• Introduction
• Area Directory & Contact Details
• Role of the Clinical Risk Adviser
• Life cycle of a claim
• CIS Publications
  -Newsletter
  -Q & A Booklet
  -Statement Writing
  -Risk Management In Mental Health Services
• Alerts
• Indemnity specifics
• STARSWeb Statistics
• Summary Report for the Mental Health Commission
• The SCA CIS Incident Notification Requirements
• Serious Adverse Clinical Events
• Informed Consent
• Publications of Interest
• Medication Safety
• Links
• Upcoming Events
• Presentations

Presentations

Governance Day Farmleigh 27^th of October

• Implications of Regulation of Health Care Professionals from a “Governance” point of view.
• Topical Issues in Risk Management, Dr Ailis Quinlan.
• Governance and Data Protection in the Health Sector, Billy Hawkes, Data Protection Commissioner.
• Governance and Patient Safety Seminar, Ciarán Breen, Director, State Claims Agency.
• Governance of Voluntary Hospitals: the CEO’s perspective.

Medication Management Issues in Mental Health Services.

• Clinical Pharmacy Audit and Change Compatibility Mode, Aoife Davis.
• Medication safety issues in Mental Health.
• Overview of Medication Incidents Reported to the Clinical Indemnity Scheme.
• Medication Management, Leadership & Governance in Mental Health Services.
• Medication Management in Approved Centres

National Modified Early Warning Score and Education Programme (Compass), June 22nd 2011, Farmleigh House.

• The National Early Warning Score and associated Education Programme, Eilish Croke, June 22, 2011.
• Acute Medicine Programme, Professor Shane O'Neill.
• Guiding Framework and Policy for the National Early Warning Score System to Recognise and Respond to Clinical Deterioration National EWS System Project and associated Education Programme.
• Implementation of the National Early Warning Score and associated Education Programme.
• MEWS and MET initiative. Local implementation experience: AMNCH Dr John Cullen.
• MEWS Bleep System in Connolly Hospital, Dolores Dempsey:Ryan, Nurse Practice Developement Coordinator (Acting), Connolly Hospital.
• Nurses experience and attitudes toward an EWSS and MET. Gerry Allen, Advanced Nurse Practitioner in Cardiology, South Infirmary-Victoria University Hospital Cork.
• How to implement and continuously improve - Quality Improvement vs. Quality Assurance.
• Report of Audit Subcommittee, Maria Donnelly, AMNCH.
• COMPASS Programme Overview, Maria Horgan, St. Luke's Hospital, Kilkenny.

Additional Information and Tools

• Connolly MEWS Phone Stickers June 2011.
• Isbar Phone Stickers June 2011.
• MEWS Part One Audit Data Analysis Tool.
• Connolly Audit of MEWS June 2011.
• SBAR Report.
• SBAR Communication Audit Tool.

Deteriorating Patient Conference

• National Acute Medicine Programme 2010, Shane O’Neill & Garry Courtney.
• Intensity of Care: Anne Hickey, Margaret Gleeson, John Kellett, Nenagh Hospital.
• Interruptions during Medication Administration: Assessing the Impact of a Set of Interventions.
• Recognition and Treatment of the Deteriorating Patient. Rapid Response Systems for Ireland? John Kellett MD, November 2010.
• Medical Emergency Team (M.E.T.) The South Infirmary-Victoria University Hospital, Cork.
• SBAR Communication Tool, Anne Marie Oglesby, RGN., MSc. Health Care(Risk Management & Quality), Clinical Risk Advisor, Clinical Indemnity Scheme.
• Early Warning Scores & ALERT™, Valerie Clarke.

AMI - Heartbeat Symposium, November 22nd 2010, Farmleigh

• Wexford General Hospital’s Experience, Anne Sinnott, Chest Pain Nurse.
• Revascularization for STEMI, Ken Maleady Chest Pain / ED, Connolly Hospital.
• Heartbeat Overview - Cork University Hospital.
• Every System Is Perfectly Designed To Get The Results It Gets, David Vaughan.
• Is It or Isn’t It, Kate O’Donovan, 2010.
• HSE West Reperfusion Strategy PilotProject, Paudie O Riordan, A/Chief Ambulance Officer, Western Region Ambulance Service.
• HeartBeat. Improving Heart Attack Care in Ireland. Past, present and future. Dr Siobhan Jennings, Consultant in Public Health Medicine.
• The Improvement Model/How to Improve, Dr Noeleen Devaney, Heartbeat Symposium, 22 November 2010.

Falls

• Slips/Trips/Falls –the CIS Perspective.
• Falls from hoists 2004-2009.
• Slip/Trip/Fall relating to Shower/ing: Events reported to the STARSWeb National Reporting System from 1st January 2004 to December 31st, 2009.
• Annual Health Burden of Falls for Older Irish People - Dr Ailis Quinlan.
• Ballymun PCT Falls & Fracture Pilot Screening Project Report 2009.
• State Claims Agency (2009) Epidemiological Study of Falls in Ireland based on Incident and Claims Data Created On STARSWeb from 2004-2008.
• Falls - Pathways to prevention for the Irish Population - Dr Ailis Quinlan.
• Setting the scene from an International and UK perspective - Cameron Swift, King's College London
• Strategy to Prevent of Falls and Fractures in an Ageing Population - Dr Marie Laffoy.
• The Inpatient Falls Prevention Programme - Department Of Medicine For The Elderly, St James Hospital.
• Falls Strategy Presentation - Community Rehab and Support Team.
• Falls in the Elderly - Bríd McAtarsney.
• Falls in Population w/ Intellectual Disability - Bernadette Flood
• HSE Dublin Mid Leinster Working Group on Falls
• An integrated approach to falls management in Pallative Care & Care of the Elderly Settings
• Falls and Fracture Prevention Programme - Áine O'Riordan
• Programme Evaluation

Workshop Proceedings

• Falls Poster presented at Health Services Quality & Safety Conference 2008
• Falls Symposium Pathways to Prevention for the Irish Population, December 2007
• Appendix 1 - Guidance For Group Facilitators
• Appendix 2 Lincolnshire Integrated Care Pathway
• Appendix 3 - Detailed Written Feedback From The Four HSE Administrative Regions

Mental Health

• Mental Health Act 2001 Children - R Smyth Presentation, Farmleigh 15-Nov-2007
• Best Practice for Effective Risk Management and the Mental Health Act 2001 - Patricia Gilheaney
• Functional Analysis of Care Environment - Dr Ruth Loane, Rita Hinchion, Simon Wale.
• An Overview of Clinical Incidents and Claims Data in Mental Health Services - Debbie Dunne.
• Risk Assessment: An Overview - Dr Margaret O'Rourke

Paediatrics

• Staff Guidelines in relation to obtaining consent for children and young people.
• Mental Health Act 2001 & Children.
• Code of Practice Relating to Admission of Children under The Mental Health Act 2001.
• Risks associated with the transfer of critically ill children.

Medication Safety

• Medication Safety. We know what we have to do - Lets do it.
• Actions That Can Make The Use Of AntiCoagulants Safer.
• The quality of medication information imparted at acute hospital discharge.
• The Evidence Base - Pharmacy services delivered at admission to and discharge from hospital.
• Hospital to Home Drug Safety Seminar
• Prescribing Safety Seminar Handouts - The GP-Hospital interface: A weak link in the perscribing chain?
• Nurse & Midwife Prescribing

Obstetric Forum Presentations

• The Epidemiology of Cerebral Palsy The experience of the West of Ireland Cerebral Palsy Register 1990-1999
• Assessment of Fetal Well Being
• Cerebral Palsy: Challenges and Opportunities
• Cerebral Palsy Claims
• Informing families of their child's disability
• Management of mothers who decline transfusion with blood/blood products
• ALERT Does one course fit all?
• Psychological care of women in pregnancy and the puerperium
• Conundrums in Perinatal Psychiatry

Open Communication - When Things Go Wrong in Healthcare

• A Chief Executive’s Perspective.
• Representing The Patient Not The Statistic - Carol Mullins.
• Being Open – International Overview 2009 - Dr Jane Cowan.
• When things go wrong - The Human Factor - Barbara Lynch.

Disability

• Policy for admission to hospital for adults with an intellectual disability.
• Safety and Quality - An Integrated Perspective, Irene O’Byrne-Maguire, Clinical Risk Advisor, Clinical Indemnity Scheme.
• Pilot of New Adverse Incident Reporting System/STARS Web database in St John of God, North East Services.
• Brian McClean, Brothers of Charity Roscommon, Challenging Behaviours - Why did we choose this project?
• Safety & Quality - An Integrated Perspective, National Federation of Voluntary Bodies, Person Centred Medication Management, David Kieran, June 13th 2007.
• Person Centred Planning – Balancing Safety & Rights, John O’Dea.
• Missing Person, St Anne’s Service Experience.
• Person Centred Planning, Stepping Out Project, Carmona Services, Balancing Safety & Risk/Opportunity
• Person Centered Planning – Balancing Safety & Risk.
• Towards a full and valued life – Balancing Risk & Seizing Opportunities.
• Accident/Incident Management Reporting and Follow up Response.
• Practice Development.

"Driving and supporting safe patient care through effective claims and risk management."