PROGRAM
Thursday, September 12, 2024 – 6-9pm EST and Friday, September 13, 2024 – 8am-4pm EST
13, 2024 / 8:15AM—4:00PM
PROGRAM HOSTS
The Indianapolis Coalition for Patient Safety (ICPS) provides a forum for Indianapolis-area hospitals to share information about best practices and work together to solve patient safety issues. A free standing non-profit, ICPS is comprised of chief executive, medical, nursing, quality/safety and pharmacy leaders as well as front line staff from the major health-systems located in Indianapolis: Ascension St. Vincent, Community Health Network, Eskenazi Health, Franciscan Health Indianapolis, Indiana University Health, Roudebush VA Medical Center, and Suburban Health Organization. While competitors in the market-place, hospital leaders have come together and agreed to not compete on safety. Coalition Hospitals pool their expert resources to accelerate patient safety improvements through community-wide efforts.
ICPS members have a shared vision and challenge of making Indianapolis and the surrounding area the safest place for healthcare. The ICPS has historically achieved accelerated outcomes by sharing resources, performance targets, accountability, and lessons learned. ICPS members undertake projects that focus on patient-centered strategies to improve safety. Using subject matter experts from Coalition hospitals, Coalition-wide multidisciplinary teams are formed to address a variety of patient safety issues including projects in medication safety, perioperative safety, infection prevention, ethics, organ donation, substance use disorders, IT/ Informatics, and maternity to name a few.
The St. Louis Area Medication Safety (SLAMS) Collaborative was founded in 2014 as a grassroots effort to discover and share medication safety best practices freely and efficiently to any interested parties in the St. Louis area. Its members represent more than 50 hospitals, not including Ascension Health, and our academic partner, St. Louis College of Pharmacy. We work together to solve medication safety issues and foster a shared vision and challenge of making St. Louis area hospitals the safest hospitals to receive medications! We believe we can achieve accelerated outcomes by sharing resources, performance targets, accountability, and experience.
CONTINUING EDUCATION INFORMATION
M2S2 Continuing Education
Accreditation
In support of improving patient care, this activity has been planned and implemented by Indiana University School of Medicine and Indianapolis Coalition for Patient Safety, Inc. Indiana University School of Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Nurses
Indiana University School of Medicine designates this activity for a maximum of 6.5 ANCC contact hours. Nurses should claim only the credit commensurate with the extent of their participation in the activity.
Pharmacists and Pharmacy Technicians
Indiana University School of Medicine designates this activity for 6.5 ACPE contact hours. Pharmacists, and Pharmacy Technicians should only claim credit commensurate with the extent of their participation in the activity. Credit will be provided to NABP CPE Monitor within 60 days after the activity completion.
Physicians
Indiana University School of Medicine designates this live activity for a maximum of 6.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Bootcamp Continuing Education
Accreditation
In support of improving patient care, this activity has been planned and implemented by Indiana University School of Medicine and Indianapolis Coalition for Patient Safety, Inc. Indiana University School of Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Nurses
Indiana University School of Medicine designates this activity for a maximum of 3.0 ANCC contact hours. Nurses should claim only the credit commensurate with the extent of their participation in the activity.
Pharmacists and Pharmacy Technicians
Indiana University School of Medicine designates this activity for 3.0 ACPE contact hours. Pharmacists, and Pharmacy Technicians should only claim credit commensurate with the extent of their participation in the activity. Credit will be provided to NABP CPE Monitor within 60 days after the activity completion.
Physicians
Indiana University School of Medicine designates this live activity for a maximum of 3.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Welcome to the 8th Annual Midwest Medication Safety Symposium (M2S2) and Bootcamp 101.
Our M2S2 Steering Committee and Program Planning Committee have been hard at work securing top-tier programming. There’s something for ever yone; from students and residents to new practitioners to more experienced clinicians We’re kicking off the series of events with Bootcamp 101, followed by a full day of programming focused on a variety of safety related topics.
Medication Safety Bootcamp 101 is a terrific primer that covers: Med Safety Over view: Importance and Roles, Definitions and Terminology, Medication/Reporting/Trigger Tools, Focus/Prevention (Human Factors, High Alert Medications, Sound Alike Look Alike Drugs, Mitigation Strategies, Safety Behaviors), and Just Cultures/ Second Victim. Ideal for learners, new practitioners, or anyone who wants a refresher or updates on the most current medication safety strategies.
Midwest Medication Safety Symposium (M2S2) is an annual interdisciplinar y regional event with a focus on improving medication safety practices and patient outcomes through education of pharmacists, pharmacy technicians, nurses, physicians and the whole interprofessional health care team.
A special thank you to our M2S2 Steering Committee for your dedication, ingenuity, and insights:
Karen Arthur, PharmD / Roudebush VA Medical Center
Eli Deal, PharmD / BJC Healthcare
Heather Dossett, PharmD (Chair) / Ascension St Vincent, Indianapolis
Jim Fuller, PharmD / Indianapolis Coalition for Patient Safety
Denise Kerley, RN / Indiana University Health
Joanna Kinger y, PharmD / Indiana University Health
Stephen Lu, MD / Indiana University Health
Paul Milligan, PharmD / BJC Healthcare
Julie Painter, RN / Community Health Network
Nathan Walleser, PharmD / Community Health Network
Jessalynn White, PharmD
And also, a special thank you to our M2S2 Program Planning Committee for your flexibility, insights, and passion for excellence:
Karen Arthur, PharmD / Roudebush VA Medical Center
Eli Deal, PharmD / BJC Healthcare
Amanda Delashmit, CPhT / Indiana University Health
Heather Dossett, PharmD / Ascension St Vincent, Indianapolis
Jim Fuller, PharmD / Indianapolis Coalition for Patient Safety
Joanna Kinger y, PharmD / Indiana University Health
Paul Milligan, PharmD / BJC Healthcare
Nathan Walleser, PharmD / Indiana University Health
Jessalynn White, PharmD
Thank you also to all of our presenters and participants for your flexibility!
Heather Dossett, PharmD Chair, M2S2 Steering Committee
Jim Fuller, PharmD President, Indianapolis Coalition for Patient Safety
M2S2 2024 Program
30
35
35
Jessalynn
M2S2 2024 Program
All Session times are Eastern Standard Time
Friday, September 13, 2024
Time
11:15am-NOON
Presentation
Medication Safety in Ambulator y Care
Stayce Woodburn, DNP, RN, PNP-BC, NE-BC - Advance Practice Officer, Assoc. Chief Nursing Officer, IU Health Physicians
Christina Madriz, MBA, MSN, RN, CENP - Director, Nursing Practice, IU Health Physicians
Margaret Beckner, BSN, RN - Practice Administrator, Nursing, IU Health Physicians
12:45pm-1:15pm Establishing a Therapeutic Biosafety Committee for Handling Cellular and Gene Therapies
Eli Deal, PharmD, BCPS, FCCP, CPS - System Director of Medication Safety and Effectiveness, BJC Healthcare
1:15pm-1:45pm Utilizing Pharmacy Technicians to Improve the Efficiency and Safety of Medication Refill
Authorization in Ambulator y Care Clinics
Miranda Arthur, PharmD BCACP - Ambulator y Pharmacy Manager, IU Health
Kevin Conner, CPhT - Ambulator y Pharmacy, IU Health
1:45pm-2:15pm
Strategic Safety Measures for Batch Compounding Processes
Allison Young, PharmD, BCSCP - Director of Pharmacy, IU Health Centralized Compounding
Noah Moyer, CPht, CSPT - Technician Super visor, IU Health Centralized Compounding
2:30pm-3:00pm Getting EXTRA with EXTRAvasations: A Journey to Update Policy, Practice, and Procedures
Elizabeth (Betsy) Vance, MSN, RN, CEN, NI-BC-Director of Nursing Practice and Innovation, Eskenazi Health
Monica Macik, PharmD, BCPS, BCOP, Clinical Pharmacy Specialist - Hematology/Oncology, Eskenazi Health
3:00pm-4:00pm
Pearls Sessions
1-Bag, 2-Bags, 3-Bags, 4. Making Sense of a Complex Life-Saving Protocol
Paul Milligan, PharmD
Navigating Drug Shortages in Primar y Care
Sarah Kain, PharmD, BCACP - Clinical Pharmacy Specialist, Ambulator y Care, Community Health Network
Scan You Believe it? Leveraging the Powers of Tableau to Improve Barcoded Scanning Compliance
Alexander Milligan, PharmD, BCPPS - Medication Safety Specialist, St. Louis Children's Hospital
Preventing Medication Stock Outs by Comparing Current and Historical Usage
Andy Kieszkowski, PharmD - Pharmacy Manager, IU Health
Hypertonic Saline Administration through a Peripheral IV
Lori Wetmore, PharmD, BCPS, BCCCP - Clinical Pharmacy Specialist - Neurocritical Care, IU Health, Methodist
Eve Anderson, PharmD, BCPS, BCCCP - Clinical Pharmacy Specialist - Neurocritical Care, IU Health, Methodist
Thursday, September 12, 2024 / 6PM—9PM EST
Bootcamp 101
Heather Dosset, PharmD, MHA, BCPS, CPHQ - Medication Safety and Pharmacy Education Pharmacist - Ascension
Jessalynn White, PharmD - Medication Safety Expert
Introductions, Housekeeping, Pre-Assessment - 10 Minutes Heather.Dossett@ascension.org jessalynnwhite@gmail.com
Denise Kerley, RN - IU Health
Overview: Importance, Roles - 10 Minutes kdkerley@iu.edu
Denise Kerley, RN - IU Health
Definitions, Terminology - 10 Minutes kdkerley@iu.edu
Paul Milligan, PharmD
Detection, Reporting - 30 Minutes paul.milligan1@outlook.com
Medication Use Process - 35 Minutes NWalleser@ecommunity.com
Nathan Walleser, PharmD, BCPPS - Network Director of Medication Safety - Community Health Network
Focus and Prevention: Human Factors, HAM SALAD, Mitigation Strategies, Safety Behaviors - 35 Minutes
Jennifer Meyer, PharmD - BJC Healthcare
Jennifer.Meyer5@bjc.org
Just Culture, Second Victim - 35 Minutes
Karen Arthur, PharmD, BCPS, CPHQ - Associate Chief, Pharmacy for Medication Safety, Informatics, and Procurement - Roudebush VA Medical Center
Karen.Arthur@va.gov
Wrap-Up: Post-assessment, Q&A - 10 Minutes
Heather Dosset, PharmD, MHA, BCPS, CPHQ - Medication Safety and Pharmacy Education Pharmacist - Ascension
Heather.Dossett@ascension.org
Jessalynn White, PharmD - Medication Safety Expert
jessalynnwhite@gmail.com
Friday, September 13, 2024 / 8:15AM—9:15AM EST
Med-ocation: Ethical Considerations in Medication Allocation
Presented by
Vice President, Clinical and Organizational Ethics, Indiana University Health
Executive Director, Fairbanks Center for Medical Ethics amartin34@iuhealth.org
Miranda I. Lynch, PharmD - River view Health miblynch24@gmail.com
Objectives:
• Create a framework for understanding broad ethical issues that arise in the context of a public health emergency/pandemic
• Analyze ethical approaches to triage/allocation of medications
Drug shortages and medication allocation have become increasingly frequent in healthcare. Challenges in the supply chain, compounded by rising demand, further burden an already strained system grappling with shortages of personnel and supplies. This session aims to examine ethical frameworks for addressing the ethical dilemmas arising from medication shortages, empowering the audience to employ ethical approaches in the inevitable scenario of medication
Key Takeaways
Friday, September 13, 2024 / 9:15AM—9:45AM EST
Psychological Safety
Presented
by
Jessalynn White, PharmD Medication Safety Expert Jessalynnwhite@gmail.com
Objectives:
• Describe the various components of a psychological safety environment
• State various behaviors that will be observed in a psychologically safe environment
• Create a psychologically safe environment utilizing various tools
Creating a psychological safe environment is a key component to achieving high reliability, which can be applied in the virtual and in person setting. The goal of this presentation is to describe the key components that comprise of a psychologically safe environment and tools to incorporate into practice to create this environment at their organization. During this active audience participatory presentation, there will be several exercises completed to help create a psychologically safe environment in the moment.
Key Takeaways
• Psychological safety is a key component to achieving high reliability
• Tools utilized to create psychological safety can be utilized in the virtual and in person setting
• Various tools can be easily incorporated into practice to create a psychologically safe environment
10:00AM—10:30AM EST
Code Response Debriefing: How to deal with the emotionally challenging aspects of clinical care
Presented by Natalie A. Madere, PharmD, BCPS, BCCCP
Clinical Pharmacy Specialist - Critical Care, Clinical Coordinator, Community Health Network nwinings@ecommunity.com
Objectives:
• Describe examples of critical incidents in the healthcare setting.
• Discuss benefits of debriefing following a critical incident.
• Implement debriefing framework in clinical practice.
• Identify debriefing resources available within your health system.
I had the opportunity to speak on 'Code Response Debriefing' at one of our CHNw preceptor development sessions and received positive feedback about this unique topic. Pharmacy learners, pharmacists, and technicians may encounter critical incidents (ex: medical error, unexpected outcome, angry family, death, etc.) frequently in their clinical practice. Healthcare professionals often do not talk about our emotions during pharmacy school and training; therefore, these critical incidents are something we are often not equipped to appropriately handle. This talk would hopefully provide insight into these scenarios we may encounter in clinical practice and provide resources/tools to help process these scenarios.
Key Takeaways
• Give pharmacists and technicians the tools to be prepared in the event of a critical incident.
• Provide resources to incorporate into critical care rotation settings for student and resident learners.
Medication Safety Strategies in Weight Management
Presented by
Sarah A. Kain, PharmD, BCACP, TTS
Clinical Pharmacy Specialist, Ambulator y Care, Community Health Network skain@ecommunity.com
Sarah M. Lowe, PharmD
PGY2 Ambulator y Care Pharmacy Resident, Community Health Network slowe@ecommunity.com
Objectives:
• Demonstrate pharmacist-managed weight management ser vice implementation
• Describe safety risks and concerns with weight management therapies
• Develop a standardized protocol and tools for weight management
The goal of this presentation is to demonstrate a pharmacist-managed weight management protocol implementation in a primar y care setting, including introduction of standardized SmartSets, note templates, and SmartPhrases in the electronic medical record. We will describe safety risks and concerns with FDA-approved vs. off-label vs. compounded therapies and adequate use of contraception during treatment.
Key Takeaways
• The audience will be able to take away various tools and standardization ideas that may reduce prescribing errors, ensure proper
Medication Safety in Ambulatory Care
Presented by Stayce L. Woodburn, DNP, RN, PNP-BC, NE-BC Advance Practice Officer, Assoc. Chief Nursing Officer, IU Health Physicians swoodburn@iuhealth.org
Christina M Madriz, MBA, MSN, RN, CENP Director, Nursing Practice, IU Health Physicians cmadriz@iuhealth.org
Margaret M Beckner, BSN, RN Practice Administrator, Nursing, IU Health Physicians mbeckner@iuhealth.org
Objectives:
• Understand the ambulatory care landscape and the impact of organizational culture on medication safety practices
• Acknowledge the strengths and weaknesses of current safety initiatives and processes in ambulatory care settings
• Identify common medication errors encountered in ambulatory care
• Recognize medication safety strategies and initiatives implemented within ambulatory care
• Comprehend the role provider medication ordering plays in medication safety and barriers to order entry
Implementation of a multifaceted, comprehensive medication safety strategy within ambulatory care, including discussion of education, implementation of bar code medication administration, and communication strategies.
Key Takeaways
• Awareness of medication safety in ambulatory care along with key insights on evaluating and implementing safety strategies.
Friday, September 13, 2024 / 12:45PM—1:15PM EST
Establishing a Therapeutic Biosafety Committee for Handling Cellular and Gene Therapies
Presented by Eli Deal, PharmD, BCPS, FCCP, CPS System Director of Medication Safety and Effectiveness, BJC Healthcare eli.deal@bjc.org
Objectives:
• Describe the potential healthcare work hazards associated with cellular and gene therapies (CGTs)
• Compare and contrast risk mitigation strategies required for handling CGTs
• Describe the BJC Therapeutic Biosafety Committee composition and development
• Review the BJC Therapeutic Biosafety Committee Assessment of Risk tools and processes
Cellular and gene therapies are becoming more common. Safe handling of these therapies requires assessments beyond traditional hazardous drug handling principles (USP 800). In the absence of clear regulatory guidelines for CGTs, health care entities must develop individualized processes for handling these therapies in a manner that protects their staff.
Key Takeaways
• Components of the therapeutic biosafety committee at BJC and the processes for assessment of risk used at our healthcare system.
Friday, September 13, 2024 / 1:15PM—1:45PM EST
Utilizing Pharmacy Technicians to Improve the Efficiency and Safety of Medication Refill Authorization in Ambulatory Care Clinics
Presented by
Miranda Arthur, PharmD BCACP
Ambulatory Pharmacy Manager, IU Health
marthur6@iuhealth.org
Kevin Conner, CPhT
Ambulatory Pharmacy, IU Health kconner2@iuhealth.org
Objectives:
• Describe the role of a pharmacy technician in authorizing medication refills in an ambulatory care clinic.
• Outline potential workflows and key performance indicators of a medication refill pharmacy technician program.
• Identify steps in the medication refill process in which medication errors are likely to occur in an ambulatory care clinic.
This presentation will discuss the non-traditional role of pharmacy technicians in authorizing medication refills in ambulatory care clinics via protocol. Topics covered will include justification of this new service and the business case for a pharmacy technician, practice workflows and protocols, and impact on incident reporting and medication safety projects of the organization.
Key Takeaways
• Audience members are encouraged to consider innovative ways that pharmacy technicians are uniquely positioned to address the healthcare workforce shortage and make a meaningful impact on the safe and effective delivery of healthcare in their organization.
Friday, September 13, 2024 / 1:45PM—2:15PM EST
Strategic Safety Measures for Batch Compounding Processes
Presented by Allison L. Young, PharmD, MS, BCSCP Director of Pharmacy, IU Health Centralized Compounding ayoung10@iuhealth.org
Noah Moyer, CPht, CSPT Technician Super visor, IU Health Centralized Compounding nmoyer@iuhealth.org
Objectives:
• Review measures that can promote safe batch compounding processes for CSPs.
Batching products provides the opportunity to add safety to medication production by allowing personnel to focus on one repeated activity. When designing these processes, it is important to consider the regulator y and compliance of the processes, particularly considering the recent updates to USP Chapters 795 and 797. There are a number of opportunities to engineer safety into batching processes. This presentation will summarize the compliance and operational considerations that must be incorporated into batching processes.
Key Takeaways
• Recognizing the potential value of batching compounded products.
• Understanding the regulator y requirements for a compliant process.
• Ability to apply the principles of medication safety to any batching processes.
Friday, September 13, 2024 / 2:30PM—3:00PM EST
Getting EXTRA with EXTRAvasations: A Journey to Update Policy, Practice, and Procedures
Presented by Betsy Vance, MSN, RN, CEN, NI-BC Director of Nursing Practice and Innovation, Eskenazi Health elizabeth.vance@eskenazihealth.edu
Monica Macik, PharmD, BCPS, BCOP Clinical Pharmacy Specialist - Hematology/Oncology, Eskenazi Health monica.macik@Eskenazihealth.edu
Objectives:
• Describe process to review current state extravasation policy, procedures, and documentation elements including order set content
• Summarize key changes to policy and procedures
• Examine the methodology used to assist with provider antidote order entry based on the affected area of injury
• Develop pathways to apply knowledge to own health system
Sharing information and knowledge gained from a one (1) year plus journey to implement policy and practices changes with extravasations. Specifically, our methods and approach, deconstructing the policy and making more user friendly, training, documentation, and order updates for this low frequency/high risk workflow.
Key Takeaways
• Review current extravasation policy and alignment with current literature
• Assess and understand which roles administer antidotes and training opportunities
• Determine how extravasation are managed, documented, and communicated in the EHR and incident reporting systems
Friday, September 13, 2024 / 3:00PM—4:00PM EST
Improving Safety Culture and Engagement Through Peer Review
SESSIONS (10 MINUTES EACH + Q&A)
1-Bag,
2-Bags,
3-Bags, 4. Making Sense of a Complex Life-Saving Protocol
Presented by Paul Milligan, PharmD paul.milligan1@outlook.com
Objectives:
• Describe the national landscape of the various dosing regimens and concentrations for dosing of acetylcysteine (NAC) for
treatment of acetaminophen (paracetamol) poisoning.
Key Takeaways
• In 2024, acetylcysteine regimens for acetaminophen overdose are complex and not standardized with at least 15 regimens requiring multiple IV concentrations and between 1 and 3 bags and rates. Extreme care should be taken, especially during patient transfers which are common. Efforts are being made to work with ISMP to assist in standardizing to a safe and effective dosing regimen.
Friday, September 13, 2024 / 3:00PM—4:00PM EST
PEARL SESSIONS (10 MINUTES EACH + Q&A)
Improving Safety Culture and Engagement Through Peer Review
Navigating Drug Shortages in Primary Care
Presented by Sarah A. Kain, PharmD, BCACP, TTS
Clinical Pharmacy Specialist, Ambulatory Care, Community Health Network
skain@ecommunity.com
Objectives:
• Examine approaches utilized by ambulatory care pharmacists to provide patient care in the setting of recent drug shortages.
The audience may enhance their practice by having a deeper understanding of the strategies and approaches available in managing drug shortages for chronic disease states in primary care to implement in their own practice.
Key Takeaways
• The audience may enhance their practice by having a deeper understanding of the strategies and approaches available in managing drug shortages for chronic disease states in primary care to implement in their own practice.
Friday, September 13, 2024 / 3:00PM—4:00PM
PEARL SESSIONS (10 MINUTES EACH + Q&A)
Improving Safety Culture and Engagement Through Peer Review
Scan You Believe it? Leveraging the Powers of Tableau to Improve Barcoded Scanning Compliance
Presented by Alexander Milligan, PharmD, BCPPS
Medication Safety Specialist, St. Louis Children's Hospital
alexander.milligan@bjc.org
Objectives:
• Understand the critical role barcoded medication administration (BCMA) plays in preventing medication errors and improving patient safety
• Strategize methods, such as Tableau Dashboards, for displaying meaningful data to nursing leaders to effectively address barriers to BCMA
• Discuss strategies to achieve and maintain high levels of BCMA compliance at your institution
Key Takeaways
PEARL SESSIONS (10 MINUTES EACH + Q&A)
Improving Safety Culture and Engagement Through Peer Review
Preventing Medication Stock Outs by Comparing Current and Historical Usage
Presented by Andy Kieszkowski, PharmD Pharmacy Manager, IU Health akieszkowski@iuhealth.org
Objectives:
• Analyze medication usage to decrease the number of stock outs.
• Examine and adjust medication PAR levels due to shifting demand.
Medication stock outs that occur on weekends can have a variety of impacts on patient care. I have helped curb the amount of weekend stock outs by utilizing a spreadsheet that can help detect and prevent medication stock outs.
Key Takeaways
• Why do medication stock outs still happen after implementing perpetual inventory?
• Being able to analyze current compared to historical medication usage can help predict and prevent stock outs.
PEARL SESSIONS (10 MINUTES EACH + Q&A)
Improving Safety Culture and Engagement Through Peer Review
Hypertonic Saline Administration through a Peripheral IV
Presented by
Lori Wetmore, PharmD, BCPS, BCCCP
Clinical Pharmacy Specialist - Neurocritical Care, IU Health, Methodist lblank@iuhealth.org
Eve Anderson, PharmD, BCPS, BCCCP
Clinical Pharmacy Specialist - Neurocritical Care, IU Health, Methodist eanders2@iuhealth.org
Objectives:
• By the end of this presentation the audience will be able to assess the appropriateness of hypertonic saline solutions and routes
Historical concerns with hypertonic saline thrombophlebitis and skin necrosis lead to administration recommendations through central lines. Newer data suggests the risks may have been overestimated, and hypertonic saline may be administered safely through peripheral lines with proper protocols and monitoring.
Key Takeaways
• Review current practices and evaluate the need for policy updates given the latest evidence
