Technical Expert/Advisory Panel

Vineet Arora, MD, MAPP


Dr. Arora is Director of GME Clinical Learning Environment Innovation and is responsible for integrating residents into the quality, safety, and value mission at the University of Chicago. Her work on quality and safety of care in teaching hospitals, including sleep deprivation and handoffs, has resulted in more than 100 peer reviewed publications, media coverage, and numerous awards from professional societies such as the Society of Hospital Medicine, the Association of American Medical Colleges, the Society of General Internal Medicine, and the American College of Physicians. Dr. Arora's video vignettes on patient safety issues have garnered over 30,000 views on YouTube and Slideshare and are used in institutions across the country to teach trainees. As Assistant Dean for Scholarship and Discovery for the University of Chicago Pritzker School of Medicine, Dr. Arora oversaw the launch of a new 4-year Quality and Safety Track to cultivate student leaders. As the Director of Educational Initiatives at Costs of Care, a 501c3 nonprofit organization, she helped launch, a Web site that houses educational modules to teach trainees about value and is coauthor of Understanding Value-Based Healthcare. She has served on the US News & World Report Expert Panel for Patient Safety for the Common Condition Rankings. She currently serves on the Editorial Board of The Joint Commission Journal of Quality and Safety and as the Social Media Deputy Editor for the Journal of Hospital Medicine. For her body of work, Dr. Arora was named as one of the "20 people who make healthcare better" by Health Leaders Magazine in 2011 and earned the Frederick L. Brancati Mentorship and Leadership Award from the Society of General Internal Medicine in 2014. As an academic hospitalist, Dr. Arora supervises medical trainees caring for hospitalized patients.

William A. Bornstein, MD, PhD


Dr. Bornstein is Chief Medical Officer and Chief Quality Officer of Emory Healthcare in Atlanta. Under his leadership, Emory has become nationally recognized as a top performer in clinical quality and patient safety. Dr. Bornstein's focus has been on the roles of organizational culture, information technology, and performance improvement methodologies in enhancing the quality, safety, and value of care. He has been a principal architect of the Emory Healthcare's cultural framework, the Emory Care Transformation Model. Most recently, Dr. Bornstein's focus has expanded to applying these principles to improving population health in his role as the founding president of the Emory Healthcare Network, a clinically integrated network dedicated to providing high-value care to the population it serves. Emory's ability to deliver high-reliability care safely to patients with Ebola virus disease has recently garnered international recognition of its advanced care capabilities. Dr. Bornstein received his undergraduate degree in mathematics from Dartmouth College and his MD and PhD (cell and molecular biology) from the Medical College of Georgia. He did his internal medicine residency at Duke and a fellowship in endocrinology and metabolism at the Massachusetts General Hospital and Harvard Medical School, where he stayed on as faculty before moving to Emory. Dr. Bornstein has served on numerous national committees and currently chairs the Steering Committee of the Integrating Quality program of the Association of American Medical Colleges and cochairs the National Advisory Panel of the Anthem Q-HIP program.

Michael Cohen, RPh, MS, ScD


Dr. Cohen is President of the Institute for Safe Medication Practices (ISMP), a nonprofit health care organization that operates the voluntary and confidential ISMP Medication Error Reporting Program (MERP). Through ISMP, MERP medical professionals and consumers learn about the causes of medication errors and error-reduction strategies are shared with the health care community, policy makers, and the public. He is a pharmacy graduate of Temple University School of Pharmacy, holds a master's degree from Temple, and has received honorary doctor of science degrees from the University of Sciences and Long Island University as well as a doctor of public service degree from the University of Maryland. Dr. Cohen is a member of the FDA Nonprescription Drugs Advisory Committee. In 2005, he was awarded a MacArthur Fellowship by the John D. and Catherine T. MacArthur Foundation. He was also the 2008 recipient of the John Eisenberg Award for Patient Safety given jointly by The Joint Commission and the National Quality Forum.

Mary Dixon-Woods, DPhil


Dr. Dixon-Woods is Professor of Medical Sociology and director of the SAPPHIRE group, Department of Health Sciences, University of Leicester, UK, and Deputy Editor-in-Chief of BMJ Quality and Safety. She leads a program of research focused on patient safety and health care improvement, health care ethics, and methodological innovation in studying health care. She is a fellow of the UK's Academy of Social Science and holds honorary positions as an Adjunct Professor in the Department of Anesthesiology and Critical Care Medicine at Johns Hopkins University, a visiting professor at Imperial College's Centre for Infection Prevention and Management, and a visiting associate professor at Dartmouth College. She was, in 2012, one of the first recipients of a Wellcome Trust Senior Investigator Award. She served on the National Advisory Group on the Safety of Patients in England, which produced the Berwick report in 2012. She was recently a member of the Patient Safety Forum at the World Innovation Summit for Health and is currently serving as an expert panel member the US National Patient Safety Foundation's review of patient safety.

Michael B. Edmond, MD, MPH, MPA


Dr. Edmond is the Chief Quality Officer and Associate Chief Medical Officer for University of Iowa Health Care and Clinical Professor of Infectious Diseases at the University of Iowa Carver College of Medicine. He previously served as the Richard P. Wenzel Professor of Internal Medicine, Chair of the Division of Infectious Diseases, and Hospital Epidemiologist at Virginia Commonwealth University in Richmond. He is a graduate of the West Virginia University School of Medicine (MD), the University of Pittsburgh Graduate School of Public Health (MPH), and the Virginia Commonwealth University School of Government and Public Affairs (MPA). He was a resident and chief resident in Internal Medicine at West Virginia University Hospitals. He then completed a fellowship in Infectious Diseases at the University of Pittsburgh Medical Center and a fellowship in Hospital Epidemiology at the University of Iowa College of Medicine. Dr. Edmond's areas of research focus on the epidemiology of health care–associated infections and the public policy implications of infection prevention. He has published numerous papers, abstracts, and book chapters, and he cowrites a blog entitled Controversies in Hospital Infection Prevention.

Rollin J. (Terry) Fairbanks, MD, MS


Dr. Fairbanks is the director of the National Center for Human Factors in Healthcare and of MedStar Health's Simulation Training & Education Lab (SiTEL), both in Washington, DC. He holds academic appointments as Associate Professor of Emergency Medicine at Georgetown University and Adjunct Associate Professor of Industrial Systems Engineering at the University at Buffalo, and he is an attending emergency physician at the MedStar Washington Hospital Center in Washington, DC. Dr. Fairbanks is a human factors/safety engineer, board certified emergency physician, private pilot, and former paramedic and EMS Medical Director, who uses his background in human factors engineering/industrial systems engineering to apply the science of safety to medical systems. His work is funded by the NIH, AHRQ, ONC, and several foundations. Dr. Fairbanks has authored more than 100 publications on health care safety and human factors, and he is an influential speaker. He serves on the National Patient Safety Foundation Board of Advisors, Emergency Medicine Patient Safety Foundation Board of Directors, and as a Health Research and Educational Trust (HRET) Senior Fellow.

Tejal Gandhi, MD, MPH


Dr. Gandhi is President of the National Patient Safety Foundation (NPSF) and the NPSF Lucian Leape Institute. In this role, she advocates for patient safety at the national level, drives educational and professional certification efforts, and helps to create and spread innovative new safety ideas. Dr. Gandhi was formerly the Executive Director of Quality and Safety at Brigham and Women's Hospital, and Chief Quality and Safety Officer at Partners Healthcare. In these roles, she led the efforts to standardize and implement patient safety best practices across hospital and health systems. She has been an invited speaker for numerous organizations, has mentored physicians in postdoctoral study, and has frequently served on committees such as The Joint Commission Medication Safety Expert Panel, the National Quality Foundation's Clinical Decision Support Expert Panel, and the ONC's Health IT Policy Committee's Safety Task Force. In 2014 and 2015 she was included in Modern Healthcare's 100 Most Influential People in Healthcare. In 2009, she received the John M. Eisenberg Patient Safety and Quality Award for her contributions to understanding the epidemiology and possible prevention strategies for medical errors in the outpatient setting. Dr. Gandhi is a board certified internist and Associate Professor of Medicine at Harvard Medical School, and she is a Certified Professional in Patient Safety.

Martin J. Hatlie, JD


Marty Hatlie is a patient advocate interested in the roles patients and families play in improving health care. Currently he serves as CEO of Project Patient Care (PPC), the Chicagoland safety and quality improvement coalition. PPC models partnership between providers and users of care, and advocates using the voice of the patient to improve care. Mr. Hatlie also serves as Director of the MedStar Institute for Quality and Safety, which is dedicated to promoting the wellbeing of users and providers of care as a core dimension of a high reliability organization. He is a codeveloper of the Healthcare & Patient Partnership Institute (H2PI) suite of tools for establishing patient and family advisory councils focused on improvement work. In 2003, Mr. Hatlie cofounded Consumers Advancing Patient Safety (CAPS), a nonprofit organization that fosters the role of the consumer as proactive partner, where he currently serves on the board of directors. He also serves on the Patients for Patient Safety Advisory Group for the World Health Organization's Patient Safety Programme, Joint Commission's Patient Safety Advisory Group, the Leapfrog Group Board of Directors, and the National Quality Forum's Measure Applications Partnership Hospital Workgroup. Previously, Mr. Hatlie was a lobbyist for the American Medical Association focused on civil justice reform. He coordinated the AMA's launch of the National Patient Safety Foundation in 1997 and served as its founding Executive Director from 1997 to 1999. He served on the Harvard Kennedy School Executive Session on Medical Error from 1998 to 2000 and the Anesthesia Patient Safety Foundation board from 1990 to 2000. Mr. Hatlie is a lawyer, licensed in Illinois and Massachusetts.

Christopher P. Landrigan, MD, MPH


Dr. Landrigan is Associate Professor of Medicine and Pediatrics at Harvard Medical School, Research and Fellowship Director of the Inpatient Pediatrics Service at Boston Children's Hospital, Director of the Sleep and Patient Safety Program at Brigham and Women's Hospital, and a practicing pediatric hospitalist. He has been studying the quality and safety of hospital care for 15 years. His research has evaluated efficiency and outcomes of care in pediatric hospitalist systems, as well as patient safety across pediatric and adult inpatient settings. His primary focus has been studying the effects of resident sleep deprivation, teamwork, and handoffs on patient safety. Dr. Landrigan has also led a series of studies evaluating the epidemiology of medical error and adverse events, the relationship between resident depression and patient safety, and the effects of computerized order entry systems on rates of medication errors. His current work focuses on evaluating the effectiveness of diverse approaches to reducing fatigue-related error, improving handoffs of care, and translating safety research into policy and practice.

Michelle Mello, MPhil, PhD, JD


Dr. Mello is Professor of Law at Stanford Law School and Professor of Health Research and Policy at Stanford University School of Medicine. She conducts empirical research into issues at the intersection of law, ethics, and health policy. She is the author of more than 140 articles and book chapters on the medical malpractice system, medical errors and patient safety, public health law, research ethics, the obesity epidemic, pharmaceuticals, and other topics. From 2000 to 2014, Dr. Mello was a professor at the Harvard School of Public Health, where she directed the School's Program in Law and Public Health. In 2013–2014 she completed a Lab Fellowship at Harvard University's Edmond J. Safra Center for Ethics. Dr. Mello teaches courses in torts and public health law. In 2013, she was elected to the National Academy of Medicine (formerly known as the Institute of Medicine).

Peter Pronovost, MD, PhD


Dr. Pronovost is a world-renowned patient safety champion and a practicing critical care physician. His scientific work leveraging checklists to reduce catheter-related bloodstream infections has saved thousands of lives and earned him high-profile accolades, including being named one of the 100 most influential people in the world by Time Magazine and receiving a coveted MacArthur Foundation award in 2008. Elected to the Institute of Medicine in 2011, Dr. Pronovost is an advisor to the World Health Organization's World Alliance for Patient Safety and regularly addresses the US Congress on patient safety issues. He is Senior Vice President of Patient Safety and Quality and Director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine. Dr. Pronovost blogs about eliminating preventable harm, improving patient outcomes and experience, and reducing waste in health care at his blog Points from Pronovost.

Ann E. Rogers, PhD, RN


Dr. Rogers holds the Edith F. Honeycutt Chair in Nursing at Nell Hodgson Woodruff School of Nursing, Emory University, where she is a professor and Director of the Graduate Program. She is nationally known for her research on sleep and was the Principal Investigator of the Staff Nurse and Patient Safety Study, which was the first study of document the hours worked by nurses and the adverse effects of these hours on patient safety. Findings from that study resulted in over a dozen manuscripts, several book chapters, and sweeping changes in nursing policies in clinical settings across the country. For her transformative impact on research and practice, she received the AACN Pioneering Spirit Award, an award from the American Association of Critical Care Nurses which recognizes significant contributions that influence acute and critical care nursing. Dr. Rogers is also one of six registered nurses in the United States who have completed the rigorous requirements for recognition as a Fellow of the American Academy of Sleep Medicine.

Hardeep Singh, MD, MPH


Dr. Singh is Chief of the Health Policy, Quality & Informatics Program at the Houston VA Center for Innovations in Quality, Effectiveness and Safety, and he is Associate Professor of Medicine at Baylor College of Medicine. He conducts multidisciplinary research on diagnostic errors, as well as on using health information technology to deliver safe and effective patient care. Dr. Singh's current research is supported by grants from the VA and AHRQ and has informed several national patient safety initiatives and policy reports, including those by the AMA, AHRQ, and IOM. Additionally, he codeveloped the "ONC SAFER Guides" for safe and effective electronic health record use and helped write national policy in the VA for test results communication. In 2012, Dr. Singh received the AcademyHealth Alice S. Hersh New Investigator Award for high-impact research. As a result of his scientific contributions, in 2013 he was appointed by the US Secretary of Health and Human Services to the Clinical Laboratory Improvement Advisory Committee, which advises the CDC, FDA, and CMS. In April 2014, he received the prestigious Presidential Early Career Award for Scientists and Engineers from President Obama for his pioneering work in the field of diagnostic errors and patient safety improvement. Dr. Singh was recently elected as a Fellow of the American College of Medical Informatics for significant and sustained contributions and advancements in the field of biomedical informatics. He also serves as the Associate Editor of the journal Diagnosis and cochairs the National Quality Forum Health IT Patient Safety Committee.

Dean F. Sittig, PhD


Dr. Sittig received his PhD in Medical Informatics from the University of Utah. His research interests center on design, development, implementation, and evaluation of all aspects of clinical information and communication systems. In addition to his work on measuring the impact of clinical information systems on a large scale, he is working to improve our understanding of both the factors that lead to success, as well as, the unintended consequences associated with computer-based clinical decision support and provider order entry systems. Most recently he has focused his efforts on developing guidelines for the safe and effective implementation and use of health information technology that are based on an eight-dimension sociotechnical model that he developed with Hardeep Singh. This work led to the development of the SAFER guides that were designed to help health care organizations conduct proactive risk assessments of their electronic health record systems. He recently coauthored an award-winning book on clinical decision support entitled, "Improving Outcomes—A Practical Guide to Clinical Decision Support Implementation." He is also the co-author of "Clinical Information Systems: Overcoming Adverse Consequences," "Electronic Health Records: Challenges in Design and Implementation," and most recently "SAFER Electronic Health Records: Safety Assurance Factors for EHR Resilience." For a listing of most of Dean F. Sittig's peer-reviewed scientific articles see:

Amy Vogelsmeier, PhD, RN


Dr. Vogelsmeier is an Associate Professor at the Sinclair School of Nursing, University of Missouri, and is coordinator of the Master's in Nursing Leadership and Health-systems Area of Study. She received her PhD in leadership and health-systems and master's degree in adult and gerontological nursing from the University of Missouri and her undergraduate nursing degree from the University of Central Missouri. Dr. Vogelsmeier has more than 20 years of practice experience in both acute and long-term care with extensive experience in leadership/management, quality improvement, and patient safety. Dr. Vogelsmeier's area of research is focused on patient safety with an emphasis on medication safety in nursing homes. Her work is among the first to explicate the role of the registered nurse in nursing home medication reconciliation practices. She has research expertise in nursing home work processes including medication administration and technology implementation. Dr. Vogelsmeier works as a consultant to the Center for Patient Safety on various projects related to medical error reporting and serves as an advisory board member to the Center's Patient Safety Organization activities specific to acute and long-term care organizations in Missouri.

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