Halifax 10 Speakers
John
Banja PhD
Associate Professor, Clinical Ethics; Assistant Director for Health Sciences
and Clinical Ethics, Center for Ethics, Emory University, Lawrenceville, Georgia
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John Banja is a Professor in the Department of Rehabilitation Medicine and
a medical ethicist at the Center for Ethics at Emory University. He also directs
the Section on Ethics for the Atlanta Clinical and Translational Science Institute
at Emory. Dr. Banja received a doctorate degree in philosophy from Fordham University
in New York and has taught and lectured on topics in medical ethics throughout
the United States. He has authored or coauthored over 150 publications and has
delivered over 800 invited presentations at regional, national, and international
conferences. He currently serves as the associate editor of AJOB-Neuroscience,
the leading scholarly journal in the field of neuroethics. Dr. Banja has conducted
research or educational projects with numerous federal and private organizations
including the NIH, the American College of Surgeons, The Agency for Health Care
Research and Quality, The National Institute for Disability and Rehabilitation
Research, the American Society for Healthcare Risk Management, and the Georgia
Hospital Association. He is a former board member of the Commission for Case
Manager Certification. His current research interests include the study of empathy
in healthcare relationships, and analyzing ethical dilemmas occurring in clinical
and translational research environments. His most recent book, Medical
Errors and Medical Narcissism, was published by Jones and Bartlett
Publishers in 2005.
Ross Baker PhD
Professor, Health Policy, Management and Evaluation, University of Toronto,
Faculty of Medicine, Toronto, Ontario
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Ross Baker is a professor in the Department of Health Policy, Management and Evaluation, University of Toronto where he teaches and does research on quality improvement, patient safety and organizational change.
Ross was principal investigator for the project “Adverse Events in Canadian Hospitals” and together with Peter Norton and a team of investigators across Canada published the results of the study in the Canadian Medical Association Journal in 2004.
Ross co-chairs a working group on methods and measures for patient safety for the World Health Organization. He also serves on the boards of the Health Quality Council of Saskatchewan, the Institute for Safe Medication Practice (ISMP) Canada, and the Clinical Standards, Guidelines and Quality Committee of Cancer Care Ontario.
Ross was a member of the National Patient Safety Steering Committee (Canada) chaired by Dr. John Wade. He currently serves as Chair of the Measurement Working Group and as a member of the Steering Committee for the Safer Healthcare Now! campaign ( the Canadian adaptation of the US 100,000 lives initiative) organized to improve patient safety.
His current research focuses on further analyses of the Canadian Adverse Events study data, and on the governance of patient safety activities in Australia, New Zealand, England and the US.
Cecilia Bloxom
Director of Communications, Canadian Patient Safety Institute, Edmonton, Alberta
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As the Director of Communications for the Canadian Patient Safety Institute, Cecilia is accountable for ensuring patient safety success by providing the right information, to the right people at the right time in the right way.
Cecilia joined CPSI from a senior management role in Public Affairs at Capital Health, Edmonton area. Throughout her time at Capital Health she had the opportunity to work in acute care, rural, geriatrics, rehab, long-term care, home care, supportive living and public health.
With a diploma in Advertising and Public Relations and a Degree in Public Relations, Cecilia has held various Communications positions over the past eleven years including working for the Alberta Public Affairs Bureau at Alberta Energy and Alberta Learning.
Pat Croskerry MD PhD
Professor, Emergency Medicine, and Medical Education, Dalhousie University
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Pat Croskerry is a Clinical Consultant in Patient Safety, and Professor in Emergency Medicine, and Medical Education at Dalhousie University. In addition to his medical training, he holds a doctorate in Experimental Psychology with Fellowship training in Clinical Psychology. He has worked in the area of Medical Error and Patient Safety for the last fifteen years. His research is principally concerned with the impact of cognitive and affective error on clinical decision making. He has published over 60 articles and 30 book chapters in the area of medical error, and medical education reform. He has worked in the area of shift-work and the impact of circadian dysynchronicity on health and performance in the workplace. He has given over 400 invited presentations at provincial, national and international levels – principally in the area of Healthcare Safety. In 2001, Dr. Croskerry directed the first of the Halifax symposia on healthcare safety in Canada which have continued annually to the final Halifax 10 symposium in 2010. In 2006, he received the Association of Faculties of Medicine of Canada Ruedy Award for innovation in medical education. In the same year he was appointed to the Board of the Canadian Patient Safety Institute. He is lead editor on the text Patient Safety in Emergency Medicine (2009).
Joan
Dawe
Former Chair, Board of Trustees, Eastern Health, Newfoundland and Labrador
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Joan Dawe is a former Deputy Minister of the Departments of Health and Community
Services and Social Services with the Government of Newfoundland and Labrador.
A nurse by training, she has held senior executive positions in nursing service
and hospital administration and has served in governance roles with numerous
health organizations at local, provincial, and national levels for this past
35 years.
At the provincial level, she is Past Chair of the Board of Trustees of Eastern
Integrated Health Authority(2004-2009); Past Chair of Board of Trustees of Health
and Community Services- St. John’s Region (2001-2004); Past President of the
Newfoundland Health Boards Association.
Nationally, Ms. Dawe served as a member of the Board of Directors and Executive
Committee of the Canadian Healthcare Association. She was Chairperson of the
National Healthcare Leadership Conference (2009) and Chairperson of the Planning
Committee for the ISQua Conference held in St. John’s NL in 1995. This was the
first time this prestigious international conference was held in Canada.
She was a recipient of the 2001 Public Service Award of Excellence in Newfoundland
and Labrador and the 2004 recipient of the Canadian Healthcare Association Award
for Distinguished Service.
Ms. Dawe is currently involved with the Canadian Health Services Research Foundation
and the Canadian Patient Safety Institute as a trainer in the "Effective
Governance for Quality and Patient Safety Education Program".
Drew
Dawson PhD
Director, Centre for Sleep Research, University of South Australia, Adelaide,
South Australia
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Professor Drew Dawson is nationally and internationally recognised for his
contributions to the scientific community and to industry in the areas of sleep
research, organisational psychology and human factors, industrial relations
negotiations, and the human implications of hours of work.
Drew has worked extensively with the aviation, manufacturing, retail, entertainment,
transportation, and mining sectors in Australia and is a world-renown expert
on fatigue in the workplace. He's instigated fatigue management programmes,
developed shiftwork and fatigue policy, undertaken pre-employment assessments,
and facilitated shiftwork education sessions. Drew also regularly presents at
national and international conferences and has provided expert witness testimony
in several fatigue-related court cases.
Ed
Etchells MSc FRCPC
Associate Director, University of Toronto, Faculty of Medicine, Toronto, Ontario
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Dr. Etchells is a staff physician with the Division of General Internal Medicine
at Sunnybrook Health Sciences Center, and an associate professor of medicine
at the University of Toronto. He is director of Sunnybrook’s Patient Safety
Service, which is dedicated to the identification, analysis and prevention of
medical error and adverse events. He was a co-investigator for the Adverse Events
in Canadian Hospitals study (the Baker-Norton Study). He has worked closely
with the Institute for Safe Medication Practices on the medication reconciliation
initiative of Safer Healthcare Now!, a national initiative to reduced medication
errors at the time of hospital admission and discharge. He was senior author
of a research paper titled Unintended medication discrepancies at the time
of hospital admission. This paper was cited as an influential paper in
the area of Quality Improvement by the 2006 Annals of Internal Medicine Update
on Hospital Medicine, and won the 2005 University of Toronto HPME Graduate
literary Award.
Rhona Flin BSc PhD FBPsS FRSE
Professor, School of Psychology, University of Aberdeen, Old Aberdeen
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Rhona Flin is Professor of Applied Psychology and Director of the Industrial
Psychology Research Centre at the University of Aberdeen. She leads a team of
psychologists conducting research on human performance in high risk industries
and healthcare. Her group’s projects include studies of leadership, culture,
team skills and decision making in acute medicine, aviation and energy industries.
She is currently studying surgeons’, anaesthetists’ and nurses’ non-technical
skills and safety climate in hospitals and is leading the Scottish Patient Safety
Research Network, established in 2007 (www.spsrn.ac.uk).
Her latest books are Safety at the Sharp End: A Guide to Non-Technical Skills
(with O’Connor & Crichton, Ashgate, 2008) and Safer Surgery: Analysing Behaviour
in the Operating Theatre (with Mitchell, Ashgate, 2009).
Amir
Ginzburg MD FRCPC
Patient Safety Officer and Physician Lead, Quality, Trillium Health Centre,
Mississauga, Ontario
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Amir Ginzburg works as a general internist and hospitalist at the Trillium
Health Centre in Mississauga, Ontario. He chairs Trillium's Medical Quality
of Care Committee which governs quality of care reviews for adverse events rooted
in system-based issues. Amir participates in strategic planning for quality
and safety and leads and supports many local improvement initiatives. Amir is
also one of the founding members of the Canadian Society of Hospital Medicine
Quality and Patient Safety Committee.
Mark Graber MD
Chief, Medical Service, VA Medical Center, Northport, New York
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Mark Graber is the Chief of Medical Service at the VA Northport Medical Center
and Professor and Associate Chair of Medicine at SUNY Stony Brook, NY.
Dr. Graber has chaired the Northport VAMC Medical Quality Assurance Committee
for 15 years, and is responsible for developing a new model of peer review that
incorporates root cause analysis of medical errors. He initiated the patient
safety curriculum for medical students and medical residents at the State University
of New York at Stony Brook School of Medicine. With Ms Ilene Corina, Dr. Graber
established the first Patient Safety Awareness Week in 2002, now recognized
internationally. He participated in the organizing committee to establish the
US’s first voluntary, anonymous medical error reporting process, the VA's "Patient
Safety Reporting System".
He has been funded by the National Patient Safety Foundation for research studies
to investigate and understand diagnostic errors in Medicine, and is regarded
as an authority in this area. With AHRQ sponsorship he chaired both the first
national conference on "Diagnostic Error in Medicine" (Phoenix, 2008)
and the second (Los Angeles, 2009).
Jim
Hornell BA BEd MEd
Chief Executive Officer, Brant Community Healthcare System, Brantford, Ontario
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Jim has been the President and Chief Executive Officer of Brant Community Healthcare
System based in Brantford, Ontario since April, 2010. A 2010 Hamilton-Niagara
Top 10 Employer and recipient of the Employer of the Year Award by the Ontario
Registered Practical Nurses Association, Brant Community Healthcare System is
an affiliated teaching site of McMaster University Michael G. DeGroote School
of Medicine.
Prior to being recruited to Ontario Jim served as Chief Executive Officer of
Cypress Regional Health Authority based out of Swift Current, Saskatchewan where
he had overall responsibility for the full continuum of care and all aspects
of community and population health services in the southwestern region of the
province. He was an active participant in that province’s Accelerating Excellence
and Quality as a Business Strategy initiatives. Jim was also Chief Operating
Officer & Vice President – Corporate Development with the Central Health
Authority in his native Newfoundland. He has two baccalaureate degrees from
Memorial University in Newfoundland and a Masters degree from the University
of Ottawa. Jim is also an accreditation surveyor with Accreditation Canada.
In addition to health care leadership, Jim has considerable experience in the
realm of corporate governance. As a volunteer, Jim has served at local, provincial,
national and international levels within the sport of hockey. He is presently
a Vice Chair of Hockey Canada and has toured internationally with several of
Canada’s national teams.
Chuck
Husak MA
Principal/Creative Director, August Lang & Husak, Bethesda, MD
Chuck Husak arrived in Washington in 1984 and has become one of the region’s
most decorated creative directors.
Before joining August, Lang & Husak in 1994, Mr. Husak was Senior VP/Creative
Director at Weitzman/Livingston in Bethesda, after spending 12 years with Ketchum
Advertising in Pittsburgh and later with Ketchum’s DC office, where he relocated
to direct the Bell Atlantic (now Verizon) business.
He has won two EMMY nominations, a Gold FREDDIE for excellence in health care
marketing, two Gold Mercury Awards in New York including Best of Show, and a
Best of Show/Broadcast Category in the Washington ADDYs. Past awards include
two One Show Pencils, a CLIO, plus dozens of Local and District II ADDYs
Aaron
Lazare MD
Professor, Chancellor and Dean Emeritus, Department of Psychiatry, University
of Massachusetts Medical School, Worcester, Massachusetts
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Aaron Lazare is the Celia and Isaac Haidak Professor of Medical Education
and Professor of Psychiatry at the University of Massachusetts Medical School.
Dr. Lazare served as Dean of the Medical School from 1990-2007 and Chancellor
of the campus, which includes the Graduate School of Biomedical Sciences and
the Graduate School of Nursing, from 1991-2007.
Dr. Lazare received his AB in 1957 from Oberlin College and his MD in 1961
from Case Western Reserve University School of Medicine. He spent one year at
Yale University Medical School before beginning 14 years of service at the Massachusetts
General Hospital (MGH), rising to the rank of Professor of Psychiatry at Harvard
Medical School. During his time at MGH, he built the outpatient psychiatry department
into the largest and most diverse in New England, and provided leadership for
founding and developing what many believe has been the most successful continuing
education course in psychiatry in the United States. He conducted pioneering
research on the importance of understanding the patient’s perspective on clinical
outcome and applying a negotiating paradigm to the doctor-patient relationship.
He is the author of the first textbook on outpatient psychiatry, Outpatient
Psychiatry: Diagnosis and Treatment, now in its second printing. In 1982, Dr.
Lazare accepted the position of professor and chair of psychiatry at the University
of Massachusetts Medical School (UMMS). He received the University’s Distinguished
Professional Public Service Award in 1988. The Department of Psychiatry won
four subsequent awards for its public sector activities. While chair of psychiatry,
Dr. Lazare initiated an entirely new sphere of scholarly activity on the subject
of shame and humiliation in medical encounters. His thesis focuses on the medical
interview as a tinderbox for shame experiences for both patient and physician.
His other areas of academic expertise are the medical interview and the healing
process of apology and forgiveness.
Dr. Lazare’s publications include 70 original articles and book chapters and
six books. Many of these articles, appearing as early as the late 1960s, are
still widely quoted and used as standard references for research and for clinical
and training programs. Dr. Lazare’s book On Apology was published in 2004. Throughout
his career, Dr. Lazare has received many honors that recognize a broad range
of accomplishments as a practising psychiatrist, researcher, scholar, author,
educator, lecturer, leader/administrator, and humanitarian. They include being:
named to Who’s Who in America; asked by the American Psychiatric Association
to give the Benjamin Rush Award Lecture; elected to the Bayonne High School
Hall of Fame; together with his wife, Louise, recipient of the humanitarianism
award from the National Conference of Christians and Jews; and named to Who’s
Who in the World. In 1993, he was selected by the Anti-Defamation League of
New England to receive the Maimonides Award for “outstanding commitment as a
physician and educator to providing quality health services and the training
of health care providers in an atmosphere of sensitivity and respect to all
people.” In 2007, Dr. Lazare received the University of Massachusetts’ highest
honor, the President’s Medal for “distinguished and unstinting services.”
Rob
Lee BA PhD FRAeS FCILT
International Consultant in Human Factors and Systems Safety, Melba, Australian
Capital Territory
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Dr Rob Lee graduated from the Australian National University in 1970 with First
Class Honours in Psychology, winning the Australian Psychological Society Prize.
In 1974 he completed his PhD in Psychology at the University of St Andrews.
His research was concerned with human performance in complex systems, with particular
reference to aircraft.
In 1976, Dr Lee was appointed Senior Psychologist, Operational Command, Royal
Australian Air Force(RAAF). He became the first RAAF psychologist to serve as
a human factors specialist on RAAF aircraft accident investigation teams. He
then joined the Bureau of Air Safety Investigation (BASI) as the Bureau’s first
human factors specialist in 1983. He established and developed the Bureau’s
capability in human factors, systems safety and research. In 1989 he became
the Director of BASI, pioneering the practical application of advanced human
factors and systems safety concepts.
In 2000 he became an international consultant on human factors and systems
safety in aviation, and other high technology industries, working with airlines,
airports, air traffic service providers, regulators and safety investigation
agencies - including the investigations of major accidents involving A320, B747,
B757 and TU154M aircraft. He was an adviser to the Boards of Inquiry into the
2005 RAN Sea King accident in Indonesia, and the 2006 Army Black Hawk accident
off Fiji.
Dr. Lee has won the Henry Wigram Award of the New Zealand Division of the Royal
Aeronautical Society, the Aviation Human Factors Achievement Award of the Australian
Aviation Psychology Association, and an International Prize from the Captain
A. G. Vette Flight Safety Research Trust of New Zealand. He co-authored the
book 'Beyond Aviation Human Factors' with James , Captain Dan Maurino
of ICAO, and Captain Neil Johnston of Aer Lingus.
Steven Lewis (Moderator)
President, Access Consulting, Saskatoon, Saskatchewan
Steven Lewis is a health policy and research consultant based in Saskatoon
as well as Adjunct Professor of Health Policy at the University of Calgary.
He has also held the position of Visiting Scholar at Simon Fraser University
in Vancouver (January to April 2007). Prior to resuming a full-time consulting
practice he headed a health research granting agency and spent seven years as
CEO of the Health Services Utilization and Research Commission in Saskatchewan.
He has served on various boards and committees, including the Governing Council
of the Canadian Institutes of Health Research, the Saskatchewan Health Quality
Council, the Health Council of Canada, and the editorial boards of several journals,
including the newly launched Open Medicine. Mr. Lewis’ published work covers
topics such as reforming and strengthening medicare, improving healthcare quality,
primary healthcare, regionalization, and the management of wait times.
Margaret
Murphy
Patient Advocate and Member Steering Committee, Patients for Patient Safety
Strand, WHO World Alliance for Patient Safety, Cork
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Margaret Murphy is a member of the Steering Group, Patients for Patient Safety
Programme, WHO Patient Safety. Following the death of her son as a result of
medical error, Margaret became actively involved as a patient safety advocate.
The focus of her work relates to seeing adverse events as having the potential
to be catalysts for change as well as being opportunities for learning, identifying
areas for improvement and preventing recurrence. She promotes this viewpoint
at local, national and international levels as an invited presenter to conferences,
hospital staffs and students. Her area of particular interest is education as
a vehicle to achieve sustainable culture change.
David
Musson MD PhD
Assistant Professor, Department of Anaesthesia, McMaster University School of
Medicine, Hamilton, Ontario
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David Musson is the Director of the Centre for Simulation-Based Learning at
McMaster University. He received his MD from the University of Western Ontario
in 1988 and completed a rotating internship at the University of Toronto in
1990. Following graduation, he served with the Canadian Air Force as a medical
officer and flight surgeon, working in the areas of aircrew medical care and
flight safety in Canada and overseas.
Since 2006, Dr Musson has been on faculty at McMaster University, where he
oversees the new Centre for Simulation-Based Learning. The Centre is a shared
resource, serving all health care programs in the Faculty of Health Sciences.
Viren
Naik MD Med FRCPC
Medical Director, University of Ottawa, Skills and Simulation Centre, Ottawa,
Ontario
Viren Naik is currently an Associate Professor in the Department of Anesthesia
at The Ottawa Hospital, University of Ottawa. He completed a Master of Education
degree and Fellowship in Education prior to being recruited to St. Michael’s
Hospital, where in 2004, he was appointed Medical Director of the Allan Waters’
Family Simulation Centre. In 2007, he was awarded the John Bradley Young Educator
Award by the Canadian Anesthesiologists’ Society, whom he now serves as the
Section Chair of Education and Simulation. In July 2009, Dr. Naik was recruited
from the University of Toronto to establish the University of Ottawa Skills
and Simulation Centre as the inaugural Medical Director. He also serves the
Royal College of Physicians and Surgeons of Canada as the past-Chair of the
Written Examination in Anesthesia, and as their first Simulation Educator tasked
with advancing simulation for both postgraduate education and continuing professional
development. In his spare time, when he isn’t apologizing to his wife Jasmine
for taking on too many roles, he enjoys sailing with her and their two kids,
Laurel and Ketan.
André
Picard
Public Health Reporter, Globe and Mail
André Picard is the public health reporter at The Globe and Mail (http://www.theglobeandmail.com)
and the author of three best selling books, including Critical Care: Canadian
Nurses Speak for Change (2001) and The Gift of Death: Confronting Canada's Tainted-blood
Tragedy (1997). He lives in Montréal.
Deborah Prowse
Board Member, Canadian Patient Safety Institute, Calgary, Alberta
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Deborah has a professional background in Social Work and in Law. She is a
private consultant in the areas of respectful workplace, human rights and
conflict management offering mediation, investigation, and training. Deborah served as
Panel Chair for the Alberta Human Rights Commission for four years. For the past ten years, she has been a Sitting Justice of the Peace in the Provincial Court of Alberta, Traffic Division.
Deborah is a single mother of a 14 year old son and is very active in his school and extracurricular activities. Deborah is a very committed and a founding member of the Calgary Health Region’s Patient/Family Safety Council. Her mother’s tragic death in 2004 was a triggering event for the Calgary Health Region, and health care professionals to think, plan and practice differently when it comes to the safety of patient care. Deborah had a significant role in speaking about her families’ experiences in a series of patient safety sessions targeted to leaders in the Region as the new patient safety policies and procedures were being launched. She is often asked to give similar addresses in other regions and health systems where there is a desire to listen, learn and make improvements to safety from the patient/family perspective.
Deborah is a member of the Board of Patients for Patient Safety Canada, a newly formed organization associated with the World Health Organization Alliance for Patient Safety.
Savik Ramkay
President, SRC Inc., Toronto, Ontario
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Savik Ramkay, President, Savik Ramkay Consulting Inc. has been involved in developing and implementing Safety Management Systems in Canadian carriers since 2003. Savik, is a licensed Aircraft Maintenance Engineer for 20 years and has spent the last 10 years at Senior Management Level positions in Safety, Security and Quality at Canadian carriers. He has developed and implemented data base solutions for organizations and mentored staff to develop sustainable succession planning for organizations. Today he offers service to organization that need to ensure their SMS Program is both compliant to the regulations and delivering sustainable value as well as developing SMS implementation plans and audits. Sharing the experience both at implementation, managing of SMS Programs and developing safety culture in organizations has been given at ICAO, China CAA, Singapore, Safeskies Australia, Transport Canada, and Canadian Health Services Research Foundation and now at Halifax 10.
Sir
Michael Rawlins
Chairman, National Institute of Health and Clinical Excellence
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Sir Michael Rawlins has been chairman of the National Institute of Health &
Clinical Excellence (NICE) since its formation in 1999. He is also an Honorary
Professor at the London School of Hygiene and Tropical Medicine, University
of London, and Emeritus Professor at the University of Newcastle upon Tyne.
He was the Ruth and Lionel Jacobson Professor of Clinical Pharmacology at the
University of Newcastle upon Tyne from 1973 to 2006 .At the same time he held
the position of consultant physician and consultant clinical pharmacologist
to the Newcastle Hospitals NHS Trust. He was vice-chairman (1987-1992) and chairman
(1993-1998) of the Committee on Safety of Medicines; and chairman of the Advisory
Council on the Misuse of Drugs (1998 - 2008)
James Reason
PhD FRAeS FBPsS FBA CBE
Professor Emeritus, Department of Psychology, University of Manchester
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James Reason, PhD, was Professor of Psychology at the University of Manchester
from 1977 until 2001, from where he graduated in 1962. Among his publications
are books on motion sickness, absent-mindedness, human error, aviation human
factors and managing the risks of organisational accidents. He has worked in
a wide variety of hazardous industries, though patient safety is now his primary
concern. He is a Fellow of the British Psychological Society, the Royal Aeronautical
Society and the British Academy. He received a CBE in 2003 for his services
to reducing the risks in health care. In 2006, he was elected an Honorary Fellow
of the Royal College of General Practitioners.
Sabina Robin
Quality and Safety, Alberta Health Services, Calgary, Alberta
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Sabina has worked as a Licensed Practical Nurse in both rural and urban facilities over the past 15 years.
Sabina’s involvement with patient safety began after losing her youngest child, Mataya, in April 2004,
following a series of communication breakdowns during a nine day hospitalization that contributed to
Mataya’s death. Sabina spoke about Mataya’s story in a patient safety video created by the Calgary
Health Region in a public forum shown at Halifax 5 in October, 2005.
Sabina was a founding member of the former Calgary Health Regions, Patient/ Family Safety Council.
A volunteer council that played a key role in advising, informing and making recommendations on
operational safety issues. Sabina’s commitment as a member of the Council has included speaking
about the importance of listening to patients and family members and the need for improved
communication between healthcare professionals and families. She has been a strong voice among the
Council in recommending the development of patient safety education for healthcare providers and pilot
testing a patient/family activated rapid response (Code 66) service and collaborating with healthcare
leaders and providers on defining a process of accountability for residents to medical leadership and
operational administration.
Sabina is a national champion for patient safety and a member of the World Health Organization’s World
Alliance, Patients for Patient Safety Canada (PFPSC). She currently chairs the PFPSC Disclosure Working
Group reinforcing the need for patient engagement in disclosure of harm related policies, procedures, and
promoting the development of an educational framework that includes disclosure processes that are patient
and family centered. Most recently the group has developed a set of Principles For Disclosing Harm to
Patients.
Blair Sadler JD
Senior Fellow, Institute for Healthcare Improvement
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Blair L Sadler is a Senior Fellow at the Institute for Healthcare Improvement,
and a member of the faculty at the UCSD Schools of Medicine and Management.
He served as Past President and CEO of Rady Children’s Hospital in San Diego
from July 1980 until July 2006. Under his leadership, Rady Children’s was the
first pediatric hospital in the United States to win the Ernest A. Codman Award
for its work in developing clinical pathways. He gave the Commencement Address
at the 2005 UCSD Medical School graduation on the health care quality revolution
and the implications for hospitals and academic medical education. He speaks
widely to healthcare Boards of Trustees about their new role in patient safety
and quality.
As a former Board member of the Center for Health Design, he has been heavily
involved in developing the business case for building better hospitals through
evidence - based design. He was the founder of the Center’s Pebble program –
a collaborative effort to identify, support and disseminate the work of pioneering
organizations throughout the world in evidence - based design.
He has consulted with several health systems throughout the world regarding
building optimally safe and low stress hospitals through evidence - based design.
These include Australia, Norway, Canada and the United Kingdom. He has written
several articles on the compelling business case for evidence based design (both
adult and pediatric) that appeared in several journals and a book sponsored
by Nachri and the Center for Health Design during 2008. He is a frequent speaker
on the topic at major meetings including the Annual Forum of the Institute for
Healthcare Improvement. He is the founder of the Blair L. Sadler International
Healing Arts Awards Competition in partnership with the Society of the Arts
in Health Care.
He has co-authored the book Transforming the Health Care Experience through
the Arts with Annette Ridenour www.artandhealthcare.com
Kathleen
Sutcliffe PhD
Associate Dean, Faculty of Development and Research, University of Michigan,
Ross School of Business, Ann Arbor, Michigan
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Kathleen M. Sutcliffe (Ph.D.) is Associate Dean for Faculty Development and
Research and the Gilbert and Ruth Professor of Management and Organizations
at the University of Michigan Ross School of Business. She received a Bachelor
of Arts degree from the University of Michigan, a Bachelor of Science degree
from the University of Alaska, a Master of Science degree from the University
of Washington, and a Ph.D. in management from the University of Texas at Austin.
Her research program has been devoted to investigating how organizations and
their members cope with ambiguity and uncertainty, team and organizational learning,
and how organizations can be designed to be more reliable and resilient. She
is currently investigating high reliability and resilience practices in wildland
firefighting, healthcare, and other high-hazard industries. Her research has
appeared in numerous scholarly journals such as the Academic Medicine, Academy
of Management Journal, Academy of Management Review, Harvard Business Review,
Medical Care, Organization Science and Strategic Management Journal. Two books
include: Medical Error: What Do We Know? What Do We Do? (co-authored with Marilynn
Rosenthal, Jossey-Bass, 2002); Managing the Unexpected: Resilient Performance
in an Age of Uncertainty (co-authored with Karl E. Weick, Jossey-Bass, 2007).
Charles
Vincent PhD
Smith and Nephew Professor of Clinical Safety Research, Department of Surgery,
Oncology, Reproductive Biology and Anaesthetics, Imperial College London, London
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Charles Vincent trained as a Clinical Psychologist and worked in the British
NHS for several years. Since 1985 he has carried out research on the causes
of harm to patients, the consequences for patients and staff and methods of
prevention. He established the Clinical Risk Unit at University College in 1995
where he was Professor of Psychology before moving to the Imperial College in
2002. He now directs the Clinical Safety Research Unit based in Department of
Department of Biosurgery and Technology, Imperial College London. He is the
editor of Clinical Risk Management (BMJ Publications, 2nd edition, 2001), author
of Patient Safety (2ned edition 2010) and author of many papers on risk, safety
and medical error. From 1999 to 2003 he was a Commissioner on the UK Commission
for Health Improvement. In 2007 he was appointed Director of the National Institute
of Health Research Centre for Patient Safety & Service Quality at Imperial
College Healthcare Trust. He is a Fellow of the Academy of Social Sciences and
of the NHS Institute for Innovation & Improvement.
Jacqueline
Vischer PhD
Professeure titulaire, École de design industriel, Faculté de l’aménagement,
Université de Montréal, Montréal, Québec
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Jacqueline Vischer is an Environmental Psychologist who has specialized in
the study of the impact of work environments on building users. Recently, she
was Professor in the Faculty of Environmental Design at the Université de Montréal,
where she founded the Groupe de recherche sur les environments de travail (New
Work Environments Research Group). She has also worked extensively as a consultant
to large organizations in North America and Europe.
Dr. Vischer is author or coauthor of six published books and a seventh in press.
She has also published numerous articles on the environmental psychology of
workspace, building evaluation, users’ needs in buildings, indoor air quality,
user-manager communication, facilities management, and architectural programming.
She has a Bachelor’s and a Master’s degree in Psychology, and a PhD in Architecture
from the University of California, Berkeley.
Albert
Wu BA MD MPH
Professor, John Hopkins Center for Global Health, John Hopkins University, Baltimore,
Maryland
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Albert W. Wu is Professor of Health Policy and Management and Medicine at the
Johns Hopkins Bloomberg School of Public Health, and director of the Hopkins
DEcIDE center for comparative effectiveness research. He received BA and MD
degrees from Cornell University, and completed Internal Medicine residency at
the Mount Sinai Hospital and UC San Diego. He was a Robert Wood Johnson Clinical
Scholar at UCSF and received an MPH from UC Berkeley. His research and teaching
focus on patient outcomes and quality of care. He has studied the handling of
medical errors since 1998, and has published influential papers including "Do
house officers learn from their mistakes" in JAMA in 1991, and "Medical
error: the second victim" in the BMJ. He has over 270 published papers
and developed an award-winning educational video on disclosure “Removing insult
from injury: disclosing adverse events.” He was a member of the Institute of
Medicine committee on identifying and preventing medication errors, and was
Senior Adviser for Patient Safety to WHO in Geneva. He teaches a series of courses
on measurement, quality of care and patient safety, and maintains a clinical
practice in general internal medicine.