prof. T.Bucknall 1&2( 1Alfred Health, Melbourne, Australia; 2Deakin University, Melbourne, Australia)(14:30 – 14:45, 12 Sep. 2013)

including 3 min of discussion(NA117) “Measuring ward round quality – experience from Urology”
Daniel Darbyshire MBBS MRCS FHEA
Clinical Fellow in Urology, Salford Royal Hospital, UK(14:45 - 16:00, 12 Sep. 2013)

Break(16:00 - 16:45, 12 Sep. 2013)

Oral Session (3): Safe healthcare technology(16:00 - 16:15, 12 Sep. 2013)

including 3 min of discussion(NA008) The Problem of the Superficial Femoral Vein: A Short Case Study
Robin Edwards (Ortho/Trauma Unit, Nobles Hospital, USA)

(16:15 - 16:30, 12 Sep. 2013)

including 3 min of discussion(NA137) “The incidence of needlestick injuries among health workers in Hungary”
Zoltan Balogh PhD, Mariann Raskovicsne Csernus, Henriett Hirdi, Vanora Hundley, Judit Meszaros CSc(University of Semmelweis Faculty of Health Science Department of Nurisng, Hungary)(16:30 - 16:45, 12 Sep. 2013)

including 3 min of discussion(NA090) “Risk of QT Prolongation Induced by SSRIs; A Case-Control Study”
Joongyub Lee, MD1, Nam-Kyong Choi, PhD1, Ye-Jee Kim 2, Bo Ram Yang 2, Mi-Sook Kim2, Xue-Mei Jin, MD 2, Jungmee
Kim, MD 2, Man Young Park3, Dukyong Yoon3, Rae Woong Park3, Byung-Joo Park, MD, PhD1,2,4
1
Clinical Epidemiology Division, Medical Research Collaborating Center, Seoul National University Hospital andSeoul National University College of Medicine, Seoul, Korea
2
Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
3
Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea;
4
Korea Institute of Drug Safety and Risk Management, Seoul, Korea

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2 World Congress of Clinical Safety (2 tentative Draft)

12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)

Presentation core time: 10 min talking + 3 discussion
The invited speaker has the different presentation period.

【13 September 2013: Hall 4a, 1st floor: Oral session, No live broadcasting】(9:30 – 12:00, 13 Sep. 2013)(9:30 – 9:45, 13 Sep. 2013)

Oral Session (4): Medication safetyincluding 3 min of discussion(NA136) “Validation of a short questionnaire to identify preference of patients for improvement of safety ofanticoagulant therapy”
Shabnam Zolfaghari (1), Christel Weiss (2), Lutz Frölich (3), Prof. Dr. med. Job Harenberg (1)Departments of Clinical Pharmacology (1), Biometry and Statistics (2), Geriatric Psychiatry (CIMH) (3), Faculty of
Medicine Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany(9:45 – 10:00, 13 Sep. 2013)

including 3 min of discussion(NA009) Active Pharmacovigilance Using Bayesian Confidence-Propagation Neural Network-Based Machine-Learning
Douglas S. McNair, MD PhD(Engineering Fellow & President, Cerner Math, USA)
(10:00 – 10:15, 13 Sep. 2013)

including 3 min of discussion(NA142) “Medication safety - options and pitfalls of electronic support tools"
Hanna Seidling (Dr. Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Germany)(10:15 – 10:30, 13 Sep. 2013)

including 3 min of discussion(NA030) “Normothermia During Operating Procedures”
Dr. Maurice Janssen, Rens Engels, Karen Kroonen, Fabian Tijssen(Orbis Medical Centre, School of Medical Physics and Engineering, Netherlands)(10:30 – 10:45, 13 Sep. 2013)

including 3 min of discussion(NA062) “Contrast Dose Management : Certegra® Informatics Platform”
S. Barbero*, F. Brucculeri*, E. Oppezzo*, C. Tappero*, GG. Taverna*, F.Maggioni^, P.Costanzo°* Radiology Department – Local Health Trust – Alexania – Piedmont, Italy^ Brand Manager Emerging Business Bayer Healthcare, Italy° Risk Manager - Local Health Trust – Alexania – Piedmont, Italy(10:45 – 11:00, 13 Sep. 2013)

including 3 min of discussion(NA093) “Simulated Medication Rounds for Undergraduate Nursing Students”
Siriwan Lim, Sok Ying Liaw
(Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore)(11:00 – 11:15, 13 Sep. 2013)

including 3 min of discussion(NA122) “BRINGING PATIENT SAFETY TO LIFE; AN INCLUSIVE APPROACH TO MEDICATION SAFETY- THE DEVELOPMENT OF A SAFER LITHIUM THERAPY GUIDELINE –“Arturo Langa MD
Consultant Psychiatrist NHS Lanarkshire (Scotland)
Editor of the International Journal of Developmental Disabilities

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2 World Congress of Clinical Safety (2 tentative Draft)(11:15 – 11:30, 13 Sep. 2013)12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)

including 3 min of discussion(NA134) “Use TRM Systems on a Miscontact Toxic Substance for Clinical Standard Procedures in Emergency
Department”
H. Y. , Han ,RN, H. P. , Ma ,Dr, C. S. , Wang , Dr, N. J. , Liou , Dr , F. C. ,Wen , RN , L. G. , Shiu, RN , S. P. , Ke , RN , P. S. ,Luo , RN ,(Taipei Medical University- Shuang Ho Hospital, Ministry of Health and Welfare,Taiwan)(11:30 – 11:45, 13 Sep. 2013)

including 3 min of discussion(NA139) “MEDICATION SAFETY”
Cidalina da Conceição Ferreira de Abreu(Coimbra Nursing School, Portugal)(11:45 – 12:00, 13 Sep. 2013)

Break(12:00 - 13:00, 13 Sep. 2013)

Lunch(13:00 - 15:00, 13 Sep. 2013)

Oral Session (5): 'Informatics and IT in clinical safety'(13:00 - 13:30, 13 Sep. 2013)(SL18)
Title: (later)
Martin Daumer (Dr. Sylvia Lawr Centre, TRIUM Analysis, Munich, Germany)(13:30 - 15:45, 13 Sep. 2013)

including 3 min of discussion(NA075)“Individual but networked: The German National Incident Reporting Network CIRSmedical.de”
Christina Gunkel, Hahnenkamp C, Sanguino Heinrich A, Thomeczek C, Rohe J
Agency for Quality in Medicine (AQuMed / AEZQ) – Joint Institution of the German Medical Association and the National
Association of the Statutory Health Insurance Physicians, Berlin, Germany(13:45 - 14:00, 13 Sep. 2013)

including 3 min of discussion(NA018) “The Trial of Patient Safety Education Using the Educational Electronic Medical Recoding System “Dr. Tomoyoshi Yamazaki *1, Muneou Suzuki *1, Kenji Araki *1, Yukiko Kai *2, Katsuhiro Hayashi *2, Katsuhiro
Umemoto *3
1: University of Miyazaki Hospital, Medical Informatics, Japan
2: Faculty of Medicine , University of Miyazaki, Japan
3: School of Knowledge Science, Japan Advanced Institute of Science and Technology, Japan(14:00 - 14:15, 13 Sep. 2013)

including 3 min of discussion(NA140) “Cultural Background and Patient Safety in OR”
Yasuhiko SUEMORI MD, MBA(Graduate School of Economics, Kyushu University, Fukuoka, Japan)(14:15 – 14:30, 13 Sep. 2013)

including 3 min of discussion(NA107)“A SYSTEMATIC APPROACH TO DEVELOP CLINICAL PERFORMANCE CHECKLISTS”
1
Jan Schmutz , Florian Hoffmann2, Walter J. Eppich3, Ellen Heimberg4, & Tanja Manser1
1
Department of Psychology, University of Fribourg, Switzerland
2
Dr. von Hauner University Children‘s Hospital, Munich, Germany
3
Northwestern University Feinberg School of Medicine, Chicago, USA
4
University Children‘s Hospital, Tübingen, Germany

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2 World Congress of Clinical Safety (2 tentative Draft)(14:30 - 14:45, 13 Sep. 2013)12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)

including 3 min of discussion(NA003) Patients Right to Information: Viewpoint of The Tunisian Association of Assistance to Victims of Medical
Errors.
Dr. Issam El Amri (Regional Health Inspector, Tunisia)
Dr. Chakib Doudech (Regional Health Inspector, Tunisia)(14:45 - 15:00, 13 Sep. 2013)

including 3 min of discussion(NA079) “Improving patient safety through standardization - the High 5s checklist”
Dr. med Daniel Berning 1, Liat Fishman2, Daniela Renner2, Christian Thomeczek2,
Constanze Lessing1
1. Institute for Patient Safety (IfPS), University of Bonn by order of the German Coalition for Patient Safety (APS),
Bonn, Germany
2. German Agency for Quality in Medicine (AQuMed), Berlin, Germany(15:00 - 17:00, 13 Sep. 2013)(15:00 - 15:15, 13 Sep. 2013)

Oral Session (6): 'Clinical safety culture'including 3 min of discussion(NA101)“Embedding a Patient Safety Culture”
Anna Johnstone (Head of Clinical Governance & Assurance (GSTT Germany))
Bill Thoma (Quality Performance Manager (GSTT Germany))(15:15 - 15:30, 13 Sep. 2013)

including 3 min of discussion(NA005) “Patient safety and quality improvement”
Dr. Carol Rocker (Vancouver Island, Canada)(15:30 - 16:00, 13 Sep. 2013)(NA007) Improving Emergency Evacuation Procedures for Nurses in China
Wu Pi Chi
(Head Nurse, Chang Gung Memorial Hospital Chiayi, Taiwan)(16:00 - 16:30, 13 Sep. 2013)

including 3 min of discussion(NA006) Improving Community-based Male Infant Circumcision Services
Paula Whittaker, Helen Gollins, Eleanor Roaf
(Public Health, NHS Tameside & Glossop, UK)

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12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)(Session) Poster presentations[Morning on 12 September 2013: Foyer, 1st floor: Poster]
Poster display time: 9:00 - 13:00 Sep 12.
Poster discussion time: 12:00 - 13:00 Sep 12.

Poster Session (1): Clinical safety strategy --- Pat 1
Moderator: Gisela Wachinger(Dr. ZIRIUS, Stuttgart, Germany)(NA066) “Strategies in Safety: Improvement of Patient/Specimen Identification errors”
Cuadrado-Cenzual MA, Alguacil Pau A; De Pedro Moro JA(Clinical Hospital Madrid. Clinical Hospital Salamanca. SPAIN)(NA067) “Risk Management. Appliyng Root Cause Analysis of Patient and Specimen Errors”
De Pedro Moro JA; Collado L; Cuadrado-Cenzual MA(Clinical Hospital Salamanca . Clinical Hospital Madrid. SPAIN)(NA073) “Safety in the Works Final Project University”
Torres Manrique B, Sarabia Cobo CM, Salvadores Fuentes P; Castanedo Pfeiffer C, Ortego Mate CM, Maazo Pérez M,
Paz Zulueta M, Sarabia Lavín R, Zabala Blanco J, Sevilla Miguelez ML.
(Departamento de Enfermeria, E.U.E. "Casa de Salud Valdecilla", Universidad de Cantabria, Spain)(NA080) “Safety Culture on Perioperative Care: Impact on Intraoperative”
Ana Maria Afonso and Maria Nazaré Cerejo(Nursing School of Coimbra, Portugal )(NA086) “Patient Safety and risk of Prolongation of Stay in Rehabilitation Hospitals”
Gacto-Sánchez Mariano, Medina-Mirapeix Francesc, García-Guillamón Gloria, Escolar-Reina Pilar.
(Departamento de Fisioterapia. Escuela Universitaria EUSES (UdG) , Spain)(NA033) “SELF-PERCEPTION ON UG PRESCRIPTION BY DENTISTRY STUDENTS TOWARDS A SAFER PRESCRIPTION”
ROIGO GUZMÁN-ÁLVAREZ1, MARA MEDEIROS DOMINGO2,3, LUCINA ISABEL REYES LAGUNES4, ALFONSO EFRAÍN
CAMPOS-SEPÚLVEDA5(1, Professor of Pharmacology, Faculty of Medicine and Dentistry-UNAM; 2. Clinical Seminar Professor, Faculty of
Medicine-UNAM; 3 HIMFG Researcher; 4, Professor Emeritus of the Faculty of Psychology at the UNAM; 5. Professor
anesearcher at the Department of Pharmacology, Faculty of Medicine, UNAM, Mexico).

(NA121) “Design for Patient Safety – A Prospective Hazard Analysis Framework for Healthcare Systems”
Jieling Long, Mecit Can Emre Simsekler, James Ward, and P John Clarkson
University of Cambridge, UK

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12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)(NA131) “Tailoring feedback to improve clinical performance.”
T.Bucknall 1&2 A.Hutchinson 1&3& A.Sales 4
1
Deakin University, Melbourne, Australia; 2Alfred Health, Melbourne, Australia 3Monash Health , Melbourne
Australia; 4University of Michigan, USA(NA114)“Informed surgical consent: Pathway to surgical risk management”
Zargham Hyder, Pavitt C, Webster A, Chan G, Qurashi K, Chopada A(Ealing Hospital, LONDON, UK)(NA115) “Effects of Nonviolent Communication Program for Nurse Unit Managers in the Hospital”
Kim, Soon-Lae 1. Chung, Hee-Shim2
1
Prof., Dr. College of Nursing, The Catholic University of Korea, Seoul, Republic of Korea
2
Deputy director of Nursing, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea

Poster Session (2): Medication and drug safety
Moderator: Dr. Shabnam Zolfaghari (Heidelberg University, Germany),(NA055) “Korean Medication Algorithm for Depressive Disorder – Antidepressant choices according to safety,
adverse event and comorbid physical illnesses”
Kyung Joon Min1, Eun-Sung Lim2, Jong-Hyun Jeong3, Young-Min Park4, Jeong Seok Seo5, Won Kim6,Won-Myong Bahk7,
Duk-In Jon8, Bo-Hyun Yoon9, Young-Chul Shin10
1College of Medicine, Chung-Ang University, Seoul, Korea; 2Shinsegae Hospital, Kimje, Korea; 3St. Vincent Hospital, Collegeof Medicine, The Catholic University of Korea, Suwon, Korea; 4Ilsan Paik Hospital, College of Medicine, Inje University,
Goyang, Korea; 5School of Medicine, Konkuk University, Chungju, Korea; 6Seoul Paik Hospital, School of Medicine, Inje
University, Seoul, Korea; 7Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea;
8
Sacred Heart Hospital, College of Medicine, Hallym University, Anyang, Korea; 9Naju National Hospital, Naju, Korea; 10
Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, Korea(NA092) “Improving Oxygen Administration at St Peter’s Hospital”
J Sandhu, L Mazin, J Powell, L Wijayasiri, M Wood
St Peter's Hospital, UK(NA049) “Propofol Addiction in Korea”
Dae-Bo Lee1, Young-Hun Cheon2, Bo-Hyun Yoon3, Kwang-Heun Lee4, Won-Myoung Bahk5, Sang-Yeol Lee6+
1.
Depatment of Psychiatry, Gunsan Medical Center, Gunsan, South Korea
2.
Department of Psychiatry, Chamsarng Hospital, Incheon, South Korea
3.
Department of Psychiatry, Naju National Mental Hospital, Naju, Republic of Korea
4.
Department of Psychiatry, Dongguk University College of Medicine, Kyoungju, Republic of Korea
5.
Department of Psychiatry, Catholic University College of Medicine, Seoul, Republic of Korea
6.
Department of Psychiatry, Wonkwang University School of Medicine and Hospital, Iksan, Republic of Korea

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2 World Congress of Clinical Safety (2 tentative Draft)

12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)(NA046) “Does Low Dose of Queitapine Make Diabetes Worse in the Diabetic Patients?”
Won-Myong Bahk1, Young Sup Woo1, Kyung Joon Min2, Bo-Hyun Yoon3, Jong-Hyun Jeong4, Sang-Yeol Lee5, Moon-Doo
Kim6, Kwang Heun Lee7, Young Joon Kwon8, Jeong-Seok Seo9
1
Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea; 2College of Medicine, Chung-Ang
University, Seoul, Korea; 3Naju National Hospital, Naju, Korea; 4St. Vincent’s Hospital, The Catholic University of
Korea, Suwon, Korea; 5Wonkwang University School of Medicine, Iksan, Korea; 6College of Medicine, Jeju National
University, Jeju, Korea; 7College of Medicine, Dongguk University, Gyeongju, Korea; 8College of Medicine,
Soonchunhyang University, Chunan, Korea; 9College of Medicine, Konkuk University, Chungju, Korea(NA124)“THE ROLE OF THE NURSE IN THE URGENT EMBOLIZATION OF BLEEDING ANGEIOMYOLIPOMA OF
THE KIDNEYS”
Stamatopoulou Eleni1, Stamatiou Konstantinos2, Christopoulos George3, Zavradinos Dimitrios4, Chrysomallis Marios 5,
Patouras Grigorios6, Heras Panagiotis7
1. RN, BSC, MSc Notional school of Public Health, Greece
2. MD, PhD General Hospital Piraeus “TZANEIO”, Greece
3. MD, Hospital Piraeus “TZANEIO”, Greece
4. MD, Hospital Piraeus “TZANEIO”, Greece
5. Nurse Student of ATEI Thessaloniki, Greece
6. RN, Nafplion Nursing Unit, General Hospital of Argolida, Greece
7. Doctor,Coordinator Director of Pathology, Nafplion Nursing Unit, General Hospital of Argolida, Greece(NA125)“THE ROLE OF THE NURSE IN SPONTANEOUS RETROPERITONEAL HEMORRHAGE AS A RESULT OF
ANTICOAGULANTS OVERDOSE”
Stamatopoulou Eleni1, Stamatiou Konstantinos2, Christopoulos George3, Zavradinos Dimitrios4, Chrysomallis Marios 5,
Patouras Grigorios6, Heras Panagiotis7
1. RN, BSC, MSc Notional school of Public Health , Greece
2. MD, PhD General Hospital Piraeus “TZANEIO” , Greece
3. MD, Hospital Piraeus “TZANEIO” , Greece
4. MD, Hospital Piraeus “TZANEIO” , Greece
5. Nurse Student of ATEI Thessaloniki, Greece
6. RN, Nafplion Nursing Unit, General Hospital of Argolida, Greece
7. Doctor,Coordinator Director of Pathology, Nafplion Nursing Unit, General Hospital of Argolida, Greece

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2 World Congress of Clinical Safety (2 tentative Draft)

12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)[Afternoon on 12 September 2013: Foyer, 1st floor: Poster]
Poster display time: 13:00 - 17:00 Sep 12.
Poster discussion time: 15:00 - 16:00 Sep 12.

Poster Session (3): Others
Moderator: Levette Lamb (Regional Patient Safety Advisor, Ireland)(NA087) “Incidence of Adverse Events among Inpatients in Rehabilitation Hospitals”
Gacto-Sánchez Mariano, Medina-Mirapeix Francesc, García-Guillamón Gloria, Escolar-Reina Pilar.
(Departamento de Fisioterapia. Escuela Universitaria EUSES (UdG) , Spain)(NA048) How Antiepileptic Drug Make Suicidality? : A Levitracetam Case Report.
Won-Myong Bahk MD, PhD1, Young Sup Woo1, Hoo Rim Song1, Kyung Joon Min2, Bo-Hyun Yoon3,
Young Chul Shin4, Sang-Yeol Lee5, Moon-Doo Kim6, Kwang Heun Lee7, Young Joon Kwon8
1
Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea; 2College of Medicine, Chung-Ang University,
Seoul, Korea; 3Naju National Hospital, Naju, Korea; 4Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea;
5
Wonkwang University School of Medicine, Iksan, Korea; 6College of Medicine, Jeju National University, Jeju, Korea;
7
College of Medicine, Dongguk University, Gyeongju, Korea; 8College of Medicine, Soonchunhyang University, Chunan,
Korea(NA050) “A Study of Prevalence of Metabolic Syndrome and Its Impact on Health Related Quality of Life andBody Image in Patients with Schizophrenia”
Sang-Yeol Lee1+, Kyung Joon Kim2, Young-Chul Shin3, Young- Joon Kwon4.
1.
MD PhD. Department of Psychiatry, Wonkwang University. School of Medicine, Iksan,, Republic of Korea
2.
Department of Psychiatry, Chungang University College of Medicine, Seoul, Republic of Korea
3.
Department of Psychiatry, Sungkyungkwang University, College of Medicine, Seoul Republic of Korea
4.
Department of Psychiatry, Soonchunghyang University, College of Medicine, Cheonan, Republic of Korea(NA053) “Problem lists in older in-patients: an old idea whose time has come?”
R Hyatt, D Sen, Z Alio, L Manku, Y Sote, P Taylor(East Lancashire Healthcare NHS Trust, Blackburn, Lancashire. UK)(NA070) “THE ROLE OF DEVELOPMENT OF SPECIFIC HUMAN RESOURCES FOR CARE DISABILITES PEOPLE”
Dr. Ligia Rusu1, Mihnea Marin1, Ileana Hamburg2
1
University of Craiova, Romania
2
IAT Gelsenkirchen, Germany(NA071) “A Case: Carbamazepine-Induced Hypersensitivity Synome “Jeong Seok Seo1 MD, PHD, Kyung Joon Min12, MD, PhD, Young Chul Shin3, MD
1
Department of Psychiatry, School of Medicine, Konkuk University, Chungju, Korea
2
Department of Psychiatry, College of Medicine, Chung-Ang University, Seoul, Korea
3
Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea

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12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)(NA074) “Purchase products for hand hygiene: a commitment to quality”
Torres Manrique B, Sarabia Cobo CM, González de la Guerra JM, González Campo M, Cabeza Díaz, P.
(Departamento de Enfermeria, E.U.E. "Casa de Salud Valdecilla", Universidad de Cantabria, Spain)(NA076) “Lithium Intoxication within normal therapeutic blood level: A case report”
1Moon-Doo Kim, MD, PhD, 1Bong-Hee Jeon, MD, 1Joon-Hyuk Park, MD, PhD, 2Kwang-Heun Lee, MD, PhD, 3Bo-Hyun
Yoon, MD, PhD, 4Young-Joon Kwon, MD, PhD, 5Sang-Yeol Lee, MD, PhD, 6Kyung-Joon Min, MD, PhD, 7Won-Myong
Bahk, MD, PhD
1Jeju National University Hospital, Jeju, Korea
2
Dongguk University Geongju Hospital, Gyeongju, Korea
3
Naju National Hospital, Naju, Korea
4
Soonchunhyang University Cheonan Hospital, Cheonan, Korea
5
Wonkwang University Hospital, Iksan, Korea
6
Chungang University Hospital, Seoul, Korea
7
Catholic University Yeouido St. Mary’s Hospital, Seoul, Korea(NA077) “Treatment of Neuroleptic Malignant Syndrome in Child and Adolescent: A case report”
1Moon-Doo Kim, MD, PhD, 1Bong-Hee Jeon, MD, 1Joon-Hyuk Park, MD, PhD, 2Kwang-Heun Lee, MD, PhD, 3Bo-Hyun
Yoon, MD, PhD, 4Young-Joon Kwon, MD, PhD, 5Sang-Yeol Lee, MD, PhD, 6Kyung-Joon Min, MD, PhD, 7Won-Myong
Bahk, MD, PhD
1
Associate Professor, Jeju National University Hospital, Jeju, Korea
2
Dongguk University Geongju Hospital, Gyeongju, Korea
3
Naju National Hospital, Naju, Korea
4
Soonchunhyang University Cheonan Hospital, Cheonan, Korea
5
Wonkwang University Hospital, Iksan, Korea
6
Chungang University Hospital, Seoul, Korea
7
Catholic University Yeouido St. Mary’s Hospital, Seoul, Korea(NA083) “Prevalence and Its Correlates of Night Eating Syndrome in Schizophrenic Outpatients”
Bo-Hyun Yoon, M.D.,1* Kyung-Joon Min, M.D.,2 Moon-Doo Kim, M.D.,3 Kwang-Hun Lee, M.D.,4 Sang-Yeol Lee, M.D.,5 JeHeon Song, M.D.1
1
Department of Psychiatry, Naju National Hospital, 2Department of Psychiatry, Chung-Ang University Hospital, Korea,
3
Department of Psychiatry, Jeju National University Hospital, Korea, 4Department of Psychiatry, Dong-Kuk University
Hospital, Korea 5 Department of Psychiatry, Wonkwang University Hospital, Korea(NA123)“Fluid therapy: Are we doing more harm than good?”James Wigley * Mr Daniel Darbyshire^ Mr Mathew Gallagher* Dr Eryl Davies▫
* Core surgical Trainee, University Hospital Southampton, Hampshire, UK^ Urology Clinical Fellow, Salford Royal Hospital, Lancashire, UK▫Urology House officer, Salford Royal Hospital, Lancashire, UK(NA068)“Risk Management.Failure Models and Effects Analysis of Identification Patient Errors”
Cuadrado-Cenzual MA; Collado Yurrita L; De Pedro Moro JA(Clinical Hospital Madrid. Clinical Hospital Salamanca. Spain)(NA088)“Incidence of Extra-Days of Hospitalization and Disability at Discharge in Patients with Adverse Events inRehabilitation”
Gacto-Sánchez Mariano, Medina-Mirapeix Francesc, García-Guillamón Gloria, Escolar-Reina Pilar.
(Departamento de Fisioterapia. Escuela Universitaria EUSES (UdG) , Spain)

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12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)(NA024)“ASSESSMENT OF HEALTH CARE WASTE MANAGEMENT PRACTICES AND KNOWLEDGE AMONGHEALTH CARE WORKERS WORKING AT TERTIARY CARE SETTING OF PAKISTAN”
Dr Ramesh Kumar*, Dr Zulifiqar ali, Dr Zulifiqar Ali Gorar and Dr Zulifiqar Khan
*PhD Public Health Fellow at Chulalongkorn University, Thailand. Health Services Academy, Cabinet Division,
Islamabad,Pakistan(NA126)“INFORMATION TO THE HEALTH PROFESSIONALS FOR THE TREATMENT OF BLINDNESS. --- RECENTSTUDIES”
Chrysomallis Marios1,Stamatopoulou Eleni2, Patouras Grigorios3, Kourkouta Lamprini 4 , Heras Panagiotis 5
1. Nursing Student of Alexander Technological Educational Institute of Thessaloniki.Thessaloniki,Greece
2. RN, BSC, MSc Notional school of Public Health, Greece
3. RN, Nafplion Nursing Unit, General Hospital of Argolida, Greece
4. Nursing Department of Alexander Technological Educational Institute of Thessaloniki.Thessaloniki, Greece
5. Doctor, Coordinator Director of Pathology, Nafplion Nursing Unit, General Hospital of Argolida, Greece

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2 World Congress of Clinical Safety (2 tentative Draft)

12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)[Morning on 13 September 2013: Foyer, 1st floor: Poster]
Poster display time: 9:00 - 13:00 Sep 13.
Poster discussion time: 12:00 - 13:00 Sep 13.

Poster Session (4): Clinical safety strategy --- Part 2Moderator: Dina Baroudi (WHO regional officer, Saudi Arabia)(NA089) “Risk Factors of Unexpected Endotracheal Extubation Involved in Nursing Care in an Academic ICU We shouleappraise staff education about physical restraints and ethical consideration to reduce the incidence.”
Prof. Tokie Nakata, Maho Murata, Masako Nakatani, Noriko Okamoto, Manabu Kume, Kazumitsu Fujimoto, Rumi
Kuwanaga, Michiyo Sekimoto, Nobuya Kusunoki, Nobuhiro Maekawa(Department of Clinical Quality and Safety Management, Kobe University Hospital, Japan)(NA028) “The Recognition and Timely Management of Severe Sepsis Within Acute Care”
Sofie Singh (Infection Control Nurse, NHS Scotland/NHS Dumfries and Galloway, UK)(NA013)“Early Management of Severe Sepsis in the Emergency Department”
Gavin Lavery (Dr. Clinical Director HSC Safety Forum, Ireland)
Mrs Levette Lamb (Regional Patient Safety Advisor, Ireland)(NA112)“A multidisciplinary team approach to Quality Improvement: Preventing Venous Thrombus Embolism& translating VTE guidelines in to practice”
Dr. Shwetha Akshaya, Assistant Executive Director for Quality & Patient Safety(Quality & Patient Safety Department, Hamad Medical Corporation. QATAR)(NA081)“To improve Communication with Patient and their Companion in Emergency Department; An Action
Research Study”
Dr. Tahmineh Salehi
Department of nursing management, School of Nursing and Midwifery, Tehran, Iran
University of Medical Sciences(TUMS)
Dr. Nahid Dehghan Nayeri, Dr. Arash Rashidian, and Dr. Eessa Mohammadi(NA045)“Assessment of Handwritten Prescription and Electronic Prescription System Prescribing Errors”
Ahmed I Albarrak1, Eman Abdurahman Al Rashidi2, Rwaa Kamil Fatani2, Shoog Ibrahim Al Ageel2, Rafiuddin Mohammed3
1: Associate Professor of Health Informatics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2: Medical student, College of Medicine, King Saud University, Riyadh, Saudi Arabia
3: Researcher, College of Medicine, King Saud University, Riyadh, Saudi Arabia

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12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)(NA110)“The use of a simulated ward round and its impact on medical error making amongst medical
undergraduates.”Dr. Thomas IM 1, Nicol LG 2, Walker KG 2 Watson AJM2
(University of Aberdeen 1 & NHS Highland 2, Scotland, UK)(NA116)“Safe sedation in endoscopy: time for a new approach?”
Dr. N Zakeri, S Webster, S Coda, A Humphries, AV Thillainayagam
Department of Gastroenterology & Hepatology, Imperial College Healthcare NHS Trust, London, United Kingdom.

(NA132)“Effort to increase the transport check lists completion rate for reducing medical errors during theintra-hospital transport of emergency patients.”
Heekang Choi
(Emergency Medical Center, Seoul National University Hospital, Seoul, Korea)(NA138)“Considering Different Nature of Hazards in Risk Identification for Patient Safety Improvement”
Simsekler M. C. E.1, Ward J. R.1, Clarkson P. J. 1
(1Cambridge University Engineering Design Centre, Cambridge, UK)(NA109) “ASSESSING THE ACCURACY OF PATIENT DATA IN ELECTRONIC SURGICAL HANDOVER SHEETS”
Toritseju Sillo, Dominic Pimenta(Department of General Surgery, Wexham Park Hospital, Slough, Berkshire, UK)(NA084)“Lifestyle is associated with job stress: the role of occupational nurse“
Hisae NAKATANI1, Mai HOSODA2, Kazuko IKEDA3, Hitomi FUJIMOTO3, Tomoko OGAWA4
1
Hiroshima University, 2Shimane Prefecture, 3 Shimane Fujitsu Limited,
4
Kawasaki University of Medical Welfare, 5Shimane University, Japan(NA069)“NEW STRATEGIES TO IMPROVE THE QUALITY AND EFFICIENCY OF HEALTH ASSISTANCE TO CHRONICCANCER PATIENTS”
Cuadrado-Cenzual MA ; Sastre J; De Pedro Moro JA.
(Clinical Hospital Salamanca. Clinical Hospital. Madrid. Spain)(NA141) “Potential Dangers of Abbreviation Use – An Audit of Abbreviation Use Within Secondary Care”

Don Koh1*, Hasnain Asharia1, Vaidehi Konteti1, Shen Chen1, Stuart D. Rosen2
1Faculty of Medicine, Imperial College School of Medicine, Imperial College London, UK
2National Heart and Lung Institute, Imperial College London, UK

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12-13 Sep 2013 Heidelberg University, Germany
by International Association of Risk Management in Medicine (IARMM)(NA128 )“THE ROLE OF UROLOGY NURSE IN THE EVALUATION OF CHRONIC PROSTATITIS PATIENT. A
PROSPECTIVE STUDY OF CHRONIC PROSTATITIS WITH EMPHASIS TO EPIDEMIOLOGICAL AND MICROBIOLOGICALFEATURES”
Stamatopoulou Eleni1, Stamatiou Konstantinos2, Christopoulos George3, Zavradinos Dimitrios4, Chrysomallis Marios 5,
Patouras Grigorios6, Heras Panagiotis7
1. RN, BSC, MSc Notional school of Public Health, Greece
2. MD, PhD General Hospital Piraeus “TZANEIO” , Greece
3. MD, Hospital Piraeus “TZANEIO” , Greece
4. MD, Hospital Piraeus “TZANEIO” , Greece
5. Nurse Student of ATEI Thessaloniki, Greece
6. RN, Nafplion Nursing Unit, General Hospital of Argolida, Greece
7.Doctor,Coordinator Director of Pathology, Nafplion Nursing Unit, General Hospital of Argolida, Greece

Poster Session (5): Infection
Moderator: Dina Baroudi (WHO regional officer, Saudi Arabia)(NA094) “The Measure of Okayama University Hospital to Prevent Inhalation/Ingestion in Dentistry”
Dr. Hajime Shirai 1,2), Seiji Iida 2), Yoshinobu Yanagi 2), Mariko Narazaki 2), Masamichi Maruyama 2), Tamaki Maekawa
2), Yasuhiro Torii 1), Manabu Morita 4), Yoshio Ohta 3), Keiji Iwatsuki 2,4)
1) Comprehensive Dental Clinic, Okayama University Hospital, Japan
2) Division of Medical Safety Management, Medical Safety Department, Okayama University Hospital, Japan
3) Kagawa Prefectural Central Hospital, Japan4) Vice-Exective Director, Okayama University Hospital, Japan(NA102) “Preventive Methods of Infectious Diseases at Special Nursing Homes in Japan”
Ayako Oura1), Takahiro Yamazaki1), Atsushi Ogihara2), Kazuhiko Machida2)
1) Graduate School of Human Sciences, Waseda University. Japan
2) Faculity of Human Sciences, Waseda University, Japan