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Preventing Medication Errors A Biographical Sketches of Committee Members J. Lyle Bootman, Ph.D., Sc.D., Cochair, is dean and professor at the University of Arizona College of Pharmacy. He is the founding and executive director of the University of Arizona Center for Health Outcomes and PharmacoEconomic (HOPE) Research, one of the first such centers developed in the world. Dr. Bootman also holds a joint appointment as professor in both the College of Medicine and the College of Public Health. He is former president of the American Pharmaceutical Association. He received his pharmacy education at the University of Arizona and his doctorate at the University of Minnesota. Additionally, he completed a clinical pharmacy residency at the National Institutes of Health. Dr. Bootman has received numerous outstanding achievement awards, most notably from the American Association of Pharmaceutical Scientists and the American Pharmaceutical Association. He has published several books, including the first text introducing the principles of pharmacoeconomics, which is used in more than 35 countries and translated into six languages. His research regarding the outcomes of drug-related morbidity and mortality has received worldwide attention by the professional and public media. Dr. Bootman is a member of the Institute of Medicine (IOM). Linda R. Cronenwett, Ph.D., M.A., R.N., Cochair, is dean and professor of the School of Nursing, University of North Carolina (UNC) at Chapel Hill, and associate chief nursing officer for Academic Affairs at the University of North Carolina Hospitals. She is a member of the board of directors of
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Preventing Medication Errors the Institute for Healthcare Improvement and The Robert Wood Johnson Foundation’s Transforming Care at the Bedside National Advisory Committee. Dr. Cronenwett earned her master’s degree in nursing from the University of Washington and her undergraduate and doctoral degrees from the University of Michigan. Prior to her appointment as dean, she was Sarah Frances Russell Distinguished Professor of Nursing Systems at UNC-Chapel Hill. Dr. Cronenwett is an elected fellow of the American Academy of Nursing and the National Academies of Practice. She served the scientific community as a member of the Nursing Research Study Section and subsequently as a member of the National Advisory Council for Nursing Research at the National Institutes of Health. She has served on the editorial advisory boards of Applied Nursing Research, the Online Journal of Knowledge Synthesis for Nursing, the Journal of Nursing Measurement, and the Joint Commission Journal on Quality Improvement. She has held numerous offices in professional associations, including president of the New Hampshire Nurses Association and chair of the American Nurses Association’s Congress of Nursing Practice. She is currently principal investigator for a national initiative, Quality and Safety Education for Nurses, funded by The Robert Wood Johnson Foundation. Through organizational initiatives, she provides leadership for efforts to improve health care education to ensure that future health professionals will be committed to and capable of creating and constantly improving the safety and quality of the health care delivery systems in which they work. David W. Bates, M.D., M.Sc., is chief of the Division of Internal Medicine at the Brigham and Women’s Hospital in Boston, Massachusetts, and a professor at Harvard Medical School and the Harvard School of Public Health, where he is codirector of the Program in Clinical Effectiveness. He is also the medical director of clinical and quality analysis for Partner’s Healthcare Systems, where he evaluates the impact of information systems across the Partner’s network. Dr. Bates’ primary interest has been the use of computer systems to improve care, and he has conducted extensive work on evaluating the incidence and preventability of adverse drug events. At the national level, Dr. Bates is chair of the National Alliance for Primary Care Informatics, and he served as one of two science advisors to the SCRIPT project, which developed medication indicators for the Centers for Medicare and Medicaid Services (CMS). In addition, he serves as an advisor to the Leapfrog Group on computerized order entry and is the editor of the Journal of Clinical Outcomes Management. Dr. Bates received his M.D. from The Johns Hopkins University School of Medicine in 1983; in 1990, he received his M.Sc. from the Harvard School of Public Health. Dr. Bates is a practicing, board-certified physician in internal medicine.
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Preventing Medication Errors Robert M. Califf, M.D., is associate vice chancellor for clinical research; director of the Duke Clinical Research Institute (DCRI); and professor of medicine, Division of Cardiology, at the Duke University Medical Center, Durham, North Carolina. He has served as an editor of landmark textbooks on cardiovascular medicine and has been an author or coauthor of more than 650 peer-reviewed journal articles. Dr. Califf has led the DCRI efforts for many of the best-known clinical trials in cardiovascular disease. He is considered an international leader in the fields of health outcomes, quality of care, and medical economics. Additionally, he has served on the Cardiorenal Advisory Panel of the U.S. Food and Drug Administration (FDA) and the Pharmaceutical Roundtable of the IOM. He also served on the IOM committee that recommended Medicare coverage of clinical trials, and he is director of the coordinating center for the Centers for Education & Research on Therapeutics (CERTs), a public–private partnership among the Agency for Healthcare Research and Quality, the FDA, academia, the medical products industry, and consumer groups. This partnership focuses on research and education that will advance the best use of medical products. Dr. Califf graduated from Duke University in 1973 and from Duke University Medical School in 1978. He performed his internship and residency at the University of California at San Francisco and his fellowship in Cardiology at Duke University. He is board-certified in internal medicine (1984) and cardiology (1986) and is a fellow of the American College of Cardiology (1988). H. Eric Cannon, Pharm.D., is director of pharmacy services and health and wellness at IHC Health Plans, a division of Intermountain Health Care in Salt Lake City, Utah. IHC is an integrated health care system with 20 hospitals, 68 physician clinics and surgery centers, and more than 450 employed community-based physicians. Dr. Cannon has worked in pharmacy for the past 15 years. He received his doctor of pharmacy degree from Idaho State University. He has pharmacy experience in the hospital, retail, long-term care, and home health areas. Dr. Cannon is a member of the Academy of Managed Care Pharmacy and currently serves on the legislative committee, which he will chair in the coming year. At IHC Health Plans, he works to develop, implement, and administer programs to control the cost and utilization of pharmaceuticals within the IHC system. He makes frequent presentations to employers, brokers, and health care providers on pharmaceutical trends and pharmaceutical management techniques. Dr. Cannon has responsibility for the management and administration of pharmaceuticals used by IHC’s members. As cochair of IHC’s Corporate Pharmacy and Therapeutics Committee, he helps promote physician/pharmacy education and interaction programs, as well as formulary
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Preventing Medication Errors development and maintenance. Through IHC Health Plans, he is working to incorporate outcomes-based pharmacoeconomic research into the formulary process. Recently, Dr. Cannon helped establish Utah AWARE, an alliance of health care providers, payers, and the pharmaceutical industry in the state of Utah that is working to educate the community about appropriate antibiotic use. He is actively involved in Intermountain’s efforts in clinical integration, disease management, and research. In addition to his responsibilities for pharmacy, Dr. Cannon oversees all health and wellness programs for the plan. He is currently working with employers to implement health management designed to improve employee productivity and decrease absenteeism. Rebecca W. Chater, R.Ph., M.P.H., is director of clinical services, Kerr Drug, Inc./KDI Clinical Services. She is a national leader in community pharmacy practice innovation. She earned both her B.S. in pharmacy and master’s in public health from UNC-Chapel Hill. A past faculty member of the UNC School of Pharmacy, she is president of the North Carolina Board of Pharmacy and a former trustee of the American Pharmacists Association. She has served in several leadership capacities with the National Association of Boards of Pharmacy. She is the 2005 recipient of the North Carolina Association of Pharmacists Innovative Pharmacy Practice Award. Ms. Chater has served on key national committees to develop a consensus definition of medication therapy management (MTM), design a model framework for MTM delivery, and collaborate with the American Medical Association to successfully establish Current Procedural Terminology billing codes specific to pharmacist services. Additionally, she was concept originator and project manager for Kerr’s new Community Healthcare Center, which anchors clinical community pharmacy services as central to an interdisciplinary health care practice. Ms. Chater has more than 100 presentations and publications to her credit and has been invited to lend her expertise to more than 30 advisory boards. She is a fellow of both the American Pharmacists Association and of the Wharton School of Business. Michael R. Cohen, Sc.D., is president of the Institute for Safe Medication Practices (ISMP), an independent nonprofit agency that reviews medication error reports submitted by practitioners to the national medication errors reporting programs operated by the U.S. Pharmacopeia (USP) and the Food and Drug Administration (FDA). ISMP also provides expert analysis of medication-related events for the Patient Safety Authority of the Commonwealth of Pennsylvania, which operates the Pennsylvania Patient Safety Reporting System. ISMP regularly provides drug safety alerts to an estimated 3.5 million U.S. and international readers through various professional journals; newsletters; websites; and four ISMP Medication Safety
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Preventing Medication Errors Alert! publications tailored for consumers, acute care, nurses, and community/ambulatory care providers. Dr. Cohen serves as associate editor of the Journal of Hospital Pharmacy and is on the editorial boards of the Journal of Intravenous Nurse Society, Journal of Patient Safety, Nursing 2006, and Healthcare Risk Control (ECRI, Plymouth Meeting, Pennsylvania). He also is a member of the Sentinel Event Advisory Group for the Joint Commision on Accreditation of Healthcare Organizations (JCAHO), and a member of the FDA’s Drug Safety and Risk Management Advisory Panel. Dr. Cohen is author of the book Medication Errors (APhA, 2006). James B. Conway, M.S., is senior fellow at the Institute for Healthcare Improvement, Cambrige, Massachusetts, and senior consultant at the Dana-Farber Cancer Institute, Boston, Massachusetts. Previously he served as executive vice president and chief operating officer of the Dana-Farber Cancer Institute from 1995 to 2005. He is also board chairman and president of the Healthcare Dimensions Hospice. Prior to joining Dana-Farber, he had a 27-year career at Children’s Hospital, Boston, as radiology administrator, assistant vice president of finance, and assistant hospital director for patient care services. He holds a master of science degree from Lesley College, Cambridge, Massachusetts, and is adjunct lecturer on health care management in the Department of Health Policy and Management at Harvard School of Public Health. A diplomat of the American College of Healthcare Executives, he received the college’s 1999 Massachusetts Regents Award as Healthcare Executive of the Year and the first Individual Leadership Award in Patient Safety from JCAHO and the National Committee for Quality Assurance (NCQA). He serves as a member and vice-chairman of the JCAHO Sentinel Events Advisory Committee, advisor to the Massachusetts Coalition for the Prevention of Medical Errors, and distinguished advisor to the National Patient Safety Foundation. He is also a member of the Clinical Issues Advisory Council of the Massachusetts Hospital Association; a member of the Medically Induced Trauma Support Services Board of Directors; a member of the executive committee of the Medical, Academic and Scientific Community Organization; and a long-time member of the board of the Ronald McDonald House in Boston. R. Scott Evans, Ph.D., M.S., is a senior medical informaticist in the Department of Medical Informatics at LDS Hospital and Intermountain Health Care, director of research in the Department of Medical Informatics at LDS Hospital, and research professor in the Department of Medical Informatics and adjunct research professor in the Department of Medicine at the University of Utah, Salt Lake City, Utah. Dr. Evans received his bachelor of science degree in zoology and master of science degree in microbiology/parasitology from Brigham Young University. He received his Ph.D. in medical biophysics
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Preventing Medication Errors and computing from the University of Utah. He is a member of the American Medical Informatics Association and a fellow in the American College of Medical Informatics. He is on the editorial board of the Journal of the American Medical Informatics Association and a reviewer for a number of peer-reviewed journals in medicine and informatics. In 1993 he received the Priscilla M. Mayden Award for outstanding contributions in the field of medical informatics, and in 1997 he received the Oslers Cloak award for excellence in caring and curing from Intermountain Health Care. His major experience and interests have been in the design, development, and evaluation of computerized tools for the selection and management of anti-infective agents, computer methods to identify and reduce adverse drug events and adverse medical device events, computerized methods to identify patients needing isolation, computerized methods to identify and reduce hospital-acquired infections, and use of medical device interfaces to improve patient safety. A number of these computerized tools are clinically operational at several Intermountain Health Care hospitals. Elizabeth A. Flynn, Ph.D., R.Ph., is associate research professor at the Center for Pharmacy Operations and Designs at Auburn University. Her specialties are the application of ergonomic design principles to prevent errors and evaluation of technology for effects on medication errors and efficiency. Among her publications are “Fundamentals of medication error research” and “National observational study of prescription dispensing accuracy and safety in 50 pharmacies.” Dr. Flynn has been a coinvestigator on research for automation companies in community and hospital pharmacy settings, and has conducted or overseen observation studies in more than 100 sites in the United States, France, the United Kingdom, and Italy. As a member of the Graduate Faculty at Auburn, she currently serves on two graduate student committees that involve medication error research. Dr. Flynn has been an investigator on research contracts totaling over $2 million. She holds a bachelor of science in pharmacy degree from the University of Florida, a master of science degree from the University of North Carolina, and a Ph.D. from Auburn University. She completed a residency at North Carolina Memorial Hospital. She received a 1999 Cheers Award from ISMP for contributions to error prevention and the 2001 Dorothy Dillon Memorial Award from the New Mexico Society of Health-System Pharmacists. Dr. Flynn is a member of the USP’s Safe Medication Use Expert Committee (2005–2010) and the Medication Error and Technologies Analysis Network in the United Kingdom. Jerry H. Gurwitz, M.D., is a nationally recognized expert in geriatric medicine and the use of drug therapy in the elderly. He holds the Dr. John Meyers Endowed Chair in Primary Care Medicine at the University of
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Preventing Medication Errors Massachusetts Medical School, where he is chief of the Division of Geriatric Medicine and professor of medicine and family medicine/community health. He also serves as executive director of the Meyers Primary Care Institute, a joint initiative of the University of Massachusetts Medical School, Fallon Foundation, and Fallon Community Health Plan, focused on promoting primary care research and education. He received his bachelor’s degree from Dartmouth College and his M.D. degree from the University of Massachusetts Medical School. Dr. Gurwitz has published numerous original articles, reviews, commentaries, and book chapters on the optimal use of drug therapy in elderly patients. He has been the recipient of the William B. Abrams Award in Geriatric Clinical Pharmacology from the American Society for Clinical Pharmacology and Therapeutics and the George F. Archambault Award from the American Society of Consultant Pharmacists. Dr. Gurwitz’s most recent research efforts relate to developing and testing interventions to reduce the risk of medication errors that lead to adverse drug events in the elderly. Charles B. Inlander is former president of the nonprofit People’s Medical Society, founded in early 1983. He guided the People’s Medical Society to its status as one of the most influential consumer health advocacy organizations in the United States. Mr. Inlander is a faculty lecturer at the Yale University School of Medicine; an adjunct faculty member at the Chicago-Kent College of Law; and a fellow of the Institute for Science, Law and Technology at the Illinois Institute of Technology. He is a health commentator on Public Radio International’s Marketplace, heard throughout the country on public radio stations. He is a founder of the Civil Justice Foundation and serves or has served on the board of directors of Consumers for Civil Justice, the National League for Nursing, the Pennsylvania League for Nursing, and the Lehigh Valley Business Conference on Health Care. He is on the advisory boards of the Citizen Advocacy Center, the Primary Care Management Association, the American Academy of Family Physicians, Health Market, and Bottom Line/Personal Publications. He was a columnist for Nursing Economics and a contributing editor for Medical Self-Care magazine. He has authored or coauthored more than 20 best-selling consumer health books. His articles regularly appear in such publications as The New York Times, Glamour, and Boardroom. Prior to joining the People’s Medical Society, Mr. Inlander established a national reputation as an advocate for the rights of handicapped citizens. He is a graduate of American University. Kevin B. Johnson, M.D., M.S., is associate professor and vice-chair of biomedical informatics, with a joint appointment in the Department of Pediatrics, at Vanderbilt University Medical School. He received his M.D.
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Preventing Medication Errors from The Johns Hopkins University School of Medicine and his master of science degree in medical informatics from Stanford University. He served as a pediatric chief resident at Johns Hopkins. He was a member of the faculty in both pediatrics and biomedical information sciences at Johns Hopkins until 2002. He is a practicing, board-certified physician in pediatrics. His research areas are clinical information systems development; the uses of advanced computer technologies, including the World Wide Web, personal digital assistants, and pen-based computers, in medicine; and electronic prescription writing tools. Dr. Johnson has served on the editorial boards of the Ambulatory Pediatrics Association as well as the Journal of the American Informatics Association (JAMIA), for which he is an assistant editor. He recently was appointed director of JAMIA’s student editorial board. He has been an active participant in the informatics efforts of many national organizations, including the American Medical Informatics Association, the American Board of Pediatrics, the Medical Informatics Special Interest Group of the Ambulatory Pediatrics Association, the American Academy of Pediatrics’ Steering Committee on Clinical Information Technologies, and the IOM’s Patient Safety Data Standards subcommittee. Wilson D. Pace, M.D., is professor of family medicine and Green-Edelman Chair for Practice-based Research at the University of Colorado. He is director of the American Academy of Family Physicians (AAFP) National Research Network. He also directs SNOCAP, a consortium of practice-based research networks within the University of Colorado. Dr. Pace’s research has focused on practice reorganization and patient safety. He leads a patient safety consortium in Colorado focused on improving care delivery in primary care offices, as well as overseeing the AAFP Developmental Center for Evaluation and Research in Patient Safety in Primary Care. He serves in an advisory capacity to a number of clinical and research health information technology projects. Dr. Pace received his M.D. degree from the University of California, Irvine in 1979. He is a board-certified practicing family physician with a Certificate of Added Qualifications in geriatrics. Kathleen R. Stevens, Ed.D., M.S., R.N., FAAN, is professor of nursing at The University of Texas Health Science Center at San Antonio, Texas. She is also founding director of the Academic Center for Evidence-based Practice, where she works to advance evidence-based quality improvement through research, education, and practice. She is an investigator with the Veterans Evidence-based Research, Dissemination, and Implementation Center for the Veterans Health Administration, with emphasis on systematic reviews and organizational change for evidence-based quality improvement. Her research includes comparison of evidence-based and traditional interventions in reducing health risk behavior, as well as investigations of
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Preventing Medication Errors evidence-based practice processes. She serves as an advisor to hospitals seeking magnet recognition status and faculty updating education programs on the topic of evidence-based quality improvement. Dr. Stevens initiated the Summer Institute on Evidence-based Practice, a national interdisciplinary conference receiving funding from the Agency for Healthcare Research and Quality (AHRQ). At the national level, Dr. Stevens is an elected officer on the board of governors of the National League for Nursing, a leading nursing education organization that sets standards for faculty and nursing education programs. She received her bachelor of science degree in nursing from Northwestern State University of Louisiana, her master of science degree in maternal and child health from Texas Woman’s University, and her doctorate in health science research and education from the Baylor College of Medicine/University of Houston program, and is a fellow in the American Academy of Nursing. Edward Westrick, M.D., Ph.D., M.S., is vice president of medical management for UMass Memorial Health Care, where he develops clinical performance improvement interventions for a large managed care network and medical center. During the last 10 years Dr. Westrick has worked with multiple Quality Improvement Organizations in Medicare’s Health Care Quality Improvement Program and served in the leadership of the American Health Quality Association. He frequently serves on expert panels and boards for such national organizations as the National Quality Forum (NQF), USP, NCQA, JCAHO, CMS, the American Health Care Association (AHCA), the Department of Veterans Affairs (VA), the Medicare Payment Advisory Commission (MedPAC), American Pharmaceutical Association (APhA), and RAND. His particular areas of expertise include performance measurement and medication management. He previously directed the SCRIPT Project on behalf of the Coalition for Quality in Medication Use. He serves on the faculties of the University of Rhode Island and Brown University Medical School and the medical staff of Eleanor Slater Hospital. His educational history includes his internship and residency (internal medicine) from Brown University, M.D. from New Jersey Medical School, Ph.D. from the University of Rhode Island (pharmacoepidemiology and pharmacoeconomics), master of science degree from Rutgers University (psychology), and bachelor of arts degree from the University of Pennsylvania (psychology). Albert W. Wu, M.D., M.P.H., is professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, with joint appointments in Epidemiology and International Health and in Medicine and Surgery in the School of Medicine. He received bachelor of arts and M.D. degrees from Cornell University, and completed internal medicine
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Preventing Medication Errors residency training at the Mount Sinai Hospital in New York and the University of California at San Diego. He was a Robert Wood Johnson Clinical Scholar at the University of California at San Francisco and received a master of public health degree from the University of California at Berkeley. His research and teaching focus on measuring health and patient outcomes and using the measures to assess treatments and quality of care. He has studied the handling and impact of medical errors since 1988. He is an authority on the development and use of patient-reported outcome assessments for HIV/AIDS, as well as other chronic diseases and critical illnesses. Dr. Wu is past president of the International Society for Quality of Life Research. He was senior associate editor of the Journal of General Internal Medicine and is associate editor of Quality of Life Research, the Journal of Patient Safety, and AHRQ Web M&M. He was co–principal investigator for an AHRQ-funded grant that developed a web-based incident reporting system for intensive care units. He is principal investigator on a National Cancer Institute grant to develop a web-based mechanism for capturing patient-reported data for outpatient practice. He is principal investigator of the AHRQ-funded Johns Hopkins DEcIDE center for the conduct of rapid, policy-relevant studies of comparative effectiveness. He is studying video vignettes of disclosure to patients and their families, and recently developed an educational video for practitioners titled “Removing Insult from Injury: Disclosing Adverse Events.” He is author of over 200 peer-reviewed publications; leads courses in the Bloomberg School of Public Health on patient-reported outcomes, quality of care, and patient safety; and is an active clinician in general internal medicine and treatment of HIV.
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