5th NATIONAL

PATIENT SAFETY CONFERENCE Aviva Stadium, Dublin 4 Thursday, 12th November 2015

PROGRA MME 8.30 – 9.15 S E S S I O N 2 REGISTRATION (tea/coffee) 11.20 – 12.30 Good practice presentations 9.15 – 9.35 Opening address BREAK-OUT SESSION A (Main Auditorium – Level 2) Mr , TD, Minister for Health Chair: Ms Triona Fortune, Deputy CEO, International Society for Quality in Health Care S E S S I O N 1 Plenary Chair: Presentation 1 Dr , Chief Medical Officer Benzodiazepines and hypnotics use in an acute mental health service Presenter: Ms Ailish Young, Pharmacist, St Patrick’s Mental Health Services, and 9.35 – 10.05 Dr Adam Kavanagh, Nurse Practice Development Coordinator, St Patrick’s Mental The future of patient safety and how to Health Services broaden from the current emphasis on the Presentation 2 study of past harms to reliability and NOCA National ICU Audit first steps – The Mater journey preparedness Presenters: Ms Mary Baggot, National Office of Clinical Audit and Ms Elaine Ms Helen Crisp, Assistant Director of Langan, Critical Care Audit Nurse, Mater Misericordiae University Hospital Research, The Health Foundation, London Presentation 3 Improving patient safety by early recognition and intervention for urinary 10.05 – 10.35 retention in the Rotunda Hospital re-audit from January 2014 to July 2014 Learning from the evidence about what Presenters: Ms Cinny Cusack, Physiotherapy Manager and Ms Mary O’Reilly, works in improving quality and safety in Practice Development Coordinator, Rotunda Hospital, Dublin 1 healthcare Presentation 4 Professor Mary Dixon-Woods, Professor of The Shocking Stocking Audit…. an audit on the use of thrombo embolic Medical Sociology at the Department of deterrent stockings for patients having surgery at Sligo Regional Hospital

Health Sciences, University of Leicester Presenter: Ms Teresa Donnelly, CNM 2 General Theatre, Sligo Regional Hospital

10.35 – 10.45 BREAK-OUT SESSION B (Havelock – Level 4) Question and answer session Chair: Dr Sarah Condell, Clinical Effectiveness Unit, Department of Health

10.45 – 11.20 Presentation 5 TEA/COFFEE (poster viewing) What can people with intellectual disabilities tell us about the medication use process? Presenter: Ms Bernadette Flood, Pharmacist, St Joseph’s Centre, Daughters of Charity Disability Support Services, Clonsilla, Dublin 15

PROGRA MME

Presentation 6 TPOT’s co design of a perioperative patient experience tool S E S S I O N 3 Presenter: Ms Lorraine Murphy, RCSI Surgery and TPOT programmes 13.30 – 13.50 Presentation 7 Launch of the NCEC Standards for Clinical Preparedness of hospitals in the Republic of for an influenza pandemic, Practice Guidance an infection control perspective Presenter: Ms Mary Reidy, Infection Prevention and Control Clinical Nurse Specialist, Introduction: Bon Secours Hospital, Strand Street, Tralee, Co Kerry Dr Kathleen Mac Lellan, Director of Patient Presentation 8 Safety and Clinical Effectiveness, Department Developing a serious game ‘Play Decide’ for supporting junior hospital doctors to of Health speak up about safety concerns Launch: Presenters: Dr Marie Ward, Prof. Eilish McAuliffe, Health Systems, School of Nursing Professor Hilary Humphreys, Chair NCEC & Dr Midwifery & Health Systems, UCD Belfield and Ms Karen Egan, Patient & Public Tony Holohan, Chief Medical Officer, Involvement in Healthcare at HSE Department of Health

BREAK-OUT SESSION C (Vavasour – Level 2) S E S S I O N 4 Chair: Ms Rosemary Smyth, Director of Training & Development, Mental Health 13.50 – 14.00 Commission Chair: Dr Philip Crowley, National Director, Quality Improvement Division, HSE Presentation 9 Introduction of a urinary catheter care bundle in the National Rehabilitation 14.00 – 14.20 Hospital – expected and unexpected benefits From the patient’s perspective Presenter: Dr Sinead McNicholas, Consultant Microbiologist, National Rehabilitation Ms Linda Dillon Hospital, Dun Laoghaire 14.20 – 14.40 Presentation 10 Developments in Portlaoise maternity Improving patient outcomes for both nosocomial and community-acquired cases of services since the CMO’s February 2014 Clostridium Difficile Infection (CDI) in Tallaght Hospital Report on Neo-natal Deaths and the Presenter: Ms Niamh Fitzgerald, Senior Medical Scientist, Microbiology Laboratory, subsequent HIQA report Tallaght Hospital. Ms Angela Dunne, Director of Nursing & Presentation 11 Midwifery, Midland Regional Hospital, Plan for Every Patient (PfEP): Introducing a mechanism for visually planning patient Portlaoise care in Beaumont Hospital 14.40 – 15.00 Presenter: Ms Amy Anslow, Project Lead, Plan for Every Patient, Beaumont Hospital, Clinical leaders – learning safety first Dublin 9 Dr Colm Henry, National Clinical Advisor and Presentation 12 Group Lead for Acute Hospitals in the HSE “Start Smart” Improving the quality of empiric antimicrobial prescribing 15.00 – 15.20 at Temple Street Putting the care into health care Presenter: Ms Michelle Kirrane, Senior Clinical Pharmacist, Antimicrobial & Mr Patrick Lynch, National Director, Quality, Paediatrics, Temple Street Children’s University Hospital Assurance & Verification Division, HSE

12.30 – 13.30 - LUNCH (poster viewing) 15.20 – 15.40 Panel discussion 15.40 – 15.45 Closing remarks Dr Tony Holohan, Chief Medical Officer

B I O G R A P H I E S 4th National

PATIENT SAFETY CONFERENCE

LocalMs Helen CrispGood is Assistant Practice Director of Research Oral at Presentationsthe Health Foundation, an independent c o n t i n ucharity e d 12.30 – 13.30 LUNCH (poster viewing) (11.20committed – 12.30) to improving health and health care. Helen coordinates the Foundation’s Croke Park Conference Centre improvement science programme, building research capacity to deliver well-defined, methodologically sound, tested and evaluated improvement interventions. The programme th Presentation 6 S E SFriday, S I O N 37 November 2014 includes original research into theory and methods for improvement, together with personal Plenary Chair: Methotrexate:research awards including A novel post approach-doctoral Improvementto safer use scienceof a toxic fellowships, medication PhD funding and Presenter:professorial fellows Dr Paul in improvementRyan, Woodview science. Family Helen previouDoctors,sly workedGlanmire, in quality Cork improvement, Dr Philip Crowley, National Director of

developing quality standards for healthcare accreditation programmes, service review and Quality and Patient Safety, HSE Ms Helen Crisp Presentationbenchmarking studies. She7 is an experienced consultant who has worked on a wide range of P R O G R A M M E Dr Helen Bevan healthcare quality improvement programmes in the UK and internationally, including QOF 13.30 – 14.30 Materassessment Board in primary on Board care, Qualitydevelopment Improvement of implementation Project support for NICE guidance and the Presenter:development Prof. of the Mary Danish Day, Quality Mater Model. Misericordiae University Hospital National Issues  The patient Perspective (Ann Bridge) PresentationDr Philip Crowley is National 8 Director of Quality Improvement with the HSE since January 2011.  Open Disclosure (Angela Tysall, National ImplementationPhilip is a doctor who of trained Care inBundles General HospitalPractice and Wide then inworked Our forLady’s five years Children’s in Nicaragua, Hospital, Lead for Open Disclosure, HSE and Dr Central America in health development. He then worked in the NHS in Newcastle upon Tyne to John Tiernan, Executive Director, Crumlintackle health – Not inequalities. without He its has challenges!!! trained in public health medicine and has worked with the Presenters:Institute of Public Paula Health McGrath in Ireland, and with Tracey the Irish Wall, College Our of Lady’sGeneral Children’s Practitioners Hospital, on refugee Crumlin and Member Engagement Division, Medical asylum seeker health and as a general practitioner in the North inner city of Dublin. Philip worked Protection Society) Presentationfor 6 years as Deputy Chief 9 Medical Officer with the Department of Health and Children until taking  National Clinical Effectiveness up his current post. Philip continues to work as a GP part-time in an inner city Dublin practice. Improving influenza vaccine uptake in Health Care Workers in the Department of CommitteeDr (Dr Philip Kathleen Crowley MacLellan,

Department of Health) GenitourinaryMs Linda Dillon is Medicine a founding memberand Infectious and former Diseases Chairperson (GUIDE), of the New Crumlin Hospital StParents James’s Group Hospital, which successfully Dublin lobbied government to build a new paediatric hospital. She is Presenteralso a founding: TBC member of the HSE Sepsis Steering Group. In 2007 she was appointed by the 14.30 – 14.50 Minister for Health to the New Paediatric Hospital Development Board as the patient and parent What does ‘care’ mean in and for health representative. She is currently a member of the HSE’s National Quality Improvement Steering Presentation 10 care? Addressing the compassion and Group; and is a member of the National Clinical Effectiveness Committee. She is Founding Director safety deficit Theof the development Alice’s Wonderland of an Foundation Integrated which Quality is a charity and that Patient endeavours Safety to Frameworkimprove the quality of Dr Justin Brophy, Executive Clinical Director, tolife supportof seriously a illmulti children-sited and Hospital their families. Group Linda is a regular presenter and facilitator on the Presenter:Diploma in Leadership John McElhinney, and Quality Groupin Healthcare Quality run and by the Safety Royal Manager,College of Physicians WNW Hospitals (R.C.P.I) and HSE Mental HealthMs Linda Services Dillon Group,is also a memberSligo Regional of the RCPI Hospital Ethics Working Group. Linda has presented on a number of occasions to final year medical students on the subject of ‘Breaking Bad News’. 14.50 – 15.10

Panel Discussion PresentationProf Mary Dixon-Woods 11 is Professor of Medical Sociology, Wellcome Trust Senior Investigator, SKINDirector Champions of the SAPPHIRE for Ki group,ds Department of Health Sciences, University of Leicester, UK, and Presenter:Deputy Editor Claire-in-Chief Lundy, of BMJ Belfast Quality andHealth Safety. & SocialA fellow Care of both Trust the Aca(BHSCT),demy of Social Sciences 15.30 – 15.35 Northernand the Academy Ireland of andMedical Queen’s Sciences, University, she leads a Belfast,programme Northern of research Ireland focused on patient Closing Remarks safety and healthcare improvement, healthcare ethics, and methodological innovation in studying Dr Tony Holohan, Chief Medical Officer healthcare. She holds honorary positions as an adjunct professor in the Department of Presentation 12 Anesthesiology and Critical Care Medicine at Johns Hopkins University, a visiting professor at Prof Mary Dixon-Woods ImprovingImperial College’s the qualityCentre for and Infection safety Prevention of care forand patientsManagement, transferred and a visiting by adjunctambulance Time: toprofessor Emergency at Dartmouth Departments College. She was, in 2012, one of the first recipients of a Wellcome Trust END Presenter:Senior Investigator Elizabeth Award. Dillon, She served Emergency on the National Department, Advisory St Group James’s on the Hospital, Safety of PatientsDublin in England, which produced the Berwick report in 2013. She was recently a member of the Patient

Safety Forum at the World Innovation Summit for Health and is currently serving as an expert panel member the US National Patient Safety Foundation’s review of patient safety. Dr Philip Crowley

Department of Health

PROGRAB I O G R AMME P H I E S 4th National

PATIENT SAFETY CONFERENCE

LocalMs Angela DunneGood is Director Practice of Nursing andOral Midwifery, Presentations Midland Regional Hospital, c o Portlaoise n t i n u e and d Croke12.30 – 13.30Park Conference Centre (11.20has 14 years – 12.30) Senior Management Experience. She worked in the Coombe Women and Infants CrokeLUNCHFriday, (posterPark viewing) Conference7th November Centre 2014 University Hospital in a Senior Management capacity for the last 8 years and was seconded to the Maternity Services at the Midland Regional Hospital at Portlaoise in March 2014. Angela is a th Presentation 6 S E SFriday, S I O N 37 November 2014 qualified as a Registered General Nurse, ICU Adult and Neonatal Nurse and a Registered Plenary Chair: Methotrexate:Midwife. She has aA BA novel in Business approach Studies to and safer Healt useh Care of aManagement toxic medication (Athlone Institute of Presenter:Technology) andDr Paul also has Ryan, a Masters Woodview in Health Family Service Doctors, Management Glanmire, (Trinity Cork College, Dublin). Dr Philip Crowley,Ms NationalAngela Dunne Director of Quality and Patient Safety, HSE. Dr Colm Henry is National Clinical Advisor and Programme Lead for Acute Hospitals in the HSE. PPresentation R O 7 G R A M M E Prior to this appointment, he was National Lead for the Clinical Director Programme from 2012 to 13.30 – 14.30 Mater2014 and Board Clinical on Director Board of Quality the Mercy Improvement University Hospital Project in Cork from 2009 to 2012. He was Presenter:appointed as Prof. Consultant Mary Geriatrician Day, Mater to the Misericordiae same hospital Universityin 2002. Hospital National Issues Dr Helen Bevan  The patient pPerspectiveerspective ((AnnMs Ann Bridge)

PresentationDr Tony Holohan was appointed 8 as Chief Medical Officer in 2008. He provides expert medical and  Bridge)Open Disclosure. (Angela Tysall, National Dr Colm Henry Implementationpublic health advice toof theCare Minister Bundles and theHospital Department Wide of in Health Our .Lady’s He has responsibilityChildren’s Hospital,for policy  OpenLead for disclosure Open Disclosure, (Ms Angela HSE Tysall and ,Dr on medical and public health matters including patient safety, quality in health care and health and NationalJohn Tiernan, Lead Executive for Open Disclosure,Director, HSE Crumlinwellbeing. – Not without its challenges!!! Presenters: Paula McGrath and Tracey Wall, Our Lady’s Children’s Hospital, Crumlin andMember Dr John Engagement Tiernan, Executive Division, Director,Medical

Prof Hilary Humphreys is Professor of Clinical Microbiology at the Royal College of Surgeons in MemberProtection Engagement Society) Division, Medical PresentationIreland and Consultant Microbiologist9 in Beaumont Hospital, Dublin. He is a member of the  ProtectionNational Clinical Society) DrEffectiveness. Tony Holohan Professional Affairs Sub-Committee of the European Society of Clinical Microbiology and Infectious Improving influenza vaccine uptake in Health Care Workers in the Department of  NationalCommittee Clinical (Dr Kathleen Effectiveness MacLellan, Diseases, is a recent Vice-President of the Royal College of Physicians of Ireland and is an Associate CommitteeDepartment (Dr of Health)Kathleen MacLellan, GenitourinaryEditor of the Journal Medicine of Hospital and Infection. Infectious He has Diseases been involved (GUIDE), in guideline development in the UK Stand James’s Ireland for Hospital, nearly 20 Dublinyears. He is Chairman of the Department of Health's National Clinical Department of Health) . PresenterEffectiveness: TBC Committee since 2010. This Committee reviews, assesses and recommends for Prof14.30 Hilary – 14.50 Humphreys national endorsement, clinical guidelines and audit. 14.30What –does 14.50 ‘care’ mean in and for health

Presentation 10 Whatcare? doesAddressing ‘care’ mean the compassion in and for health and Mr Patrick Lynch is the HSE’s National Director for Quality Assurance and Verification. Patrick has care?safety Addressingdeficit the compassion and Thealmost development 25 years senior of managementan Integrated experience Quality and in the Patient healthcare Safety sector Framework in both Ireland and toabroad. support Having a multistarted-sited his career Hospital working Group in intellectual disability services with the St. John of God safetyDr Justin deficit Brophy,. Executive Clinical Director, Presenter:Brothers, he wentJohn onMcElhinney, to work in a rangeGroup of Quality roles with and the Safetyformer MidlandManager, Health WNW Board. Hospitals During the DrHSE Justin Mental Brophy, Health Executive Services Clinical Director, Group,1990s he Sligo spent Regional 8 years heading Hospital up an International NGO in Kathmandu, Nepal after which he HSE Mental Health Services. returned to the Ireland to take up a position again with the Midland Health Board before becoming 14.50 – 15.10 the Deputy Director of the Health Boards Executive. Since the establishment of the HSE he has held 14.50Panel –Discussion 15.10 Presentationa number of positions as11 Assistant National Director in the Population Health Directorate, the HSE’s Mr Patrick Lynch SKINTrans formationChampions Programme for Kids and latterly the Integrated Services Directorate, prior to taking up the Complaints Driving Improvements. Presenter:role of National Claire Director Lundy, in January Belfast 2015. Health Patrick & Social has a PostCare Graduate Trust (BHSCT), Diploma in Health Systems Mr15.30 Peter – 15.35 Tyndall, Ombudsman. NorthernManagement Ireland and a Mastersand Queen’s degree University,in Change Management. Belfast, Northern Ireland Closing Remarks

15.10Dr Tony – 15.30Holohan, Chief Medical Officer Dr Kathleen Mac Lellan is Director of Patient Safety and Clinical Effectiveness, Department of Panel Discussion PresentationHealth. She leads the clinical 12 effectiveness policy function and supports the National Clinical ImprovingEffectiveness the Committee quality to and promote safety evidence of care-based for patientshealthcare transferred through quality by assured ambulance clinical Time: toeffectiveness Emergency processes. Departments She has recently taken leadership of the Patient Safety policy brief. END15.30 – 15.35 Presenter: Elizabeth Dillon, Emergency Department, St James’s Hospital, Dublin Closing Remarks Dr Kathleen Mac Lellan Dr Tony Holohan, Chief Medical Officer.

Dr Philip Crowley

Department of Health