Plenaries
Engaging Patients: A Simulation | Was It Really a Miracle on the Hudson?
The Patient Safety Culture Proposition | Lucian Leape Institute Town Hall
Engaging Patients: A Simulation
This interactive experience will demonstrate how to help patients be more involved with their own or their family’s healthcare, in particular learning about the possibility of misdiagnosis. Using a health care simulation vignette and audience participation exercises, the attendees will experience how simulations can be used to teach about new concepts.
Was It Really a Miracle on the Hudson?
Jeff Skiles was the first officer on USAirways Flight 1549 when it made an emergency landing in the Hudson River shortly after takeoff. In this plenary, he will offer insight into why the famous incident was not a miracle, but rather the result of years of culture change and safety advancements in aviation. In this session, Skiles will be joined by Rollin J. (Terry) Fairbanks, MD, MS, an emergency physician, human factors engineer/safety scientist, and a private pilot who specializes in applying safety engineering techniques and research methodology to medical systems. Together they will offer an interactive discussion about safety from the perspective of the aviation industry and the health care environment. The speakers will use real-life examples to demonstrate the impact of factors such as teamwork, standardization, systems approaches, and near-miss reporting.
The Patient Safety Culture Proposition: 16 Design Laws to Observe, Five Skills We Must Develop
David Marx, chief executive officer, Outcome Engenuity, LLC, will introduce attendees to key concepts about our ability to collectively produce better outcomes, the five skills we need to develop, and the 16 laws that serve as constraints in the design of socio‐technical systems. Attendees will leave with a knowledge of five necessary areas of skill:
- Values and Expectations
- System Design
- Behavioral Choices
- Learning Systems
- Justice and Accountability
The session will also look at how these skills can be applied to the health care concepts presented throughout the 2012 Congress program.
Lucian Leape Institute Town Hall with Special Guests from HHS

Composed of national thought leaders with expertise in patient safety, the Lucian Leape Institute at NPSF functions as a think tank to identify new approaches, innovations and methods to create and sustain improvements in culture, process, and outcomes. At this session, Institute members will share their insights into patient safety work with a particular focus on the work of the federal Partnership for Patients initiative. Representatives from the Department of Health and Human Services and the Center for Medicare and Medicaid Innovation will join the Institute members in a Town Hall format that will allow for a dynamic exchange among the panelists and questions from the attendees.





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