Day 1 – Monday 24 October
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8:00 |
Registration opens
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8:45 |
All delegates head to Exchange Hall
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8:50 |
Opening remarks and reflections on World Patient Safety Day (video)
Professor Chris Whitty, Chief Medical Officer for England and UK Representative on the Executive Board of the World Health Organisation
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Chair’s welcome
- Set the scene for the Congress with an up-to-date overview of patient safety
- Understand the major shifts in patient safety over the last year and what steps need to be taken to make further progress
- Learn how you can make the most of the next two days to improve patient outcomes within your own organisation
Shaun Lintern, Chair, Patient Safety Congress and Health Editor, The Sunday Times
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9:00 |
NATIONAL UPDATE
Opening keynote address
A national update on the NHS Patient Safety Strategy: Where are we now?
With Patient Safety Specialists and the first Patient Safety Commissioner for England now appointed, as well as new frameworks being rolled out, there is renewed impetus to put national priorities into practice at local level. Join Dr Aidan Fowler as he revisits the strategic aims of the NHS Patient Safety Strategy three years after its launch and get an update on where significant progress has been made, what areas require more momentum and how national priorities have shifted to get safety back on track.
Dr Aidan Fowler, National Director of Patient Safety, NHS England & NHS Improvement and Deputy Chief Medical Officer at the Department of Health and Social Care
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9:20 |
Keynote panel
Why aren’t we learning from past mistakes? Breaking the cycle of repeat errors to advance the safety agenda
- Identify long-standing barriers to change and discuss the underlying factors in healthcare that make it hard to implement key learnings and make real progress
- Debate the effectiveness of national reports and enquiries
- Re-thinking approaches to safety issues amidst increased system pressures – how can this be effectively tackled in a staffing crisis?
- Focusing on really understanding the problem before coming up with solutions to ensure long-term sustainability and safety
- Discuss practical ways you can break down barriers to improvement in your organisation
Professor Mary Dixon-Woods, Director and Professor of Healthcare Improvement Studies, THIS Institute and University of Cambridge
Professor Ted Baker, Former Chief Inspector of Hospitals, CQC
Tom Bell, Organisational Culture and Ethics Consultant, Trainer, Author, Speaker, former NHS Manager, and Whistleblower
Professor Sir Robert Francis QC, Chair, Healthwatch England
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10:05 |
Keynote panel
Putting an end to gender bias in healthcare: Re-setting the dial on women’s health and safety
- Hear from a female patient about their experiences with sodium valproate and the challenges faced as a woman navigating the health system
- Consider the recurring theme from personal testimonials and healthcare scandals in recent years, that women’s voices and patient safety concerns are being ignored or dismissed
- Address the lack of transparency around the risks of medicines and medical devices
- The need to discuss both benefits and risks of investigations and medication
- Ending the culture of doctor knows best - Is there a clash of values between medical paternalism and patient autonomy?
Emma Murphy, Founder, Independent Fetal Anti-Convulsant Trust (IN-FACT)
Janet Williams, Founder, Independent Fetal Anti-Convulsant Trust (IN-FACT)
Professor Matthew Cripps, Director of Behaviour Change, NHS England and NHS Improvement
Professor Marian Knight, Professor of Maternal and Child Population Health, University of Oxford
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10:45 |
Meet our Partners / Refreshment break
Explore the exhibition hall and be sure to catch up with our partners who have a variety of patient safety solutions to help you with your current challenges and priorities. Simply head over for a chat or connect with them via the event app to book a meeting
Tea, coffee and refreshments available
Outpatients’ department
Head over to the exhibition hall to the ‘Outpatient’s Department’ zone and catch up with speakers after sessions! This is an opportunity to meet the speakers one to one and ask your questions
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Delegates can now break into the following 5 tracks and attend sessions which focus on hands-on learning and practical case-studies. Send your colleagues to different tracks to get the most out of the content |
Room |
Charter 1 |
Exchange Auditorium |
Charter 3 |
Exchange 9 |
Charter 2 |
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Building Restorative Organisations
Chaired by Matt Discombe, Correspondent, HSJ
In association with Radar Healthcare
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Human factors
Chaired by Dr Dawn Benson, Programme Manager, Clinical Human Factors Group and Dr Lauren Morgan, Director, Morgan Human Systems Ltd
In association with BD
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Patient safety in non-acute settings
Chaired by Rahul Pasumarthy, Head of Consulting, Wilmington Healthcare
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Patient and family engagement
Chaired by Rachel Power, Chief Executive, The Patients Association
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Supporting our workforce
Chaired by Annabelle Collins, Senior Correspondent, HSJ
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11:30 |
Panel
Tackling bullying and harassment: What a restorative just culture looks like in practice
- Hear examples of how the lack of a just culture can lead to bullying, misperceptions, and an increase in patient safety errors
- Understand the difficulties of dealing with bullying from a leadership perspective
- Find out what a restorative just culture actually means, how to implement it and what it should look like in practice
- Share successful strategies from trusts on how to manage and prevent the disproportionate impact of bullying on minority groups
Amanda Oates, Executive Director of Workforce, Mersey Care NHS Trust
Ranjit Kirton, Workplace Behaviour Innovator,
The Behaviour Garage
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Panel
Modelling what good looks like: An automation approach to addressing medication error
- Understand human factors that influence the collaboration between humans and automation
- Digital evolution and resistance to change: Understanding barriers to overcome, fully embrace and implement system automation
- Learn how automation can support clinical practice and deliver improved medication management
- Proof of concept -Hear examples from trusts that have adopted connected Medication Management and how this has helped reduce errors, waste and increased efficiencies
In association with BD
James Davis,
Chief Innovation Officer, Royal Free London NHS FT
Steve Tomlin, Director of the Children’s Medicines Centre,
Associate Chief Pharmacist – Research and Innovation,
Great Ormond Street Hospital
Francine de Stoppelaar, Director of Pharmacy, Cleveland Clinic
Sarah Stern, Chief Pharmacist and Director of Medicines Optimisation,
North Middlesex University Hospital NHS Trust
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Restart a Heart: Optimising survival rates through rapid response to out-of-hospital cardiac arrests
- Hear directly from doctor on how he and his team help save the life of an athlete who suffered a cardiac arrest
- Gain insight into the National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
- Learn about a clinician-led quality improvement initiative around prompt CPR to improve patient outcomes
- Join a practical workshop on CPR training across the 2-day Congress to learn how to respond in life-threating situations
Dr Jonathan Tobin, GP and Club Doctor, Wigan Athletic Football Club (pre-recorded)
Dr. Marisa Mason, Chief Executive, NCEPOD
Professor Andrew Lockey, President of Resuscitation Council UK
Chaired by Dr Alison Tavaré, Clinical Lead, NHS@Home SW and Primary Care Clinical Lead, West of England Academic Health Science Network
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Is anybody ‘Learning from Deaths’? – Implementing safety improvements based on a review of the national LfD Programme
- Analysis of national statutory reporting within the NHS in England 2017-2020
- Understanding what ‘Learning’ and ‘Actions’ have occurred
- A review of how trusts have assessed the impact of their actions
- Hear examples of how trusts are engaging with and involving families in their LfDs work
- Recommendations for how the LfDs programme can be developed and implemented further and what this means for your organisation
Dr Zoe Brummell, Anaesthetic and Intensive Care Medicine Specialist, University College London Hospitals NHS FT
Dorit Braun, Patient Representative
Dr Emma Rowland, A&E Consultant, Homerton University Hospital NHS FT
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Workshop
Tackling discrimination and inequality in healthcare
We know that inclusive workplaces are crucial for both staff wellbeing and for patient safety. So why are so many still experiencing discrimination and what can we do to change it?
In this interactive session we will:
- Reflect on the impact of discrimination in healthcare
- Consider how cultures aid discrimination at work
- Explore the work the GMC is doing to tackle inequality issues
- Identify what you can do locally to create a more inclusive culture, including resources and support available to you
In association with the GMC
Chris Lawlor, Senior Regional Liaison Advisor, Outreach Development Support Unit, General Medical Council
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12:20 |
Time to move between sessions
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Room |
Charter 1 |
Exchange Auditorium |
Charter 3 |
Exchange 9 |
Charter 2 |
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Building Restorative Organisations |
Human Factors |
Patient safety in non-acute settings |
Patient and family engagement |
Supporting our workforce |
12:25 |
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NATIONAL UPDATE |
Driving a culture of learning from patient safety incidents: Making the switch from NRLS to LFPSE
- Hear about the transition from the current National Reporting and Learning System (NRLS) to Learn from Patient Safety Events (LFPSE)
- When and why: Understand the reasons behind the change and how the new reporting system will benefit your teams and support national learning and improvement
- Find out how the system will work in practice to speed up incident data capture
- Understand how to triangulate LFPSE with CQC, NICE, policy, and audit to provide local assurance and continuous improvement
- Take away strategies you can implement to achieve quality insight and improve safety and compliance culture
In association with InPhase
Lucie Mussett, Patient Safety Lead and Senior Product Manager LFPSE, NHS England and Improvement
Robert Hobbs,
Chief Executive Officer, InPhase
Warren Edge, Senior Associate Director of Assurance & Compliance, County Durham and Darlington NHS FT
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Reducing the risk of Never Events: A deep dive into misplaced nasogastric tubes
- Learn about a common never event involving a nasogastric tube and why it is also a national issue
- Hear about the post-incident investigation process which resulted in no findings of care gaps or staff errors
- The importance of being proactive and inquisitive and how this resulted in identifying previously unknown gaps
- Learn how one trust is evaluating all PH strips on the market in order to adopt the best device and minimise error
- How this work has resulted in new guidelines that openly acknowledge the gaps in the system with the aim of preventing incidents
Karl Emms, Lead Nurse for Patient Safety, Birmingham Women’s and Children’s NHS FT
Fiona Terry, Neonatal Matron, Joint Project Lead, Birmingham Women’s and Children’s NHS FT
Jennifer Abbott, Clinical Educator, Birmingham Women’s and Children’s NHS FT
Michelle Moseley, Senior Specialist Nurse, Birmingham Women’s and Children’s NHS FT
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Improving outcomes and experiences of patients discharged from mental health hospitals
- Find out about a research study initiated by a patient who experienced difficulties when discharged
- Hear how this co-led study aims to improve outcomes for service users being discharged from mental health hospitals
- Gain insight into the factors and challenges that prevent mental health hospitals from providing a seamless discharge experience for patients
- Plans to co-produce a new toolkit for discharge using systems engineering approaches to healthcare which can be applied and adapted to the discharge process
- Understand how this research has the potential to positively impact patient safety and patient experience
Sarah Rae, Patient Representative
Lisa Grunwald, Minds Study Manager, Norfolk and Suffolk NHS FT
Professor John Clarkson, Professor of Engineering Design, University of Cambridge and Professor of Healthcare Systems, Delft University of Technology
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What does true co-production look like? The impact of patient input and involvement on quality improvement
- Hear how the involvement of patients helped trusts to think differently about safety initiatives based on their own experience using the health service
- Discuss and share approaches you can take to attract patient partners, and understand what training, support and conditions are required to enable meaningful co-production
- Hear successful examples from trusts that involved patient partners in QI projects and assess the positive impact on patient safety and staff experience
- Key takeaways: Take back strategies to help you involve patients as partners in your work to help shape and influence improvements in your organisation
Professor Charlotte McArdle, Deputy Chief Nursing Officer – Safety & Improvement, NHS England
John Curtin, Quality Improvement Partner, Leeds Teaching Hospitals Trust (LTHT)
Dr Anna Winfield, Specialist in Geriatrics and QI, Leeds Teaching Hospitals NHS Trust Trust
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Harnessing digital to join up systems and processes to facilitate real learning and improvement
- Discuss what good quality looks like and the challenges around ensuring organisations are getting the full picture of whether or not they are delivering good quality
- How a siloed approach to learning from incidents and the use of multiple tools and systems makes its harder to identify trends and there for prevents learning
- Find out what solutions are available to help you join up different processes. Hear examples from a trust on how this has positively impacted safety outcomes in their organisation
In association with Radar Healthcare
Paul Cresswell, Associate Director of Quality Governance, North Bristol NHS Trust
Molly Kent, Patient Safety Specialist, Radar Healthcare
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13:15 |
Lunch break in the Exhibition Hall
Meet our Partners
Explore the exhibition hall and be sure to catch up with our partners who have a variety of patient safety solutions to help you with your current challenges and priorities. Simply head over for a chat or connect with them via the event app to book a meeting
Outpatients department
Head over to the exhibition hall to the ‘Outpatient’s Department’ zone and catch up with speakers after sessions! This is an opportunity to meet the speakers one to one and ask your questions
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Patient Safety Specialist Networking Lunch
Please note this lunch is invitation only and exclusively for Patient Safety Specialists.
If you have received confirmation of your attendance for this networking lunch, please head to Exchange 1. If you haven’t registered but would like to attend, please head to the location to see if there are still seats available.
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Room |
Charter 1 |
Exchange Auditorium |
Charter 3 |
Exchange 9 |
Charter 2 |
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Building Restorative Organisations
In association with Radar Healthcare
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Human Factors |
Patient safety in non-acute settings |
Patient and family engagement |
Supporting our workforce |
14:15 |
Are we losing sight of what good looks like? Reversing the impact of normalised deviance on patient safety
- Explore the systematic conditions and flaws that set up good people to fail and the long-term effect this has on patient care when behaviours do not change
- The importance of a top-down approach, ensuring good practice is carried out and followed through by leaders to embed a strong safety culture across the entire organisation
- Discuss and share actions you can implement now to help identify and manage unsafe practices and behaviours before they become normalised and pose risks to patient safety, quality care, and employee morale
Professor Rebecca Lawton, Professor in Psychology of Healthcare, University of Leeds and Director, NIHR Yorkshire and Humber Patient Safety Translational Research Centre
Professor Matthew Cripps, Director of Behaviour Change, NHS England and NHS Improvement
Ranjit Kirton, Workplace Behaviour Innovator,
The Behaviour Garage
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Panel
Challenges and possibilities of integrating human factors and ergonomics into healthcare
- Hear from experts on the current barriers and opportunities of bringing human factors into the health system
- Discuss ways you can get past system and cultural issues to operationalise human factors thinking
- Hear different perspectives on the system from each speaker, whilst also learning from their shared thinking to help you incorporate human factors in your organisation
In association with NHS Supply Chain
Dr Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England and NHS Improvement
Professor Paul Bowie, Programme Director (Safety & Improvement), NHS Education for Scotland
Colette Longstaffe,
Product Assurance Specialist-Clinical and Product Assurance (CaPA), NHS Supply Chain
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Panel
Achieving true integration: Valuable lessons from mature integrated care systems outside England
- The key challenges faced in the establishment of systems-level care through the lenses of finance, workforce and operational delivery
- Find out how advanced levels of integration significantly enhanced patient safety, especially against the backdrop of covid-19
- Find out what initial challenges these systems faced when starting their integration journey, as well as key elements required for ICSs to succeed
- How to best measure and assure patient safety when designing, implementing and refining acre pathways at systems level
In association with RLDatix
Jonathan Webb, Head of Safety & Learning at NHS Wales Shared Services Partnership
Liz Jones, Chief Marketing Officer (International), RLDatix
Anders Nilsson, Business Development Manager, RLDatix
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Involving families well using the new PSIRF guidance: A why, how and what guide to Positive family engagement on system and patient safety
Under the new PSIRF guidance, there will be greater engagement with families following an incident. This session focusses on how to do that well, why you do it and address some possible issues around this including:
- How to engage well with families after a patient safety incident and the impact this has on families, staff, and the investigation
- The importance of having difficult conversations with families and how do this well
- Why does Duty of Candour matter to families?
- What does positive family engagement uniquely bring to investigations?
- What does a blame-free culture look like and how does it benefit families and staff?
Rosi Reed, Training Coordinator, Making Families Count
Frank Mullane MBE, Member, Making Families Count
Jen Sunman, Member, Making Families Count
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NATIONAL UPDATE
Casting a safety net between primary and secondary care: A digital approach to sustaining safety across the patient pathway
- Hear about the challenges and safety issues patients experience as they move between primary, acute and virtual care settings
- Assess the dynamic between secondary care leadership and primary care delivery and how this relationship can be fine-tuned to improve patient safety
- Hear from a digitally advanced organisations and find out how they use digital to support organisational strategy, not lead it
- Get a national update on the Digital Clinical Safety Strategy and how it will help protect patients using hybrid models of care
Jyoti Mehan, Chief Executive, Health Care First Partnership
Dr Mona Johnson, Associate Director, Clinical Content & Decision Support, NHS Digital
Mel Briers, Digital Clinical Safety Nurse Specialist, Sussex Community NHS Foundation
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15:05 |
Time to move between sessions
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Room |
Charter 1 |
Exchange Auditorium |
Charter 3 |
Exchange 9 |
Charter 2 |
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Building Restorative Organisations |
Human Factors |
Patient safety in non-acute settings |
Patient and family engagement |
Supporting our workforce |
15:10 |
Panel
Balancing no-blame with accountability: Playing your part by speaking up to create a health system that owns up to error
- Address issues around blame and defensiveness as key contributors to the lack of safety progression over the past decades
- Debate why defensiveness remains a core issue within the system and understand what factors are preventing a shift in culture, at both national and local level
- Practical, initial strategies for leaders to build a psychologically safe environment, that encourages transparency and honesty amongst staff
- Responding to error: Learn how you can create a just culture where you ensure staff are speaking up when things go wrong without blame or fear of reprisal
- Understand the impact this will have on patient safety through the prevention of repeat errors
John Walsh, OD Lead / Freedom To Speak Up Guardian, Leeds Community Healthcare NHS Trust
Tom Bell, Organisational Culture and Ethics Consultant, Trainer, Author, Speaker, former NHS Manager, and Whistleblower
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A digital approach to reducing never events within the operating room
- Get an understanding of the core patient safety challenges within the operating room
- Understand the power of reviewing procedures to help reduce never events and the role technology can play to support this
- Hear examples of how integrating technology into existing ways of working has helped support clinical expertise
- Learn about the cost savings and financial impact on patients, staff and the system
In association with Proximie
Matthew Green, Director Strategic Partnerships and Initiatives, Proximie
Jacque Mallander, Health Economist and Director, Economics by Design
Ed Marsden, Founder, Eva
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Reducing health inequalities for people with learning disabilities: Looking beyond the disability to improve safety
- Recognise the dangers of diagnostic overshadowing for people with a learning disability and hear examples of avoidable patient harm caused as a result
- Find out what you can do to prevent diagnostic overshadowing – hear about the RCP Acute Care toolkit for people with learning disabilities
- Take back practical, reasonable adjustments you can make in your organisation to enhance safety for patients
- Learn about how addressing inequalities can be embedded as a golden thread to help drive improvement”
Gavin Howcraft, Expert by experience
Moor Eric, Acute Liaison Nurse – Learning Disability Service in Hertfordshire County Council Adult Care Services
Scott Riley, South West Inclusion Health Lead, NHS England and NHS Improvement (South West) (pre-recorded)
Chaired by Dr Alison Tavaré, Clinical Lead, NHS@Home SW and Primary Care Clinical Lead, West of England Academic Health Science Network
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Assessing quality of care in the home: Ensuring patients and families have the tools to safely self-manage
- How covid-19 has challenged perceptions around what patients can or should do – causing a major shift towards self-management at home
- Assess the situational variables that could present risks to patients
- Understand the type of training and resources required for patients, families and clinicians to effectively identify and prevent potential risks in the home
- Hear examples of tools and training available that enhance safety in the home
Jono Broad, Senior Manager Personalised Care, NHS England SW
Matthew Riley, Service User Representative
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Identifying innovative solutions to promote quality improvement with an already-stretched workforce
- Address the difficulties systems have in trying to drive evidence-based practice initiatives whilst coping with the service disruption and low staffing levels
- Assess how covid-19 has led to a ‘start and stop’ approach to QI, impacting staff’s engagement with improvement programs
- Hear best practice examples on how you can prevent staff burnout, to ensure your workforce have the capacity and energy required to engage with these programmes
- Take back strategies on how you can prepare your teams to reposition QI and accelerate innovation to improve patient outcomes
In association with Wolters Kluwer
Dr Emily Audet, National Medical Director’s Clinical Fellow, Internal Medicine Trainee Doctor - West Midlands
Rachel Dicker, Product Management Associate Director, Wolters Kluwer, Health, Learning, Research and Practice
Chaired by Shaun Lintern, Chair, Patient Safety Congress and Health Editor, The Sunday Times
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16:00 |
Meet our Partners / Refreshment break
Explore the exhibition hall and be sure to catch up with our partners who have a variety of patient safety solutions to help you with your current challenges and priorities. Simply head over for a chat or connect with them via the event app to book a meeting
Tea, coffee and refreshments available
Outpatients department
Head over to the exhibition hall to the ‘Outpatient’s Department’ zone and catch up with speakers after sessions! This is an opportunity to meet the speakers one to one and ask your questions
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Regroup with all attendees in the Exchange Auditorium for the closing keynote |
16:30 |
The James Reason Lecture
Planning for the unthinkable: Responding to catastrophe in a healthcare setting
- Hear from Professor Lucy Easthope, the UK’s leading authority on disaster management and recovery
- Get a look behind the scenes at some of Lucy’s work on major disasters, including 9/11, the 7/7 bombings, the Indian Ocean tsunami and covid-19
- Find out how healthcare systems should plan for disasters and the aftermath, prioritising emergency planning, compassion and putting those affected at the heart of arrangements
- Assess why and how things go wrong in disaster management and what you can do to prevent repeat errors
- Key considerations and takeaways: Short-term and long-term actions you can implement at local level
Professor Lucy Easthope, UK Leading’s Authority on Recovering from Disaster, Professor in Practice of Risk and Hazard, University of Durham and Fellow in Mass Fatalities and Pandemics at the Centre for Death and Society, University of Bath
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17:10 - 18.00 |
Closing remarks and end of day 1 – Please take time to provide feedback via the event app
Networking reception in the Exhibition Hall
After full day of discussions, debates, and learning, end your day through networking with colleagues, new acquaintances and partners. Get ready for the Awards celebration later in the evening!
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