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Press Release

For Immediate Release
For Information Contact:
William Minogue
Maryland Patient Safety Center

More than 1,300 Maryland Health Care Providers Convene
to Talk About Safe Patient Care

“The Power of Apology” Kicks off
the Third Annual Maryland Patient Safety Conference

Baltimore, Maryland, March 23, 2007 - “There is no such thing as a simple mistake.  Even the most obvious error has multiple causes.  Most of those causes are not under the control of the person whose action resulted in the injury.  They are the result of poorly designed systems for which the organization is responsible,” said Lucian Leape, M.D., Adjunct Professor of Health Policy, Department of Health Policy and Management, Harvard, in the opening address at the Third Annual Maryland Patient Safety Conference held in Baltimore today.

“When patients are harmed by our mistakes, there are two victims—the patient and the caregiver who was the instrument that caused the harm,” according to Dr. Leape, who is known as the father of the modern patient safety movement.  “Both need treatment and support.” 

Dr. Leape’s keynote address, The Power of Apology, was one of 23 sessions held during today’s Conference, sponsored by the Maryland Patient Safety Center, which drew more than 1,300 representatives from Maryland hospitals and nursing homes, hospitals in Washington, D.C. and Delaware, regulatory agencies, and other health care organizations in the region. 

“Apology and disclosure are critical focus areas for this year’s Conference,” said William Minogue, M.D., FACS, Executive Director of the Maryland Patient Safety Center.  Sorrell King from the Josie King Foundation and Dr. Albert Wu from The Johns Hopkins University also shared how apology can begin the healing process for both patients and health care providers. Leading health care experts and professionals from Maryland and around the nation shared best practices and the latest in evidence-based solutions for patient safety during this full-day conference. 

Three Maryland hospital executives shared their commitment to improving patient safety in their hospitals during a panel presentation.  William G. Robertson, president and CEO of Adventist HealthCare, said that the hospital’s governing board is the driver and needs to set the standards for patient safety.  Carl J. Schindelar, president and CEO of Franklin Square Hospital Center, provided details of Franklin Square’s initiatives in preventing patient falls and their proactive efforts to combat health care-acquired MRSA infections.  Ed Miller, M.D., CEO, Johns Hopkins Medicine, and Dean, The Johns Hopkins University School of Medicine, focused on the importance of data and involving all employees at the bedside in patient safety.  All three hospital executives agreed patient safety improvements occur at a slow pace and success does not happen overnight.

In his third year presenting at the Conference, Jon C. Lloyd, M.D., FACS, Regional MRSA Prevention Coordinator, Centers for Disease Control and Prevention (CDC), VA Pittsburgh Healthcare System, moderated a panel on Maryland hospital health care professionals who are adopting the techniques that he has led at the VA Pittsburgh Healthcare System to achieve dramatic reductions in the prevalence of health care-acquired MRSA infection.  A key factor to the success of this initiative was its regional coordination of infection control including tracking patients with MRSA infections and asymptomatic carriers through health care systems, and taking appropriate precautions as defined by the CDC.

Many of the Conference sessions also shared the approaches and outcomes from initiatives conducted by the Maryland Patient Safety Center—the lessons and solutions learned through safety culture collaboratives;  identifying safer ways to prescribe medications for children and enhancing patient safety through electronically based medication and allergy reconciliation that were initiatives conducted through a  grant award from the Maryland Patient Safety Center and the Cardinal Health Foundation; and an update on the adverse event reporting tool being developed by the Center.

“Since this Conference began in 2004, it has grown tremendously,” said Dr. Minogue.  “It is one of the core initiatives of the Maryland Patient Safety Center along with other education and training activities that has, to date, raised awareness about evidence-based strategies among 4,500 Maryland health care professionals.”

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The Maryland Patient Safety Center, a joint venture of the Maryland Hospital Association and the Delmarva Foundation, was created by the legislature and established by the Maryland Health Care Commission in 2004.   Through its collaborative, non-regulatory approach, it works with hospitals and health care providers to study the causes of medical errors and unsafe practices and put practical, evidence-based improvements in place to prevent errors and deliver safe patient care.

The Third Annual Maryland Patient Safety Conference was held in cooperation with The Beacon Institute, LifeSpan’s educational affiliate; CareFirst; Health Facilities Association of Maryland; Maryland Association of Healthcare Executives; Maryland Chapter of the American Society of Consultant Pharmacists; Maryland Nurses Association; Maryland Organization of Nurse Executives; Maryland Society for Healthcare Risk Management; and Maryland Society of Health System Pharmacists.