2. Message from IHI Frank Federico Executive Director

3. Frank Federico Executive Director

4. All Teach; All Learn

6. Medication Safety for IHI Campaigns Focus on high-alert medications Opioids Insulin Anticoagulants Sedatives/hypnotics

7. Large Scale Initiatives Around the World Medication Management – High-alert medications – Medication Reconciliation – Failure Mode and Effects Analysis (FMEA)

8. Focus on Opioid Safety Effective medications for pain management Even when used properly, opportunity for adverse events Segment of patients may be a greater risk Addiction potential Fear of addiction/ADE may lead to uncontrolled pain Lack of expertise in pain management may lead to greater harm Patients/families have a role Overuse linked to development of pressure ulcers because of lack of mobility

9. Bundles “A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes.” Carol Haraden, Vice President, IHI

10. Opioid Safety Bundle Identify evidence-based practices All needed to improve care Result is improved outcomes

15. Leading the World in Opioid Safety Your work will benefit all patients Identifying those interventions that are most effective and most easily adopted Ensure that patients are receiving the pain management/relief needed and not experiencing adverse events On behalf of all patients, thank you.