ctlab - October 2004 Workshop

Probabilistic Risk Assessment Chicago Insight Study (PRACTIS)

The Cognitive Technologies Laboratory convened a two-day seminar on October 21-22, 2004 at Gift of Hope headquarters in Elmhurst, IL, to address issues related to risk assessment in healthcare. The workshop was the culmination of a year-long research project that was funded by the Agency for Healthcare Research and Quality (AHRQ) and supported by the Gift of Hope. Workshop participants examined the potential for use of the probabilistic risk assessment method to determine the likelihood of future adverse events in organ transplantation. The workshop included healthcare, social science, design/engineering, and policy experts from governmental agencies, transplant and healthcare organizations, and universities.

Results of the PRACTIS project and the workshop will be available in a project report to be completed in 2005.

References
-	Battles JB, Kanki BG [2004] The use of socio-technical probabilistic risk assessment at AHRQ and NASA In International Conference on Probabilistic Safety Assessement and Management. Berlin, Germany: Springer-Verlag. (67 KB)
-	Comarow A [2003] Jesica's Story US News & World Report. 135(3): ()
-	Frank MV [2000] Probabilistic analysis of the inadvertent reentry of the Cassini spacecraft's radioisotope thermoelectric generators Risk Analysis. 20(2): 251-60. (495 KB)
-	Wreathall J, Nemeth CP [2004] Assessing Risk: The Role of Probabilistic Risk Assessment (PRA) in Patient Safety Improvement Quality & Safety in Health Care. 13(3): 206-12. (144 KB)

Participants

Albolino, Sara	Support staff	University of Chicago , Dept. of Anesthesia & Critical Care
Battles, James	Meeting Facilitator	Agency for Healthcare Research and Quality (AHRQ)
Bitan, Yuval	Support staff	University of Chicago , Dept. of Anesthesia & Critical Care
Cameron, Karen	Manager, Trng. & Prof. Education	Gift of Hope; North American Transplant Coordinators Organization (NATCO) Representative
Carraro, Joan	Education Coordinator	University of Chicago , Dept. of Anesthesia & Critical Care
Cook, Richard	Principal Investigator	University of Chicago , Dept. of Anesthesia & Critical Care
Cronin, David	Transplant Surgeon, Investigator	Yale University
Crowley, Jay	Senior Advisor for Patient Safety	US Food and Drug Administration (USFDA)
de Roey, Joachim	Transplant Coordinator	University Hospital, Leuven , Belgium
Harland, Robert	Investigator	University of Chicago, Dept. of Surgery
Lawrence, Cindy	Transplant coordinator	Duke University
Lazda, Velta	Director, Histocompatibility Lab	Gift of Hope
Lichtenfeld, Dean	Quality Director	Gift of Hope
Mayer, Celeste	Patient Safety Officer	University of North Carolina
McBride, Ginny	Project Officer, RN	Organ Procurement and Transplantation Network (OPTN)
McLemore, Chevene	Procurement coordinator	University of Chicago
Millis, Michael	Transplant Surgeon	University of Chicago, Dept. of Surgery
Mowll, Chuck	internal champion, organ donation issues	Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)
Mozes, Martin	Medical Director, Organ & Tissue Donor Network	Gift of Hope
Myer, Kevin	Executive Director	LifeNet
Nemeth, Christopher	Support staff	University of Chicago Dept. of Anesthesia & Critical Care
Nunnally, Sandra	Support staff	University of Chicago Dept. of Anesthesia & Critical Care
Reason, James	Consultant	Mentaksis, Inc.
Rivero, Ozzie	Transplant Coordinator, Director, Organ Procurement	University of Chicago
Schmeiser, Bruce	Engineer, PhD	Purdue University
Schultz, Evelyn	Director, Organ Recovery Services	Gift of Hope
Wailoo, Keith	Historian	Rutgers the State University of New Jersey
Williams, Chris	Director of Technology Services	United Network for Organ Sharing (UNOS)
Wreathall, John	Consultant	John Wreathall & Company
Young, Jon	Head of Systems Risk and Analysis Group, Environmental Technology Division	Pacific Northwest National Laboratory

Agenda

Thursday, 21 October
13:30 Introduction of the participants [Battles]
13:50 Survey of the workshop [Battles]
14:00 The JS event & the public response [Wailoo]
14:20 The JS event as a model of reactions to failure [Cook]
14:40 Break
14:15 PRA basics and PRA of transplant mismatch [Wreathall]
16:00 Discussion [Wailoo & Battles]

Friday 22 October
08:00 PRA basics and assessment of the transplant PRA [Wreathall]
08:45 PRA lessons for healthcare [Battles]
09:30 Patient safety issues identified in PRACTIS [Cook]
10:00 Break
10:20 Developing recommendations [Battles]
11:20 Commentary & Summary [Reason]
12:00 Discussion and conclusion [Battles & Wailoo]
13:15 Adjourn