AATS Surgical Patient Safety Course

Preliminary Program
Day 1 | Friday, June 29, 2018


7:30 AM

Registration and Continental Breakfast

8:00 AM

Welcome and Introduction
James H. Abernathy, III, Johns Hopkins Medicine
Thoralf M. Sundt, III, Massachusetts General Hospital

Steven J. Yule, Brigham & Women's Hospital/Harvard University

Session I: Opening Keynote Address

8:05 AM

Stranger in a Strange Land: The Convergence of Human Factors Science
and Safety in Healthcare

Steven J. Yule, Brigham & Women's Hospital/Harvard University

Session II: Establishing Common Ground
  Moderators:
James H. Abernathy, III, Johns Hopkins Medicine
David C. Fitzgerald, Medical University of South Carolina
Steven J. Yule, Brigham & Women's Hospital/Harvard University

8:30 AM


Accident Theory: Why Do Bad Things Happen to Good People
Sarah Henrickson Parker, Virginia Tech Carilion School of Medicine

8:50 AM


Accountability Without Shame or Blame: Both Sides of Just Culture
Thoralf M. Sundt, III, Massachusetts General Hospital

9:10 AM


High Reliability Organizations: Lessons Learned from Other Industries
Kenneth R. Catchpole, Medical University of South Carolina

9:30 AM

Panel Discussion

10:00 AM

Coffee Break

Session III: Group Workshop #1 Behavioral Science
  Panelists: 
David J. Bunnell, Washington DC VA Medical Center
Lisa M. Morrissey, Harvard Medical School
Sarah Henrickson Parker, Virginia Tech Carilion School of Medicine
Roving Moderators: 
James H. Abernathy, III, Johns Hopkins Medicine
Thoralf M. Sundt, III, Massachusetts General Hospital

10:30 AM


Teaching Non-Technical Skills for the Operating Room
Douglas S. Smink, Brigham and Women’s Hospital
Steven J. Yule, Brigham & Women's Hospital/Harvard University

Panel Discussion

Session IV: Luncheon Keynote Address
Please collect your lunch and return to the General Session room for the Keynote Address.

11:45 AM


Speaking Up
Charlotte Guglielmi, Beth Israel Deaconess Medical Center

Session V: Advancing Teamwork
  Moderators: 
Robert D. Jaquiss, UT Southwestern 
Kenneth R. Catchpole, Medical University of South Carolina
Steven J. Yule, Brigham & Women's Hospital/Harvard University
Marco A. Zenati, Harvard Medical School 

12:45 PM


The Current State of Teamwork Science: How Teamwork Research in Real and
Simulated Environments Can Advance the Safety Agenda

Sarah Henrickson Parker, Virginia Tech Carilion School of Medicine

1:05 PM


Improving Surgical Patient Safety at the System Level - the MGH Family Experience
Elizabeth A. Mort, Harvard Medical School

1:25 PM 


Adapting Best Practices from High Performance Teams in Aviation:
The Military and Sports for Medical Practice

Douglas R. Johnston, Cleveland Clinic

1:45 PM


Lessons Learned Observing the Natives: Impact of Interpersonal
Communication Style on Teamwork and Engagement

Emmilie L. Aveling, Harvard T.H. Chan School of Public Health

2:05 PM

Panel Discussion

2:30 PM

Coffee Break

Session V: Abstract Presentations

 

Moderators:
James H. Abernathy, III, Johns Hopkins Medicine
Thoralf M. Sundt, III, Massachusetts General Hospital
Steven J. Yule, Brigham & Women's Hospital/Harvard University

1.

The Forgotten "Never Event": Establishing a Ventilator- Heart Lung Machine
Communication Bridge to Mitigate Failure-to-Ventilate Errors When Weaning from Bypass

Geoffrey Rance, Veterans Affairs Boston Healthcare System

2.

Intelligent Interruption Management System to Enhance Safety and Performance
in Complex Surgery

Marco A. Zenati, Harvard Medical School

3.

Mortality in Low-Risk Cardiac Surgery Patients: Perioperative Analysis of Contributing Factors
Omar A.V. Mejia, Heart Institute of Sao Paulo Medical School

4.

OR to Intensive Care Patient Handover: Using the "Theory of Change" Method for
Sustainable Change in Behaviors

Mahim Malik, Aga Khan University 

5.

Community-based Participatory Research (CBPR) Principles in Cardiac Operating Room
to Improve Patient Safety

A.H. Hermosura, University of Hawaii and The Queen's Medical Center

Session VII: Concurrent Breakout Sessions
Please choose one session to attend.

4:00 PM

Concurrent Session A: Briefings, Debriefings and Checklists in the Operating Room
Robert D. Jaquiss, UT Southwestern
Kenneth Shann, Massachusetts General Hospital
Kenneth R. Catchpole, Medical University of South Carolina

4:00 PM

Concurrent Session B: Updates and Handoffs in the ICU
David J. Bunnell, Washington DC VA Medical Center
Glenn J. Whitman, Johns Hopkins Hospital

Session VIII: Setting the Tone in the Operating Room 

 

Moderators: 
David J. Bunnell, Washington DC VA Medical Center
David C. Fitzgerald, Medical University of South Carolina

5:00 PM


Debate: Should the ‘Sterile Cockpit’ Be Implemented in Every Operation
to Reduce Distractions?

Pro:Marco A. Zenati, Harvard Medical School
Con: Thoralf M. Sundt, III, Massachusetts General Hospital

5:15 PM

Building a Resonant Team
Jamie Ungerleider, Driscoll Children's Hospital
Ross Ungerleider, Driscoll Children's Hospital

5:45 PM

Welcome Reception
Collective Reflection and Poster Viewing.
All poster abstracts available to view at the end of the program.


Day 2 | Saturday,  June 30,  2018

7:00 AM

Continental Breakfast

Early Bird Session: Projects in Progress
  Moderators:
Sarah Henrickson Parker, Virginia Tech Carilion School of Medicine
James H. Abernathy, III, Johns Hopkins Medicine

8:00 AM


Welcome and Reflections on Day 1: What Did We Know, What Did We Learn?
Steven J. Yule, Brigham & Women's Hospital/Harvard University
Roving Moderators:
James H. Abernathy, III, Johns Hopkins Medicine
Thoralf M. Sundt, III, Massachusetts General Hospital

Session IX: Learning From Our Experience
  Moderators: 
William Riley, Massachusetts General Hospital
Glenn J. Whitman, Johns Hopkins Hospital
Steven J. Yule, Brigham & Women's Hospital/Harvard University

8:15 AM


Near Misses and Safety Reporting Systems
William Berry, Harvard T.H. Chan School of Public Health

8:35 AM


The ANZCP Near Miss Database for Perfusion: What Have We Learned
About Our “Almost Happened” Events?

David C. Fitzgerald, Medical University of South Carolina

8:55 AM


Coaching to Improve Performance
Douglas S. Smink, Brigham and Women’s Hospital

9:15 AM


Flow, Disruptions and Black Boxes: What Can They Teach Us About
Operating Room Performance

James H. Abernathy, III, Johns Hopkins Medicine

9:35 AM

Panel Discussion

10:15 AM

Coffee Break

Session X: Group Workshop #2 Implementing Patient Safety in Surgery 
  Panelists:
David L. Feldman, Hospitals Insurance Company, Inc.
Douglas R. Johnston, Cleveland Clinic
Kenneth Shann, Massachusetts General Hospital
Roving Moderators: 
James H. Abernathy, III, Johns Hopkins Medicine
Thoralf M. Sundt, III, Massachusetts General Hospital

10:45 AM


Making Change Happen
Thoralf M. Sundt, III, Massachusetts General Hospital

Panel Discussion

Session XI: Luncheon Keynote Address
Please collect your lunch and return to the General Session room for the Keynote Address.

11:45 AM


Surgical Patient Safety: Opportunities for Collaboration Across Specialty Societies
Ajit Sachdeva, American College of Surgeons

Session XIII: Taking Care of Ourselves to Foster Surgical Safety
  Moderators: 
James H. Abernathy, III, Johns Hopkins Medicine
Jamie Ungerleider, Driscoll Children's Hospital
Ross Ungerleider, Driscoll Children's Hospital

1:00 PM


The Impact of Fatigue
Luiz Quinonez, Boston Children's Hospital

1:20 PM

 

Burnout
David J. Bunnell, Washington DC VA Medical Center

1:40 PM


Second Victim
Jamie Ungerleider, Driscoll Children's Hospital

Session XIII: When Bad Things Happen 
  Moderators: 
William Berry, Harvard T.H. Chan School of Public Health
Jamie Ungerleider, Driscoll Children's Hospital

2:00 PM

Repairing Relationships After the Dust Has Settled
Ross Ungerleider, Driscoll Children's Hospital

2:20 PM


Optimizing Disclosure
Cheryle Totte, Beth Israel Daconess Medical Center

2:40 PM


Legal Implications
David L. Feldman, Hospitals Insurance Company, Inc.

3:00 PM


Sky’s the Limit? The Future of Human Factors Science and Safety in Healthcare
Sarah Henrickson Parker, Virginia Tech Carilion School of Medicine

3:30 PM

Closing Remarks / Meeting Adjourns


AATS 2018 Surgical Patient Safety Poster Abstracts  
P1. A Box Is Not Just A Box
Alberto Antonicelli1, Carlo Capra2, Bryan M. Burt3
1Independent Scientist; 2Department of Anesthesia Intensive Care, 

Tradate Hospital, Italy; 3Baylor College of Medicine, Houston, Texas, USA

P2. Lower Discharge Hemoglobin Level and 30-Day Readmission Rates after Coronary Artery Bypass Surgery
Brian C. Cho1, Vincent M. DeMario1, Nadia B. Hensley1, Charles H. Brown1, Kaushik Mandal2, Glenn J. Whitman2, Steven M. Frank1 

1Department of Anesthesiology and Critical Care Medicine; 2Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland

P3. Process-Model-Driven Guidance to Reduce Surgical Procedural Errors
Heather M. Conboy, George S. Avrunin, Stefan C. Christov, Lori A. Clarke, Leon J. Osterweil, Marco A. Zenati

University of Massachusetts Amherst; Quinnipiac University; VA Boston Healthcare System, Harvard Medical School 

P4. Developing a Quality Standard for Verbal Communication during Cardiopulmonary Bypass Procedures
R.A.F. de Lind van Wijngaarden1, S. Siregar1, A. Fraaije1,2,3, A. Abbas1, M.G. Hazekamp1, R.J.M. Klautz1
1Department of Cardiothoracic Surgery, Heart and Lung Center, Leiden University Medical Center; 2Department of Science

Education and Communication; 3Department of BioMedical Engineering, Technical University Delft, The Netherlands.

P5. A Novel Method of Cognitive Task Analysis Using Video Vignettes to Assess Intraoperative Cognitive Processes in Cardiac Surgery
Roger D. Dias, Marco Zenati, Heather M. Conboy , Lori A. Clarke, Leon J. Osterweil , George S. Avrunin , Jennifer Gabany, Steven Yule
STRATUS Center for Medical Simulation; Department of Surgery, Brigham and Women’s Hospital; VA Boston Healthcare System; Harvard Medical 

School; University of Massachusetts Amherst

P6. 

P7. Improving RBC Utilization in Cardiac Surgery with Teamwork and Audits with Feedback
Nadia B. Hensley, Steven M. Frank MD, Vincent M. DeMario, Brian Cho, Glenn J. Whitman, Chun W. Choi, James Abernathy III

The Johns Hopkins University School of Medicine

P8. Exploration of Enhanced Healthcare Provider Performance using Sensor Technology and Physiologically-driven Biofeedback.
Lauren Kennedy1, Sarah Henrickson Parker2

1Department of Translational Biology, Medicine, and Health, Virginia Polytechnic Institute and State University; Virginia Tech Carilion Research Institute; 
2Department of Basic Science Education, Virginia Tech Carilion School of 
Medicine; Virginia Tech Carilion Research Institute

P9. Rational Transfusion versus Preoperative Anemia, Who is to Blame? Causal Mediation Analysis after Statewide Quality
Improvement Initiatives to Reduce Blood Transfusions in Cardiac Surgery

Omar AV Mejia, Luiz AF Lisboa, Luis AO Dallan, Pablo MA Pomerantzeff, Ricardo R Dias, Marco AP Oliveira, Gustavo I Judas,

Fabio A Gaiotto, Jose AD Santiago, Gisele A Lapenna, Roberto Rocha e Silva, Fabio B Jatene and REPLICCAR Study Group

P10. The Caprini Risk Assessment Model for Venous Thromboembolism Prevention after Fundoplication:
Evaluating Patient Safety and Compliance

Shriya Reddy1, Helene Sterbling1, Kei Suzuki1,2, Virginia R. Litle1,2

1Boston University School of Medicine; 2Boston Medical Center

P11. Fraction of Expired Oxygen: A Novel Safety Approach to Monitor Oxygen Delivery to the Heart Lung Machine Oxygenator
Rithy Srey, Geoffrey Rance, Jacquelyn Quin, Kay Leissner, Houman Amirfarzan, John Handrahan, Miguel Haime, Marco A Zenati

VA Boston Healthcare System, West Roxbury, MA 

P12. Aiming for an “Opioid-free” Therapeutic Strategy for Management of Postoperative Pain in Thoracic Patients
Undergoing Thoracotomy or Thoracoscopy: Program Development and Implementation

Joy Stephens-McDonnough; Syed S. Razi; Nestor Villamizar; Dao Nguyen

Thoracic Surgery Division, Miller School of Medicine - University of Miami Hospital, Miami, FL

P13.

Georg Trummer, Matthias Eschenhagen, Fabian Kari, Matthias Bock, Michael Berchtold-Herz, Michael Südkamp, Friedhelm Beyersdorf

University Heart Center Freiburg, Cardiovascular Surgery, Hugstetter Str. 55, 79106 Freiburg, Germany

P15. The Utility of the Surgery Task Load Index (SURG-TLX) in Cardiac Surgery Teams
Hill Wolfe, Roger D. Dias, Jennifer Gabany, Steven J. Yule, Marco A. Zenati

VA Boston Healthcare System, West Roxbury, MA 

P16. First Reported Use of Team Cognitive Workload for Root Cause Analysis in Cardiac Surgery
Marco A. Zenati1,2,3, Roger D. Dias2,4, Kay Leissner1,2, Suzana Zorca1,2, Pamela Bellino5, Houman Amirfarzan1,2,
Jennifer M. Gabany1,2,3, Steven J. Yule2,4
1Divisions of Cardiothoracic Surgery and Anesthesiology, Veterans Affairs Boston Healthcare System; 2Harvard Medical School,
Harvard University; 3Medical Robotics & Computer Assisted Surgery (MRCAS) Laboratory, Harvard Medical School, 

4STRATUS Simulation Center, Brigham & Women’s Hospital, 5Center for Patient Safety, Veterans Affairs Boston Healthcare System, Boston, MA

P17. A Cognitive “Safe Zone Rule” to Protect Situation Awareness and Improve Communication in Surgery
Marco A Zenati, Roger D Dias, Jennifer M Gabany, Steven Yule
Division of Cardiac Surgery, Veterans Affairs Boston Healthcare System and Harvard Medical School, STRATUS Center for

Simulation, Brigham and Women’s Hospital, Boston, MA

P18. A Novel Coaching Intervention to Support Team Flow in Complex Surgery
Chiara H Megighian1, Jennifer M Gabany2, Roger D Dias3, Giovanni D Megighian1, Ina Gjikondi1, Marco A Zenati2
1Executive Education & Leadership Coaching Services, Center for Excellence in Public Leadership (CEPL), George Washington University,
Washington, DC; 2Division of Cardiac Surgery, Veterans Affairs Boston Healthcare System and Harvard Medical School; 3STRATUS Center for
Medical Simulation, Brigham & Women’s Hospital, Boston, MA