APSF Stoelting Conference 2024
September 4 - September 5
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“Transforming Anesthetic Care: A Deep Dive into Medication Errors and Opioid Safety”
Scroll down to watch the individual presentations from the conference below.
Day 1: Introduction and Session 1: Organizations Committed to Reducing Medication Error
Day 1: Session 2: Factors Affecting Medication Errors
Day 1: Panel: APSF 40th Anniversary: A Conversation with the Pioneers
Day 1: Session 3: Medication Errors, the Patient, and the Healthcare Professional
Day 1: Session 4: Human Factors and Medication Errors
Day 1: Session 5: Opioid Safety and the Patient and Health Care Professional
Day 2: Session 6: Technology Innovation to Minimize Opioid Harm
Day 2: Finalizing Recommendations and Next Steps
Scroll down to watch the individual presentations from the conference below.
“Transforming Anesthetic Care: A Deep Dive into Medication Errors and Opioid Safety”
Click the names or photos below for more information.
Planning Committee:
September 4-5, 2024
Markell Conference Center, MGB
399 Revolution Dr,
Somerville, MA 02145
In-person registration is closed. For conference inquiries, please contact Stacey Maxwell, APSF Administrator ([email protected]).
Thank you for supporting the 2024 Stoelting Conference:
For information on how to support this conference, please contact Sara Moser, APSF Director of Development ([email protected]).
OBJECTIVES
1. Enhance Knowledge of Medication Error Prevention
Equip attendees with the latest strategies and best practices for reducing medication errors, including insights from global efforts and collaborations with organizations committed to patient safety.
2. Address Factors Contributing to Medication Errors
Analyze the cognitive, labeling, and systemic factors contributing to medication errors, and discuss actionable strategies to mitigate these errors
3. Promote Opioid Safety in Anesthetic Care
Examine the role of healthcare professionals in addressing the opioid crisis, exploring methods to prevent opioid-induced respiratory depression, manage unused opioids, and leverage technology to minimize opioid harm
4. Support Healthcare Professionals in Mitigating Medical Errors
Provide insights into the impact of clinician burnout, the need for peer support and legal perspectives on medication errors, including the criminalization of medical errors
5. Foster Innovation in Medication Safety Technologies
Identify the latest technological innovations in medication safety, such as barcoding, RFID, and augmented intelligence, and discuss adoption challenges and benefits in preventing drug diversion and managing opioid risks
PROGRAM
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*All times are EST
7:00 – 9:00 PM
Check-in and Pre-Conference Reception
Assembly AB and Prefunction
The Row Hotel at Assembly Row
6:00 – 7:15 AM
Full Buffet Breakfast and Networking
Assembly AB
The Row Hotel at Assembly Row
7:30 – 8:00 AM
Markell Conference Center, MGB,
399 Revolution Dr,
Somerville, MA
Introduction
Elizabeth Rebello, MD, FASA, FACHE, CPPS, CMQ
Professor of Anesthesiology and Perioperative Medicine
University of Texas MD Anderson Cancer Center
Elizabeth Rebello, MD, FASA, CPPS, is a practicing anesthesiologist and Professor of Anesthesiology and Perioperative Medicine at the University of Texas MD Anderson Cancer Center. A pharmacist by training, she has been involved in quality and patient safety efforts in the perioperative environment and Diversity, Equity, and Inclusion efforts for over fifteen years.
She serves as the Chair of the American Society of Anesthesiologists’ (ASA) Quality, Management and Departmental Administration Committee and led the Medication Safety Workgroup to standardize drug concentrations. She serves on the United States Pharmacopeia Expert Compounding Committee, US Food and Drug Administration Pharmacy Compounding Advisory Committee, and chairs the APSF Patient Safety Advisory Group on Medication Safety.
Remarks from APSF President Daniel J. Cole, MD
Daniel J. Cole, MD
Professor of Clinical Anesthesiology
Department of Anesthesiology and Perioperative Medicine at the David Geffen School of Medicine
University of California, Los Angeles
Daniel J. Cole, M.D. is the President of Anesthesia Patient Safety Foundation and serves on the Board of Directors. A neuroanesthesiologist by training he currently services as a Professor of Clinical Anesthesiology in the Department of Anesthesiology and Perioperative Medicine at the David Geffen School of Medicine, University of California, Los Angeles. He has published extensively, with more than 350 original manuscripts, chapters, abstracts, and editorials to his credit. He is also a distinguished lecturer with over 300 invited presentations on a broad range of topics in anesthesiology.
Cole is a past president of the American Society of Anesthesiologists. He is the Executive Director for Professional Affairs for the American Board of Anesthesiology, and the American Board of Medical Specialties. Most importantly he is a champion for patient safety throughout his many roles in organized medicine.
Session 1: Organizations Committed to Reducing Medication Error
8:00 – 9:15 AM
Introductions
Nat Sims, MD
Cardiac Anesthesiologist, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital
Associate Professor of Anesthesia, Harvard Medical School
Ronald S. Newbower, PhD and Eitan Family MGH Endowed Chair in Biomedical Technology Innovation
Nat Sims, MD, is a cardiac anesthesiologist who has devoted his career to developing advanced tools and systems that improve patient safety and care while also reducing cost. As an accomplished pilot, Sims found inspiration for improving medicine in the technologies of aviation safety. Working with interdisciplinary teams of biomedical engineers, nurses, and experts from multiple clinical specialties, he and his colleagues pioneered improvements in patient monitoring, patient transport and error-free intravenous drug delivery systems. His most significant invention includes the original concepts for “smart drug infusion pumps”, which were developed in 1992 at Massachusetts General Hospital in collaboration with engineers at a local subsidiary of Baxter Healthcare and implemented clinically in 1997. Sims has garnered recognition from various professional organizations, including the Association for the Advancement of Medical Instrumentation, for his work to improve medical devices and equipment. Sims is the winner of the 2017 Nathaniel Bowditch Prize. Awarded by the MGH Board of Trustees, the prize recognizes individuals or teams that have made significant contributions in improving patient care while reducing cost. Currently Sims holds the Ronald S. Newbower, PhD and Eitan Family MGH Endowed Chair in Biomedical Technology Innovation. Sims earned his bachelor’s degree from Harvard College and his medical degree from Columbia University College of Physicians and Surgeons. He completed his residency and fellowship training at Massachusetts General Hospital.
Collaborating Medication Error Prevention with the Food and Drug Administration (FDA)
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Sevan Kolejian, PharmD, MBA, BCPPS
Director
Division of Mitigation Assessment and Medication Error Surveillance (DMAMES)
Office of Medication Error Prevention and Risk Management (OMEPRM)
Office of Surveillance and Epidemiology (OSE)
Center for Drug Evaluation and Research
U.S. Food and Drug Administration (FDA)
Dr. Kolejian is Director of the Division of Mitigation Assessment and Medication Error Surveillance (DMAMES) within FDA’s Office of Medication Error Prevention and Risk Management (OMEPRM). In her capacity as the Division Director for DMAMES, she provides oversight, coordination, and technical expertise for post-marketing activities involving evaluation of the Risk Evaluation and Mitigation Strategies (REMS) and medication error prevention of regulated drug and drug/device products. She is widely recognized as an expert in medication error prevention, risk mitigation strategies, and program evaluation.
Dr. Kolejian received her undergraduate degree in Biochemistry & Molecular Biology from the University of Maryland Baltimore County, her Doctor of Pharmacy from Virginia Commonwealth University, and Master of Business Administration with concentration in leading organizations from Johns Hopkins University Carey School of Business. She completed an Executive Fellowship in Patient Safety, and has earned certificates in Aging Studies, Drug Development and Regulatory Sciences, Medication Safety, and Pharmacoepidemiology. Before joining FDA, Sevan was a full time clinical pediatric pharmacist and medication safety facilitator at Johns Hopkins Children’s Center in Baltimore, Maryland.
Strategies to Decrease Medication Errors: Insights from the ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings
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Rita Jew, Pharm.D., MBA, BCPPS, FASHP
President, Institute for Safe Medication Practices (ISMP)
Rita K. Jew, Pharm.D., MBA, BCPPS, FASHP is President at the Institute for Safe Medication Practices (ISMP) where she provides leadership in advocacy of ISMP’s mission and vision to stakeholders and develops and implements strategic goals. She also provides oversight and actively participates in consultation, education, publications, alerts and error reporting programs and oversees the development of new guidelines, programs, products and services. Prior to joining ISMP, Dr. Jew held various leadership positions including Director of Pharmacy at UCSF Health, Executive Director of Pharmacy & Clinical Nutrition Services at CHOC Children’s and Clinical Manager at Children’s Hospital of Philadelphia. Her 25 plus-year tenure in hospital pharmacies encompassed broad experiences in pharmacy leadership, clinical pharmacy services, formulary management, medication safety, pharmacy operations, centralized pharmacy services, pediatric pharmacy services, healthcare technology and automation, sterile & non-sterile compounding, finance and revenue-cycle, 340B program, CQI/lean, clean room and pharmacy construction, emergency preparedness and establishing pharmacy residency programs.
Dr. Jew presented and published extensively on clinical topics in pediatrics, extemporaneous compounding, vaccines, healthcare technology and automation as well as various topics on pharmacy operations and medication safety. She held adjunct faculty appointments at various Schools of Pharmacy and School of Nursing. She has received numerous awards and accolades from professional organizations.
Dr. Jew received her Pharm.D. from University of California at San Francisco, completed an ASHP-Accredited Residency in Clinical Pharmacy at Thomas Jefferson University Hospital and received her MBA from the Wharton School, University of Pennsylvania. She is a Board Certified Pediatric Pharmacy Specialist (BCPPS).
Inextricable: The Foundational Connection Between IHI’s Safety Initiatives and Medication Safety
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Patricia McGaffigan, MS, RN, CPPS
President, Certification Board for Professionals in Patient Safety
Senior Advisor Safety, Institute for Healthcare Improvement
Patricia is President, Certification Board for Professionals in Patient Safety, and Senior Advisor, Patient and Workforce at the Institute for Healthcare Improvement where she is senior sponsor of the IHI’s Lucian Leape Institute, co-chair of the National Steering Committee for Patient Safety, and key liaison to IHI’s strategic relationships and initiatives for the nursing profession. She is the former COO and SVP of Safety at the National Patient Safety Foundation, graduate of the AHA-NPSF Patient Safety Leadership Fellowship Program and IHI Fellow, and nationally recognized speaker. Patricia serves on numerous national committees, taskforces, and technical expert panels, including the AHRQ Survey of Patient Safety Culture Technical Expert Panel and the Joint Commission’s Journal on Quality and Patient Safety Editorial Advisory Board and Sentinel Event Alert Advisory Committee. Patricia serves on the boards of the Massachusetts Coalition for the Prevention of Medical Errors, the Foundation to Advance Nursing in Massachusetts, and the I-PASS Institute, and is a member of Planetree’s Person-Centered Certification Committee. She is the recipient of the American Association of Critical Care Nurses Lifetime Member Award, the 2023 University of North Texas Health Science Center’s Mary E. Luibel Distinguished Service Award and was named to the 2024 and 2023 Becker’s Review List of Patient Safety Experts to Know. Patricia received her BS in Nursing from Boston College and her MS in Nursing from Boston University.
Global Efforts in Medication Error Reduction from the WFSA and WHO
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Adrian Gelb, MBChB, FRCPC, FRCA
Distinguished Professor (Emeritus),
Department of Anesthesiology & Perioperative Care,
University of California, San Francisco (UCSF)
Adrian W Gelb is Distinguished Professor (Emeritus), Department of Anesthesiology & Perioperative Care, University of California, San Francisco (UCSF). He served as Professor & Chair of Anesthesia at Western University, Canada, before coming to UCSF as Vice Chair (2004 -2011). Dr Gelb has served as President of 4 international organizations and other leadership roles in multiple national and international Anaesthesia Societies. He is the Past President of the World Federation of Societies of Anaesthesiologists (WFSA) and a patient safety leader. WFSA is an umbrella organization for 140 national anesthesia societies.
Working with WHO and other global groups, he is a strong advocate for expansion of access to SAFE anesthesia. He is an active academic with > 300 publications (h-Index 65, citations >16,000) with a focus on the neurosciences and has served on many international editorial boards. He is an accomplished communicator and has given over 400 invited lectures around the world, including 17 named lectureships. He has won awards for research, teaching and mentorship.
8:55 – 9:10 AM
Q&A Speakers
9:10 – 9:30 AM
Mid-Morning Break
Session 2: Factors Affecting Medication Errors
9:30 – 10:45 AM
Introductions
Tricia Meyer, PharmD, MS, FASHP, FTSHP
Adjunct Professor of Anesthesiology
Texas A&M College of Medicine
Meyer was awarded the American Society of Health System Pharmacists Best Practices and Distinguished Service award. She was also awarded by her state society the Pharmacy Leadership, Pharmacy Collaborative and the Lewis Smith Pharmacy Practitioner award. She is a co-author for the ASHP Guidelines on Surgery and Anesthesiology Pharmaceutical Services and the joint paper from Society of Critical Care Medicine, American College of Clinical Pharmacy & ASHP on the role of the Critical Care Pharmacist. She has also contributed to the Standardize for Safety Initiative from a FDA grant to ASHP on standardized concentrations. She worked with the Institute for Safe Medication Practices on the Safe Medication Use in Perioperative and Procedural Area Guidelines. She received the Abbott National Quality Award for 3 years and the Organon Leadership Award in Hospital Pharmacy. Meyer is recognized as an ASHP Fellow.
Meyer’s clinical interest is in the field of anesthesiology where she has published and conducted numerous research studies. She was appointed as the first pharmacist to the Anesthesia Patient Safety Foundation and currently serves on the Education and Training Committee and Editorial Board. She regularly contributes to the Anesthesia Patient Safety Foundation Newsletter on perioperative medication safety. She is involved with Consensus Panel on the Guidelines for Management of Postoperative Nausea and Vomiting. The guidelines are being updated and the 5th revision of the guidelines will be published in later 2024. Meyer was recommended by ASHP and appointed by CMS to a Technical Expert Panelist on Ambulatory Surgery metrics.
The Cognitive Basis for Human Error and the Best Practices to Reduce Error
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Joyce Wahr, MD, FAHA
Professor Emeritus, Department of Anesthesiology
University of Minnesota
Dr. Joyce A. Wahr is a Professor Emeritus of Anesthesiology at the University of Minnesota. She began her medical training at the University of Colorado, graduating in 1978. She then did two years of surgery internship at the University of Michigan, then completed a residency in Anesthesiology at University of California at San Francisco, where she was privileged to work with John Severinghaus, Ron Miller, and Mike Roizen. After two years in private practice in California, she returned to Michigan and joined the faculty at the University of Michigan in 1984.
Dr. Wahr was one of the first at the University of Michigan to specialize in cardiac anesthesiology, and, with her like-minded colleagues, to develop a specialized cardiac anesthesia team. She worked closely with Dr. Orringer, Chair of Thoracic Surgery, to develop a cardiothoracic intensive care team model that included surgeons, anesthesiologists, and anesthesia and surgery residents. She served as the first Director of Cardiac Anesthesiology, moving on to direct a busy Cardiac Research team from 1990-2003. During those years, the University of Michigan Division of Cardiothoracic Anesthesiology was a founding member of the Multi-Center Study of Myocardial Ischemia (McSPI), a consortium of 25 academic cardiac anesthesiology teams that enrolled over 7,000 cardiac surgery patients in a detailed outcome database.
Her primary focus is patient safety and quality. From 2007 until 2014, she served as the Chair of the Society of Cardiovascular Anesthesiologists Foundation, an organization responsible for the FOCUS Patient Safety initiative, bringing together operative nursing, perfusionists, surgeons, and anesthesiologists to tackle the issues of human error in the cardiac OR. As part of this interest, she has a deeper interest in medication safety in anesthesia and the perioperative period, having authored several papers on this subject, and co-authored Medication Safety in Anesthesia and the Perioperative Period with Alan Merry. She served as Vice-Chair for Quality and Safety in the Department of Anesthesiology at the University of Minnesota from 2018-2024.
An Anesthesiologist’s Perspective on Labeling: The ASA Statement, USP Involvement and ASTM Standard
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Rick Botney, MD
Upon finishing his residency, Dr. Botney completed a fellowship in Human Performance and Patient Safety with David Gaba, focusing on simulation, and human factors and equipment design. He landed at Oregon Health and Science University (OHSU) and spearheaded the establishment of a simulation program. In addition, he was the first chair of OHSU’s Patient Safety Committee. He was also a member of OHSU’s Medication Safety Committee, the Oregon Medical Association’s Patient Safety Committee, and a Technical Advisory Committee for the Oregon Patient Safety Commission, whose focus was preventing harm from oversedation in hospitalized patients. He has published on a wide variety of safety-related topics, including the human factors of medical device design, simulation, fire, electrical, and laser safety, infusion pump safety, and failure of the oxygen supply. He is a co-author of the text Patient Safety in Plastic Surgery.
Dr. Botney is a longstanding contributing member of the Association for the Advancement of Medical Instrumentation’s (AAMI) Human Engineering Committee and, more recently, the Health Information Technology and Infusion Devices Committees. Since 2017, he has been a member of the ASA Committee on Equipment and Facilities, and is currently a member of United States Pharmacopeia’s Nomenclature and Labeling Expert Committee and its Labeling Subcommittee. He revised the ASA Statement on Labeling of Pharmaceuticals For Use in Anesthesiology, which was approved in 2020. Dr. Botney is also APSF’s representative to ASTM, in order to reinstate several standards related to medication labeling, beginning with a revision of the D4774 Standard Specification for User Applied Drug Labels in Anesthesiology. Although Dr. Botney retired from clinical practice in 2021, he continues to be actively involved in issues important to anesthesiology.
Perspective on the Challenges of Labeling from Industry
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Angie Lindsey
Vice President, Marketing
Pharmaceuticals
Fresenius Kabi USA
Angie Lindsey is a vice president of marketing for Fresenius Kabi in the United States. In this role Angie leads all aspects of the company’s marketing strategy and functions for the anesthesia and analgesia vial business, prefilled syringes and +RFID smart-labeled portfolios.
Fresenius Kabi is a global health care company that specializes in lifesaving medicines and technologies for infusion, transfusion and clinical nutrition. The company’s products are used to help care for critically and chronically ill patients.
Angie has more than 25 years of experience in sales and marketing roles of increasing responsibility and leadership within the pharmaceutical industry. She joined Fresenius Kabi in 2012 after serving in various positions at Takeda Pharmaceuticals and AstraZeneca.
Industry Response to Mitigating Potential Medication Errors in Simulation
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Michael Greenberg, MD
VP, Medical Affairs
Eagle Pharmaceuitcals
Mike Greenberg, MD, an emergency physician by training, is the Vice President of Medical Affairs at Eagle Pharmaceuticals where he is responsible for data generation, scientific and clinical information exchange and drug safety across Eagle’s acute care/hopsital and hematology/oncology portfolios.
In addition to his experience as an emergency physician and medical affairs professional, Dr. Greenberg has also worked with the Federal Agency for Healthcare Research and Quality (AHRQ) to raise awareness of comparative effectiveness research, and as acted as a consultant to teams focusing on Risk Evaluation and Mitigation Strategies (REMS) and Drug Safety Communications at the FDA Center for Drug Evaluation and Research (CDER).
Mike earned his medical degree at the State University of New York Upstate Medical University and completed a residency in Emergency Medicine at the University of Massachusetts.
Strategies to Mitigate Medication Errors with the Unprecedented Rise in Drug Shortages
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Erin Fox, PharmD., MHA, BCPS, FASHP
Associate Chief Pharmacy Officer of Shared Services
University of Utah Health
Erin R. Fox, Pharm.D., MHA, BCPS, FASHP is Associate Chief Pharmacy Officer of Shared Services at University of Utah Health and is responsible for drug information and drug policy, pharmacy informatics, purchasing, billing, 340B, and antimicrobial stewardship. She also serves as Professor (adjunct) in the Department of Pharmacotherapy at the University of Utah College of Pharmacy. She and her team have provided drug shortage information for the ASHP Drug Shortage Resource Center since 2001. Erin serves as a media resource and advocate for changes to improve the ongoing drug shortage situation. She has published over 40 peer-reviewed articles related to drug shortages, including the ASHP guidelines on managing drug shortages. Erin is recognized as an expert in drug shortages and has received the ISMP Cheers Award and the ASHP Award of Excellence for efforts related to drug shortages. She served as a member of the National Academies of Sciences, Engineering, and Medicine Committee on Security of America’s Medical Product Supply Chain. Erin testified for the Senate Homeland Security and Government Affairs Committee hearing on drug shortages in March, 2023.
10:35 – 10:50 AM
Q&A Speakers
11:00 AM – 12:00 PM
Panel: APSF 40th Anniversary: A Conversation with the Pioneers
Moderator
Mark Warner, MD
Professor of Anesthesiology
Mayo Clinic, Rochester, Minnesota
Mark Warner, MD is a professor in anesthesiology at the Mayo Clinic. In his institution, he has served as chair of the Department of Anesthesiology, the physician leader of its hospitals, executive dean of its College of Medicine and Science, and a member of its Board of Governors.
Warner has served in the leadership of several national anesthesiology organizations. He has been president of the American Society of Anesthesiologists, the American Board of Anesthesiology, the Academy of Anesthesiology, and the Anesthesia Patient Safety Foundation.
Speakers
Jeff Cooper, PhD
Professor of Anaesthesia at Harvard Medical School and Massachusetts General Hospital
Jeffrey B. Cooper, Ph.D. is Professor of Anaesthesia at Harvard Medical School and Massachusetts General Hospital. He is the founder, Executive Director Emeritus and Senior Fellow of the Center for Medical Simulation, which is dedicated to the use of simulation in healthcare to improve the process of education and training and to avoid risk to patients.
Dr. Cooper is one of the pioneers in what is now called patient safety. He did landmark research in medical errors in the 1970’s and is a co-founder of the Anesthesia Patient Safety Foundation (APSF). He was for many years Director of Biomedical Engineering at Massachusetts General Hospital and then Partners Healthcare System.
Among his numerous honors are the John M. Eisenberg Award for Lifetime Achievement in Patient Safety from the National Quality Forum and the Joint Commission and the Distinguished Service Award of the American Society of Anesthesiologists, the only non-MD to receive the honor.
John Eichhorn, MD
Professor of Anesthesiology (Retired) and Provost’s Distinguished Service Professor, University of Kentucky, Lexington, KY
John H. Eichhorn, MD, is a retired professor of anesthesiology who was part of the original leadership and remains active in the APSF, where he served as the founding publisher and Editor of the APSF Newsletter from its inception in 1985 until 2002, and continuing on the Editorial Board today. Dr. Eichhorn, as one of the earliest leaders of the anesthesia patient safety movement, also chaired the committee that created the original “Harvard Monitoring Standards,” which led to standards from ASA, many other national societies, and the WFSA. The resulting 1986 JAMA article was recognized in 2015 as #10 of “The 20 most important anesthesia articles ever published.” Dr. Eichhorn introduced the concept and term “safety monitoring” in a landmark 1989 Anesthesiology paper that showed significantly improved intraoperative patient safety from enhanced continuous monitoring, particularly incorporating the then-new technologies of capnography and pulse oximetry. He sat on the ASA Committee on Standards of Care for the first 20 years after its creation in 1985, chairing it for five of those years in the 1990’s. He co-chaired the group that inspired the original 1992 WFSA “International Standards for a Safe Practice of Anaesthesia.” Later, Dr. Eichhorn served the World Health Organization on the Safe Anaesthesia Working Group helping to develop the WHO Surgical Safety Checklist and also update the WFSA standards. Recipient of numerous awards, honors, and named lectureships, he is also a Patient Safety Leadership Fellow of the Health Forum-American Hospital Association. From the Joint Commission/National Quality Forum consortium in 2010, he received the highest honor there is for patient safety efforts: the Eisenberg Patient Safety and Quality Award for Individual Achievement. In 2023, Dr. Eichhorn was honored to deliver the APSF E.C. Pierce, MD, Memorial Lecture at the annual meeting; his topic was “Integrating Behavior and Technology for Anesthesia Patient Safety.” Now retired to Silicon Valley in California, he continues to promote anesthesia patient safety at every possible opportunity.
12:00 – 1:00 PM
Lunch
Session 3: Medication Errors, the Patient, and the Healthcare Professional
1:00 – 2:45 PM
Introductions
Josh Lea, DNP, MBA, CRNA
Certified Registered Nurse Anesthetist
South Shore Hospital
Assistant Editor
APSF Newsletter
Josh Lea, DNP, MBA, CRNA is a Certified Registered Nurse Anesthetist at South Shore Hospital and Assistant Editor of the APSF Newsletter.
Josh attended Georgetown University for his nurse anesthesia degree. His areas of interest focus on patient safety, clinician well-being and ultrasound imaging. Josh has published and presented on these topics nationally and internationally and is a member of the APSF Board of Directors, and has served on NEU DEI Committee, MGH Wellness Committee and as Chair of the APSF Advisory Group on Culture of Safety. Connect with him on Facebook and LinkedIn. Josh lives in Boston, MA with his husband and enjoys staying active and exploring New England.
Preventable Medical Harm from the Patient Perspective
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Yvonne Gardner
Yvonne experienced an unimaginable loss in 2016 when her 21-year-old son, Parker, tragically passed away due to respiratory depression following a routine tonsillectomy. After this devastating event, Yvonne discovered that many others had also succumbed to similar circumstances after taking prescribed opioid medications. Determined to make a difference, she collaborated with the Utah State Legislature to pass a concurrent resolution aimed at educating the medical community about the often-overlooked dangers of opioid-induced respiratory depression. (https://le.utah.gov/~2018/bills/static/SCR004.html)
Cherishing the memories she shared with her son, Yvonne finds her greatest blessings in her husband, eight children, and eight grandchildren. She believes that navigating the challenges of life, including the profound grief of losing a loved one, requires finding the blessings amidst the trials. Quoting William Shakespeare, she often reflects how, “Tears water our growth.”
Through sharing her personal story and the stories of others in her community, Yvonne hopes to raise awareness and ultimately put an end to the preventable deaths caused by opioid-induced respiratory depression.
Recovery and the Recovery Room: Second Victim Syndrome and the Need for Peer Support
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Toni Zito, MSN, RN, CPAN, CAPA FASPAN
Certified Perianesthesia Nurse
Cleveland Clinic Hillcrest Hospital
Antoinette “Toni” Zito is a registered nurse with over 30 years of perianesthesia nursing experience. She is a certified perianesthesia nurse and is currently practicing in the perioperative unit at Cleveland Clinic Hillcrest Hospital where she cares for both pediatric and adult patients throughout all phases of care. Her MSN focused on Nursing Education, and she most recently served as a perioperative education program coordinator for surgical services, creating and providing education for nurses in the perioperative setting. She continues as a Nursing Professional Development Specialist for special projects. Toni is a national speaker, author and researcher with a focus on safety in the perianesthesia environment. A member of the American Society of Perianesthesia Nurses, she currently serves on the Board as the Director for Education and the liaison to the APSF. She is recognized as a Fellow in the American Society for Perianesthesia Nurses for her contributions to perianesthesia nursing. She ended her appointment as nursing clinical faculty this year, to focus on travel and spending time with her growing family.
Clinician Burnout, Medication Errors, and the ASA Survey
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Amy Vinson, MD
Pediatrician and Pediatric Anesthesiologist
Boston Children’s Hospital
Assistant Professor of Anesthesia
Harvard Medical School
Amy Vinson is a Pediatrician and Pediatric Anesthesiologist at Boston Children’s Hospital and an Assistant Professor of Anesthesia at Harvard Medical School. She attended college and medical school in Georgia before coming to New England where she completed a residency in pediatrics at Brown, an anesthesiology residency at BIDMC and Pediatric Anesthesiology fellowship at Boston Children’s Hospital. She has a long-standing interest in well-being, burnout, peer support, and substance use disorder in anesthesiologists and has lectured widely on these subjects. She currently serves as the Chair of the ASA’s Committee on Physician Well-being, is the ASA representative to the National Academy of Medicine’s Action Collaborative on Clinician Well-being and Resilience and is the Chief Wellness Officer for own department. Her research on Burnout in Anesthesiologists has twice been published in the journal Anesthesiology and she has numerous other publications and research manuscripts on subjects related to overall physician well-being. She is a self-described “well-being pragmatist” focusing on systemic and organizational factors impacting well-being and burnout. On her off time, she enjoys time with family, fitness, playing music and home improvement.
Medication Safety from a Trainee Perspective
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Amanda Milburn, DO
PGY-3 Anesthesiology Resident
St. Joseph’s University Medical Center
Amanda Milburn, DO is a current PGY-3 anesthesiology resident at St. Joseph’s University Medical Center in Paterson, New Jersey. She completed her medical training at New York Institute of Technology College of Osteopathic Medicine and completed her Transitional Year residency at Northwell Plainview Hospital on Long Island where she served as her intern Class Representative. Amanda is passionate about patient safety, patient advocacy and quality improvement. Her current QI project is Omnicell medication optimization throughout her training hospital’s anesthetizing locations. She has collaborated with the Pharmacy department to assess inventory and determine ways to improve patient safety, increase operational efficiency, decrease preventable waste and limit expenditures. Outside of the hospital, Amanda enjoys fitness, spending time with her family, going to the beach & trying new restaurants.
Medication Errors and Liability
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Paul Lefebvre, JD
Lead Claims Professional & Risk Advisor
Preferred Physicians Medical
Paul is a Lead Claims Professional & Risk Advisor with Preferred Physicians Medical, the nation’s only anesthesia-specific professional liability insurance company. Paul manages moderate and high severity litigation files for anesthesiologists, certified registered nurse anesthetists, certified anesthesiologist assistants, and anesthesia practices located in more than two dozen states. In his role within PPM’s risk management program, Paul conducts live seminars, serves as a patient safety resource for anesthesia professionals across the country, and contributes to PPM’s risk management newsletter, Anesthesia & the Law. He is a member of the Anesthesia Patient Safety Foundation’s Editorial Board, Medication Safety Patient Safety Priority Advisory Group, and Corporate Advisory Council.
Paul is a 2010 graduate of Saint Louis University Law School, where he attained certificates in health law and clinical health care ethics. Prior to joining PPM, Paul served as General Counsel for the Missouri State Board of Registration for the Healing Arts.
Criminalization of Medical Errors and the APSF Response
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Steve Greenberg, MD, FCCP, FCCM
Clinical Professor
Department of Anesthesiology/Critical Care
University of Chicago
Steven Greenberg has been practicing Anesthesiology and Critical Care Medicine at Endeavor Health in Evanston, Illinois, since 2006. He graduated from the University of Wisconsin-Madison Medical School and continued his medical training at Northwestern University Feinberg School of Medicine in the field of Anesthesiology. There, he served as Chief Resident of Anesthesiology and was inducted into the Alpha Omega Alpha Chapter for clinical excellence. After his residency, Dr. Greenberg completed his training at Massachusetts General Hospital in Boston, MA, as a critical care fellow. He currently serves as Clinical Professor in the Department of Anesthesia and Critical Care at the University of Chicago Pritzker School of Medicine since 2018. In addition, Dr. Greenberg has been appointed to be the Jeffery S. Vender Endowed Anesthesiology Chair of Research and Education, where he has focused his efforts on reshaping the Anesthesiology Research Program at Endeavor and is enhancing perioperative safety research. He also was the longest serving ICU Medical Director of Evanston Hospital for the last decade and a half. Dr. Greenberg created and developed the Endeavor Health Extracorporeal Membrane Oxygenation (ECMO) Program and served as ECMO Medical Director for 6 years. The ECMO program outcomes are well above the national and international averages.
Dr. Greenberg has given over 100 lectures nationally and internationally, served on 4 editorial boards for anesthesia and medical journals and published several articles and has contributed to a variety of book chapters in Anesthesiology and Critical Care Medicine texts. He has served on a variety of notable national committees including the Program Committee for the Society of Critical Care Medicine (SCCM), the Adult Concepts of Critical Care Committee for the SCCM (served as chair of the Adult Concepts course in 2014-2015), the Critical Care Steering Committee for the American College of Chest Physicians and was a member of the American Society of Anesthesiologists Committee on Critical Care Medicine. He was the Co-Chair of the 2019 SCCM Annual Congress in San Diego, CA. With his interest in safety, he has also served on both the editorial and executive boards of the Anesthesia Patient Safety Foundation (APSF) and was appointed by the President to the position of Editor-in-Chief for the APSF Newsletter in 2017. This publication is distributed to 700,000 out of the 850,000 anesthesia professionals worldwide and it remains the most widely read safety publication globally. In addition, he was appointed to Associate Editor, Patient Safety Section, of Anesthesia & Analgesia. In 2020, he was elected by the APSF Board of Directors to be the Secretary of the organization (one of four officer positions) due to his work in extending patient safety education to 234 countries worldwide. In 2023, he continued his focus on spreading anesthesia patient safety education worldwide as he helped to create and co-chair the first ever Anesthesia Patient Safety Symposium (APSS), a Malaysian Virtual Safety Conference that was attended by over 1000 participants from 48 different countries. In 2024, Dr. Greenberg created and co-chaired the first ever International Conference on Anesthesia Patient Safety (ICAPS) held in Tokyo, Japan, and in collaboration with the ASA, JSA, and JFA. In 2024, he was elected as Vice President of the APSF. With his focus on safety, he has provided lectures for multiple national and international organizations on handoff communication, goal directed therapy, neuromuscular blockade, perioperative safety priorities, clinical deterioration, and developing practical point of care protocols for massive transfusion/hemorrhage.
2:30 – 2:45 PM
Q & A Speakers
2:45 – 3:00 PM
Mid-Afternoon Break
Session 4: Human Factors and Medication Errors
3:00 – 4:15 PM
Introductions
Emily Methangkool, MD, MPH
Chair of the Olive View-UCLA Department of Anesthesiology
Associate Professor of Clinical Anesthesiology
David Geffen School of Medicine
University of California, Los Angeles
Emily Methangkool, MD, MPH serves as the Chair of the Olive View-UCLA Department of Anesthesiology and is an Associate Professor of Clinical Anesthesiology at the David Geffen School of Medicine at the University of California, Los Angeles. Emily is passionate about patient safety, quality improvement, cardiac anesthesia, and gender equity in medicine, and has written about and spoken on these topics at the national level. She has been published in the New England Journal of Medicine, JAMA, Anesthesia and Analgesia, and the British Journal of Anaesthesiology. She is the current Vice Chair of the American Society of Anesthesiologists Committee on Patient Safety and Education, Chair-Elect of the Women in Cardiothoracic Anesthesia Special Interest Group of the Society of Cardiovascular Anesthesiologists, Director of the APSF Social Media Ambassador program, and a member of the APSF Board of Directors.
Feedback and Constraint Mechanisms
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Eliot Grigg, MD
Associate Professor of Anesthesiology and Pain Medicine
University of Washington
Anesthesiologist
Seattle Children’s Hospital
Dr. Grigg is an Associate Professor of Anesthesiology and Pain Medicine at the University of Washington and an attending anesthesiologist at Seattle Children’s Hospital. He is board certified in pediatric anesthesiology with a clinical focus in anesthesia for spine surgery and pediatric pain medicine. He is the Director of Sedation at Seattle Children’s Hospital where he created the sedation service and oversees sedation and anesthesia outside of the operating room.
His early research career included work in battlefield medicine, electronic health information systems, telemedicine and biological disaster preparedness. More recently, he speaks and publishes nationally about quality improvement, human factors and medication safety. He has served on multiple medication safety groups with the American Society of Anesthesiologists, the Society of Pediatric Anesthesia and the Institute for Safe Medication Practices. Other interests include workspace design, and he has helped design and implement several new operating rooms and procedural spaces at Seattle Children’s Hospital.
Technology Updates: Barcoding and RFID – Adoption and Challenges
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Monica Harbell, MD
Associate Professor of Anesthesiology
Mayo Clinic, Phoenix, Arizona
Monica W. Harbell, MD, FASA, is an Associate Professor of Anesthesiology at Mayo Clinic in Phoenix, Arizona. Dr. Harbell graduated from New York University School of Medicine and completed Anesthesiology residency and Regional Anesthesia Fellowship at University of California, San Francisco. Since 2017, she has been faculty at the Mayo Clinic Arizona Department of Anesthesiology and Perioperative Medicine, where she serves as the Associate Chair of Education, Anesthesiology Residency Program Director, and Vice Chair of the Mayo Clinic Arizona Patient Safety Subcommittee. Dr. Harbell is the Chair of the ASA Committee on Patient Safety and Education and is a Member of the ASA Committee on Practice Parameters. She is passionate about patient safety, medical education, regional anesthesia, gender equity in medicine and has published over 40 peer-reviewed publications on these topics.
Decision Support Software and Mitigating Medication Errors
Karen Nanji, MD, MPH
Associate Professor of Anesthesia
Massachusetts General Hospital
Dr. Nanji is an Associate Professor of Anaesthesia at Harvard Medical School and an anesthesiologist in the Department of Anesthesia, Critical Care and Pain Medicine at Massachusetts General Hospital. Her research activities focus on patient safety and the innovative use of technology to prevent medication errors. Most recently, she led the development of a real-time medication safety software platform for the OR, called GuidedOR, that provides point-of-care medication safety checks and is being disseminated by Guided Clinical Solutions to hospitals across the US. Dr. Nanji has published extensively on patient safety, medication use and clinical informatics.
Previously, Dr. Nanji was a consultant at McKinsey & Company, where she served digital health clients. Dr. Nanji chairs the Perioperative Medication Safety Task Force of the World Federation of Societies of Anesthesiologists. She also serves on the steering committee for the Anesthesia Quality Institute’s national Anesthesia Incident Reporting System (AIRS), and she led a Massachusetts state expert panel to investigate a series of adverse events that occurred during surgery. Dr. Nanji serves on the Board of Trustees at Boston Children’s Hospital and is a co-founder of the Food Allergy Science Initiative at the Broad Institute of MIT and Harvard. Dr. Nanji earned a Bachelor of Applied Science in Industrial Engineering and an M.D. from the University of Toronto, as well as a Master of Public Health degree from the Harvard School of Public Health.
Human factors considerations in medication safety: What is the evidence?
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Matthew Weinger, MD, MS
As an academic anesthesiologist and human factors engineer (HFE), Dr. Weinger has been teaching and conducting research in patient safety, HFE, human centered design (HCD), medical device development and innovation, and decision making for more than 30 years. He has published more than 200 papers and been on more than 70 grants & contracts (including 15 federal projects as PI). He has given more than 250 invited presentations and received recognition for his mentoring and teaching as well as several awards for contributions to HFE and patient safety. He is a Fellow of the American Association for the Advancement of Science (AAAS) and of the Human Factors and Ergonomics Society (HFES)
Dr. Weinger designed, evaluated, implemented, and promulgated best practices and technologies to improve care quality and safety. He has been a long-time proponent of systems-based approaches to improve perioperative medication safety including advocating for continuous monitoring of patients receiving parenteral opioids, standardized drug labeling, and advanced drug displays. He was an early adopter of medical simulation and continues to be a leading researcher in simulation-based training and assessment. In his efforts to apply HFE theory and methods to health care, he sought out and disseminated cross-disciplinary learning from other industries to improve understanding, research methods, and clinical tools & processes. He has developed meaningful measures of healthcare system safety and clinician performance. For example, in the early 1990s, he and his colleagues used behavioral task analysis and workload measures to evaluate clinician workflow, workload and performance during medication administration. He introduced to healthcare the concept of the non-routine event (NRE), defined as any event that deviates from optimal or expected care for a specific patient in a specific clinical situation. His team has captured thousands of NREs across many clinical domains including many that involve medication errors. He has used HFE and human-centered design (HCD) methods to improve healthcare processes including for medication administration and decision support. He was actively involved in the design and development of the user interface of two FDA-approved parenteral infusion pumps including one that is currently on the market.
Dr. Weinger served as the Secretary and a member of the Executive Committee of the APSF from 2005 to 2020. He has also held leadership roles in the Society for Technology in Anesthesiology (STA), the Anesthesia Quality Institute (AQI), and the Association for the Advancement of Medical Instrumentation (AAMI). He served on the Board on Human Systems Integration (BOHSI) of the National Academy of Sciences, Engineering, and Medicine (NASEM). He was a founding member of the editorial board of Simulation in Healthcare and of the American Society of Anesthesiologists (ASA) Simulation Education Editorial Board.
4:00 – 4:15 PM
Q & A Speakers
Session 5: Opioid Safety and the Patient and Health Care Professional
4:15 – 5:15 PM
Introductions
Ken Johnson, MD
Professor and Vice Chair of Research
Department of Anesthesiology
University of Utah
Ken B Johnson, MD is a professor and vice chair of research in the department of Anesthesiology at the University of Utah. His clinical research interests include opioid pharmacogenomics, neuromuscular blockade monitoring, and medical device development. His education interests include sedation training for non-anesthesiologist sedation practitioners and high fidelity simulation training for maintenance of certification in anesthesia. He is an executive section editor of clinical pharmacology for Anesthesia and Analgesia, a committee member of the American Board of Anesthesiology’s Observed Structured Clinical Exam development team, and a member of the American Society of Anesthesiology’s Simulation Education Editorial Board. Prior work supported by APSF include (i) development of resident training techniques using approaches that reduce time to diagnosis and treatment of for management of adverse airway and respiratory events and (ii) development of a device that uses selected respiratory monitor to detect ventilatory compromise and prompt and stimulate patients to breath.
Role of the Anesthesiologist in the Opioid Crisis
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Chad Brummett, MD
Senior Associate Chair for Research
Bert N. La Du Professor of Anesthesiology
Professor, Anesthesiology
Dr. Brummett is a Professor at the University of Michigan where he serves as the Senior Associate Chair for Research. He has more than 300 publications, including articles in top journals such as JAMA, JAMA Surgery, Anesthesiology, and Annals of Surgery. He serves as a Co-Director of the cross-campus Opioid Research Institute at the University of Michigan. He is also the Co-Director of the Opioid Prescribing Engagement Network (OPEN) at the University of Michigan, which aims to apply a preventative approach to the opioid epidemic in the US through appropriate prescribing after surgery, dentistry and emergency medicine. In addition, his research interests include predictors of acute and chronic post-surgical pain and failure to derive benefit for interventions for interventions and surgeries primarily performed to treat pain. In particular, Dr. Brummett is interested in nociplastic or centralized pain and the association of this phenotype with post-surgical pain outcomes. He has served as the Co-PI of multiple NIH grants (R, P, and U) studying these concepts, and also receives funding from the Michigan Department of Health and Human Services, SAMHSA, CDC, and multiple foundations.
Opioid Induced Respiratory Depression in the Post Operative Period
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Toby Weingarten, MD
Professor of Anesthesiology
Mayo Clinic, Rochester, Minnesota
Toby Weingarten, MD, is a professor of anesthesiology on the faculty at Mayo Clinic for 19 years. He has focused his academic career on postoperative outcomes having published more than 250 peer reviewed articles. His interests include postoperative nausea and vomiting, urinary retention, and most importantly opioid induced respiratory depression. His work helped identified an association between perioperative gabapentinoids and critical postoperative respiratory depression events and has helped further our understanding of the phenotypic presentation of postoperative respiratory depression. He has served on the board of directors of the Society of Anesthesia and Sleep Medicine and as the Executive Section Editor of Sleep Medicine on Anesthesia & Analgesia.
Association of Intraoperative Opioid Administration With Postoperative Pain and Opioid Use
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Patrick Purdon, PhD
Professor of Anesthesiology, Perioperative and Pain Medicine
Professor of Bioengineering (by Courtesy)
Stanford University School of Medicine
Patrick L. Purdon, Ph.D., is a Professor of Anesthesiology, Perioperative and Pain Medicine and Professor of Bioengineering (by Courtesy) at Stanford University School of Medicine. Dr. Purdon received his A.B. in Engineering Sciences from Harvard College in 1996, his M.S. in Electrical Engineering from MIT in 1998, and his Ph.D. in Biomedical Engineering from MIT in 2005. Dr. Purdon’s research focuses on the mechanisms of anesthesia, methods to solve the bioelectromagnetic inverse problem, and novel technologies for brain monitoring. He has published over 130 peer-reviewed publications, is an inventor on 19 pending patents and is a Fellow of the American Institute for Medical and Biological Engineering. Dr. Purdon has won numerous awards, including the prestigious National Institutes of Health Director’s New Innovator Award.
Intraoperative Opioid Waste: Patient Safety Implications
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Krish Ramachandran, MD, MBA
Dr. Satya Krishna “Krish” Ramachandran is an internationally recognized leader in healthcare quality and patient safety. After his early years in India, he developed his medical and leadership career at the Oxford Radcliffe hospitals, the University of Michigan, and Brandeis University and at Harvard. Krish is a busy clinician, educator and a widely cited researcher. He is an Assoc. Professor at Harvard Medical School, practices anesthesiology, runs a highly successful quality and safety fellowship program in collaboration with the Royal College of Anaesthetists and HMS, and drives healthcare change through his leadership roles in Boston including an appointment as Associate Medical Director of Anesthesia at CRICO. Throughout his career, he has brought together diverse teams across disciplines, organizations, and continents. He is the Founding-Director of the “International Institute for Health Innovation”.
5:00 – 5:15 PM
Q & A Speakers
5:15 PM
Day 1 Closing Remarks/Adjourn
6:00 – 9:00 PM
Mid-Conference Reception
6:00 – 7:15 AM
Full Buffet Breakfast and Networking
Assembly AB
The Row Hotel at Assembly Row
Session 6: Technology Innovation to Minimize Opioid Harm
7:30 – 8:45 AM
Introductions
Ken Johnson, MD
Professor and Vice Chair of Research
Department of Anesthesiology
University of Utah
Ken B Johnson, MD is a professor and vice chair of research in the department of Anesthesiology at the University of Utah. His clinical research interests include opioid pharmacogenomics, neuromuscular blockade monitoring, and medical device development. His education interests include sedation training for non-anesthesiologist sedation practitioners and high fidelity simulation training for maintenance of certification in anesthesia. He is an executive section editor of clinical pharmacology for Anesthesia and Analgesia, a committee member of the American Board of Anesthesiology’s Observed Structured Clinical Exam development team, and a member of the American Society of Anesthesiology’s Simulation Education Editorial Board. Prior work supported by APSF include (i) development of resident training techniques using approaches that reduce time to diagnosis and treatment of for management of adverse airway and respiratory events and (ii) development of a device that uses selected respiratory monitor to detect ventilatory compromise and prompt and stimulate patients to breath.
Innovation in Detecting Opioid Induced Ventilatory Depression
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Gee Mathen
Director, Pharmacy Clinical Applications and Technical Services
Texas Children’s Hospital
Houston, Texas, USA
Gee Mathen is the director of pharmacy clinical applications and technical services at Texas Children’s Hospital in Houston. Previously, as assistant director of pharmacy applications and technical services, he managed a team of Epic Willow pharmacy experts who had just completed a 3-campus implementation of Epic® and Omnicell®.
Mr. Mathen received his degree in Industrial Engineering from the University of Houston. His numerous certifications include Epic Willow certification; EpicCare® Inpatient certification; EpicCare Inpatient Decision Support Master’s certification; Advanced Quality Improvement and Patient Safety; and Resiliency Engineering and Patient Safety. Mr. Mathen oversees the Technology, Inventory and Financial Teams for the Pharmacy at Texas Children’s. Mr. Mathen has been at Texas Children’s for 33 years and has a deep passion to improve the practice of Pharmacy by using technology.
Lauren Lobaugh, MD
Associate Professor,
Baylor College of Medicine.
Clinical Pediatric Anesthesiologist,
Texas Children’s Hospital,
Houston, Texas.
Lauren Lobaugh is an Associate Professor at Baylor College of Medicine and a clinical pediatric anesthesiologist at Texas Children’s Hospital in Houston, Texas.
She completed her residency at Medstar Georgetown University Hospital followed by a clinical anesthesia fellowship at Children’s Hospital of Philadelphia. She then returned home to Texas for a faculty fellowship in Quality Improvement at Texas Children’s Hospital and continued as a staff anesthesiologist. She earned her Master’s degree in Applied Science in Healthcare Quality and Patient Safety at Johns Hopkins University Bloomberg School of Public Health in 2019.
Quality Improvement and Patient Safety remain a passion and integral part of Lauren’s career. She serves locally as the Director of Safety and Co-Chair of her department’s Quality Improvement Committee. She is the course director of two quality improvement electives at Baylor College of Medicine. Nationally, She serves as a member of the Society of Pediatric Anesthesia’s Quality Improvement and Patient Safety Committee, Wake Up Safe, the American Academy of Pediatrics Council on Quality Improvement and Patient Safety, and ASA’s Committee for Patient Safety and Education.
Anesthesia and Information Technology Partnerships to Prevent Drug Diversion
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Dom Carollo, MD
Anesthesiologist and Pediatric Anesthesiologist
Assistant Chief Medical Information Officer in Anesthesia
Ochsner
Dr. Carollo earned his medical degree from Louisiana State University, New Orleans. He completed both his internship in Internal Medicine and residency in Anesthesia at Ochsner Clinic Foundation New Orleans, LA. He completed a Pediatric Anesthesia Fellowship and a Sub-fellowship in Congenital Cardiac Anesthesia at Children’s National Medical Center Washington, DC. Dr. Carollo is board-certified in anesthesiology and pediatric anesthesiology. He has been on staff at Ochsner since 2011. He also serves as the Assistant Chief Medical Information Officer in Anesthesia for the system.
Amanda Hays, PharmD, MHA, BCPS, CPHQ, FASHP
Director, Medical Affairs
St. Louis, MO
Education: B.S. Pharm, St. Louis College of Pharmacy, 2001; Pharm.D., St. Louis College of Pharmacy, 2002; PGY-1 Pharmacy Practice Residency, SSM-Health, St. Louis, MO, 2003; ASHP Pharmacy Leadership Academy, 2011; Master of Healthcare Administration, Simmons University, 2014
Dr. Hays is a pharmacy leader with over 20 years of experience in clinical and operational pharmacy practice, medication safety, stewardship, and healthcare quality. In her current role, Dr. Hays leads cross-functional teams, serving as the voice of the clinician and patient while ensuring product safety and efficacy. She participates in medication technology solution development and product focused outcomes research. She supports the dispensing and pharmacy automation medical affairs team with safety and quality efforts as well as supporting integrated solutions platform products. She is passionate about safety and is honored to be a Fellow of the American Society of Health System Pharmacy (ASHP).
Dr. Hays is a 2002 graduate of UHSP and completed a PGY-1 residency at SSM-St. Mary’s. She has been an active member of the American Society of Health System Pharmacy (ASHP) and served as faculty on the ASHP Opioid Stewardship Certificate program, ASHP Opioid Stewardship Task Force, and is a co-author on the 2022 ASHP Controlled Substance Diversion Prevention Guidelines. Dr. Hays frequently publishes and presents at regional, state, and national meetings on various quality and safety topics. She has been honored at her healthcare organizations with Medication Safety Pharmacist of the Year in 2006, Director of the Team of the Year in 2012, and the Leader of the Year in 2018, and achieved Fellowship status with ASHP in 2021.
Augmented Intelligence to Address Gaps in Managing Risk of Opioid Harm
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Sesh Mudumbai, MD, MS
Associate Professor,
Department of Anesthesiology, Perioperative, and Pain Medicine,
Stanford University School of Medicine
Sesh Mudumbai, MD, MS, is a board certified anesthesiologist and health services researcher dedicated to enhancing patient safety through innovative research and clinical practice. After completing a Patient Safety Fellowship and a Masters in Health Services Research at Stanford University, he joined the faculty as an Assistant Professor in the Department of Anesthesiology, Perioperative, and Pain Medicine. His work focuses on optimizing therapeutic strategies and reducing adverse outcomes related to opioid management, leveraging artificial intelligence and machine learning to address these challenges. He has published extensively, particularly on national-level issues within the Veterans Affairs (VA) healthcare system and methods to improve the quality of perioperative and pain management.
Dr. Mudumbai’s contributions include pioneering perioperative health informatics within the VA and enhancing clinical decision-making and risk management in opioid prescribing. His work develops predictive models using machine learning to identify patients at risk of opioid harm, informing safer prescribing practices. As a thought leader, he has spoken at national and international forums, sharing insights on integrating informatics tools and with a multidisciplinary and collaborative approach to mitigate opioid risks.
8:30 – 8:45 AM
Q & A Speakers
8:45 – 10:00 AM
Breakout Groups
10:00 – 11:00 AM
Finalizing Recommendations and Next Steps
11:00 AM
Adjourn
Our deepest thanks to Stacey Maxwell, APSF Administrator, for her tireless support of APSF and of this conference!
