Session Full Program · Contributors · Organizations · Search Program · Flagged · Happening NowMore…Search ProgramFlaggedHappening NowOral Presentations: Safety Investigations for Care Processes (PS2)Session ChairsHanna J BartonUniversity of Wisconsin - MadisonAsfand KhanEmbry-Riddle Aeronautical UniversityAdventHealthEvent TypeOral PresentationsTracksPatient Safety Research and InitiativesTimeMonday, March 251:30pm - 3:00pm CDTLocationSalon A-3Presentations1:30pm - 1:48pm CDTClosing the cross-institutional referral loop: Consultants’ and referrers’ perceived barriers and impact on clinical careAuthorsApril SavoyMichael WeinerTeresa Damush1:48pm - 2:06pm CDTOperating Room to Intensive Care Unit Patient Handoffs and the Risks of Patient HarmAuthorsNara SpallEdson MartinezCláudia SimõesPaul BarachMaria José Carvalho Carmona2:06pm - 2:24pm CDTImplementation of Systemic Contributors and Adaptations Diagramming for Event ReviewAuthorNikoleta Kolovos2:24pm - 2:42pm CDTSystemic Contributors and Adaptations Diagramming: Implementation in a Proactive Safety and Performance Monitoring Program in Central Sterile ProcessingAuthorsChristine JefferiesMichael F. RayoCarrie MillerBen LawlerKen Catchpole2:42pm - 3:00pm CDTCoordination Patterns That Underpin Adaptive Capacity in Complex Systems: A Sterile Processing Department Case StudyAuthorsSudeep HegdeJacob HionisChristine JefferiesGabriel SegarraSteven FosterMichael RayoKenneth CatchpoleLawrence FredendallKevin Taaffe