ACP International Conference 2022

As a former Assistant Director in a jurisdictional Ambulance Service and having served on the executive of the Professional Board for Emergency Care, HPCSA, Navin is experienced in health systems management and regulation. His research and policy interest includes critical theory, transformative pedagogy, gender-based violence prevention and evidence-informed decision making that intersects state and civil society interests in emergency care. Navin was co-chair of the Belgium Red Cross First Aid for First Responders EBM project in sub-Saharan Africa and is a certified alternate dispute resolution mediator. He supervises higher degree research in South Africa and Australia, in the fields of Paramedicine, social inclusivity, health professions education, emergency and forensic medicine.

Max is the pioneer recipient of the Singapore Civil Defence Force’s Paramedic Scholarship. He began training as a combat medic in 2017 as part of Singapore’s military conscription. He subsequently joined the Singapore Civil Defence Force having been inspired by his attachments to the civilian ambulances. Max is finishing up his degree and is looking forward to completing his Honours next year. His research interests include out-of-hospital cardiac arrest, paramedic mental health and more recently – organisational psychology.

Matt is a 23 year veteran in the prehospital environment. He currently has the luxury of a job share position between working as a MICA Flight Paramedic and a Clinical Support Officer with Ambulance Victoria. Matt also has worked as a teaching associate with Monash University for the last 20 years, where he has developed an interest in research leading to several peer reviewed articles that have been published

Associate Professor Scott Devenish is the Paramedicine Discipline Lead for the School of Nursing, Midwifery and Paramedicine at the Australian Catholic University (ACU). Scott is a Registered Paramedic, and a Fellow of the Australasian College of Paramedicine. Scott actively contributes to the Paramedicine profession through high quality teaching, academic leadership, peer-reviewed publications, the supervision of research higher degree candidates and through research mentorship. He leads a team of dedicated academics ensuring ACU paramedic programs of study meet the needs of the constantly evolving Paramedicine profession to produce future outstanding clinicians, researchers, and leaders.

Dr Mya Cubitt is a NZer, living in Australia with her South African husband and their three Australian children. Mya trained at Otago University, completing her advanced training in Emergency Medicine with a peripatetic journey across Australia, the Buchanan Prize for the highest scoring candidate in the fellowship exam for the Australasian College for Emergency Medicine (ACEM) and a fellowship in Paediatric Critical Care at The Royal Children’s Hospital. She has a masters degree in Trauma Science from Queen Mary University, completing a dissertation on frailty assessments in trauma and in 2021, Mya convened the first seminar and research workshop on Geriatric Trauma, #GEMSEM2021.

Dr Angela Martin has worked as a registered paramedic and manager for 20 years in state and private sectors. She is a published author and long-standing advocate for Community Paramedicine. Her PhD thesis was an international exploratory study on perspectives of Community Paramedicine through multiple stakeholder lenses. Angela is an active committee member on the ACP Community Paramedicine working group, and lead investigator of an ACP study exploring the landscape of Community Paramedicine across Australasia. Angela is passionate about bridging health service delivery gaps in rural and remote communities, and is employed as a remote paramedic and project consultant with SDS, leading the development of a contemporary pre-hospital education package for the WACHS Kimberly Ambulance Service. Angela's achievements include being awarded the PA SAAS Rod Kershaw Scholarship (2013), SA Ambulance Service Clinical Excellence Commendation in Professional Development (2016), and the prestigious SA Emergency Services medal (2018), for exceptional leadership and contribution to regional communities through her advocacy, research and involvement in the development of a Community Paramedicine program in rural SA. Angela's qualifications include: PhD, BN, GDipN (Emerg), Dip.ParaSci (Amb), Dip.Mgt., Cert. IV TAE.

Alex has years of clinical and research experience, with an interest in the bridge between the pre-hospital and in-hospital environment in critical care. He is currently doing his PhD in pre-hospital resuscitation of major trauma patients. Alex divides his time between clinical care, research, mentoring and teaching our future paramedics.

Paramedic honours graduate from Charles Sturt University, Port Macquarie, in 2022. Pavani has recently completed research in discrimination faced by paramedics, particularly racism. Her research aims to understand how diversity is represented and treated in paramedicine, as well as the pathways and support offered to paramedics. Pavani hopes to gain employment as a paramedic as she continues her research in cultural competency within the profession.

Matt has been Senior Lecturer in Paramedic Science at Teesside University in the UK since 2007. This followed an ambulance career with the Yorkshire Ambulance Service. He set up a BSc (Hons) Paramedic Science course for existing paramedics to top-up to degree level and contributed to Teesside’s pre-registration degree programme. He holds a BSc in Sociology and Social Psychology, an MSc in Paramedic Science and is currently undertaking a PhD looking at the use of Emergency Medical Services by patients experience back pain.

Bronwyn Beovich has worked in the Department of Paramedicine at Monash University for 6 years and is currently a Senior Teaching Fellow, working within both undergraduate and postgraduate areas. With a clinical healthcare background, she commenced university-based healthcare research and healthcare educational research 15 years ago and has published over 25 papers within the paramedicine field.

James Maskey is a celebrated social impact professional, striving to enhance the mental, physical, and social wellbeing of the first responder community. James is currently the 'Sector Specialist' of Fortem Australia. Fortem Australia is a not-for-profit organisation that supports the mental fitness and wellbeing of first responders and their families – the people who protect and care for our community. James is a retired front-line Queensland Police Officer with a service history including General Duties and the Child Protection & Investigation Unit. In 2013, James was diagnosed with Post Traumatic Stress Disorder and subsequently transitioned out of the Queensland Police Service in 2015. James was also formerly the National Engagement Manager of Beyond Blue’s Police and Emergency Services Program. James is deeply committed to driving cultural change, high-value policy reform, and additional government support to support positive mental health and wellbeing in the first responder sector. Additionally, James is an advocate for individual first responders and works tirelessly to increase help-seeking behaviours, remove barriers to accessing supports such as entrenched stigma, and ultimately create mentally healthy workplaces within the first responder sector. For his ongoing mental health advocacy efforts in the first responder sector, James was recognised as one of Pro Bono Australia's 'Impact 25 Award' recipients for 2019, honouring the social and human services sector's most influential people for their significant and positive impact in Australia and around the world. James is currently undertaking a Master of Leadership degree at Deakin University, researching mental health leadership in the first responder sector.

Jason is a clinical manager and paramedic with St John WA, and completing a Master's degree by research at Curtin University focussing on assessment of patient conscious state during emergency calls. He has worked in the prehospital care field for over 10 years as a frontline paramedic and in health service liaison and secondary triage roles before joining the clinical governance team. He has interests in patient safety, telephone triage and telehealth, and systems for recognising patient deterioration.

Brendan is registered paramedic, researcher and clinical guideline developer with the Queensland Ambulance Service. In his current role, he is involved in the development and implementation of clinical practice guidelines utilised by ambulance clinicians in Queensland. In addition to an undergraduate degree in Paramedical Science, Brendan holds a Master’s degree in Public Health majoring in Epidemiology and Research Methods. Brendan has a passion in the translation of evidence-based practice into the clinical setting, most notably in the fields of resuscitation and coronary reperfusion. Brendan has authored a number of publications of these topics and is a regular reviewer for various emergency medical journals.

Simon is an Intensive Care Paramedic with the South Australian Ambulance Service, delivering pre-hospital critical care, as well as developing the service’s personal safety training programmes. In addition to training paramedics, Simon is also employed by Flinders University as a personal safety lecturer. He is a successful martial artist of over 20 years, achieving black belts in several disciplines and has been inducted into his ambulance service’s elite Special Operations Team as a Rescue Retrieval Paramedic. Simon is a director of Guardian Personal Safety Training teaching occupational violence solutions around Australia and overseas.

Sam is a Critical Care Paramedic with the Queensland Ambulance Service. He has been involved in prehospital care and emergency response for over 14 years, has significant experience working in fire/HAZMAT, confined space rescue and USAR environments. Sam is currently based in Townsville QLD and his areas of interest include clinical education, toxicology and motorcycle trauma.

Meg grew up in Perth Western Australia, where she studied at Edith Cowan University and graduated with a Bachelor of Science in Paramedicine. Meg then moved to the UK where she worked for London Ambulance Service as a Paramedic on both the ambulance and first response car. After 4.5 years in London Meg has returned to Perth and is now working as a Paramedic for St John Ambulance WA.

Oliver has been a Registered Nurse and Registered Paramedic for over eight years. Six years working in the paediatric intensive care unit at the Queensland Children's Hospital, becoming an advanced paediatric life support instructor. More recently, he has been at the Royal Brisbane and Women's hospital in the Emergency and trauma centre, where he's been one of the department's clinical facilitators and has acted as a Nurse educator for the Medical emergency response team. Oliver has continued prehospital exposure as a private Paramedic working in event space, covering festivals and high-risk sporting events. Oliver is currently halfway through his Midwifery training.

Jeremy is a current P1 Paramedic with NSW Ambulance working in a regional centre. Jeremy has extensive experience in the education space as an Educator with Surf Lifesaving, previous roles within private RTOs, and more recently as a CPD educator with ACP. Jeremy has completed a Bachelor's degree in Medical and Health Sciences and a Bachelor's degree in Clinical Practice (Paramedic).

Dr. Spelten is Associate Professor with La Trobe University Rural Health School and the Violet Vines Marshman Research Centre. Her work focusses on workforce innovation and quality of care. As an occupational psychologist, she has been privileged to work multidisciplinary, and has worked across many different health care disciplines. She is principal supervisor of 10 regional PhD Students, five of which are industry PhDs with local rural organisations. She has received two awards for her translational research. Dr. Spelten is Deputy Editor of the Australian Journal of Rural Health and she has published more than 100 articles.

Dr Scott Stewart is a Senior Lecturer and Professional Practice Lead at ACU Ballarat. He has also taught at VU, Monash and St George’s University of London. Scott recently completed his PhD in teaching paramedic students Evidence Based Practice.

Lloyd is the HOD of Emergency Medical Sciences at the Cape Peninsula University of Technology, where they currently offer a range of undergraduate and post graduate qualifications in Emergency Medical Care. Lloyd qualified as a paramedic in 1989 and is currently enrolled in doctoral study on quality in EMS. Lloyd has extensive experience in EMS education and training as well as EMS operations. He was previously the Chairperson of the Professional Board for Emergency Care at the Health Professions Council of South Africa, and is currently serving his second term on the Board.

Elisabeth graduated from Western Sydney University with a Bachelor of Health Science: Paramedicine in 2021. She is now working as a registered paramedic in a state emergency ambulance service. Elisabeth enjoys studying the pathophysiology behind her patient’s presenting conditions.

Operational Manager of Health Equity Unit at Sunraysia Community Health Services (SCHS) a regional community in North West Victoria. SCHS provides primary and preventive care for community members who are at risk of poor health outcomes, and experience health disparities through a Social Determinants of Health (SDoH) lens. The centrepiece of care at SCHS is providing a client relationship based care coordination approach, that identifies and attempts to address the SDoH for clients, work with consumers and community members, to structure their care around the context in which they live and work.

Mitchell Cowan is a Senior Cardiac Physiologist at Royal North Shore Hospital and Clinical Specialist at Biosense Webster. He specialises in Electrophysiology & Cardiac Devices, currently sitting on the EP Test Writing Committee for IBHRE and the Professional Standards Committee for PICSA. He is a published author in JACC on the management of ventricular arrhythmias and is currently involved in research projects on the QT interval as well as predicting sudden death in TAVI. He has also written chapters on atrial flutter, RVOT VT & ARVC in the “Cardiac Electrophysiology in Clinical Case Review” textbook. He has lectured at local and international conferences and is passionate about educating staff and increasing the professional standards of healthcare to facilitate better patient care.

Kenny Ng is a lecturer for the Cardiac Ultrasound program at Western Sydney University and a Cardiac Physiologist at Royal North Shore Hospital. He has been heavily involved in echocardiography education and training leading him to develop and run a hands-on echo training program in Sydney. Apart from cardiac ultrasound, he is also assists in the education of staff in the other areas of cardiac physiology such as Cardiac Catheterisation Lab, Electrophysiology and Electrocardiography He has also been an invited speaker at multiple national education meetings and webinars.

Damian is a Registered Nurse and endorsed Nurse Practitioner and has been directly involved in delivering advanced wound management services for over 20 years. His current positions are as A/Nurse Practitioner Chronic Wound and Stoma Service within a Community Health Service and Clinical Nurse Consultant for Wound Management in a Brisbane Metropolitan Hospital. He is actively involved in gaining knowledge, promoting best practice and building evidence in the field wound management. He holds post graduate qualifications in Wound Management and Masters of Nurse Practitioner. He conducts regular wound management education and has presented at conferences Locally, Nationally and Internationally and currently involved as a Primary or Associate Investigator on several research projects. Damian has held committee positions on both the Australian Wound Management Association (AWMA) National Committee (now Wounds Australia) and Queensland Committee. He is a past President of the Queensland Branch and a current Committee Member of Wounds Australia – Queensland.

Jake is an intensive care paramedic (MICA) with Ambulance Victoria and has over 13 years of industry experience, including working as a clinical instructor and educator at both the Advanced Life Support (ALS) and Intensive Care Paramedic (ICP/MICA) levels in Melbourne, VIC. He has an interest in prehospital trauma care, clinical decision making in high-acuity/complex settings and developing paramedic mindset-growth towards evidence-based practices.

Brendan is a senior lecturer within the department of paramedicine and a registered Paramedic. Brendan is enrolled as a PhD candidate with his thesis investigating alternative care pathways by evaluating the impact of a hospital based community care program and the evaluation of the introduction of community paramedicine programs across the globe. Brendan has a keen research interest in alternative care pathways, non-transport, referral services, palliative care and community paramedicine.

Jason is a Specialist Pharmacist working with the Queensland Ambulance Service to ensure the quality use of medicines in the pre-hospital setting. He has worked in various roles in the health system, including clinical and management roles in public hospital pharmacy departments in a wide range of speciality areas. In 2021 he completed his PhD in pharmacy practice at the Queensland University of Technology.

Alecka is a Paramedic at a GP clinic and is the Course Coordinator of the postgraduate Community Paramedicine courses at Edith Cowan University (ECU) in Perth, Western Australia. She is a long-suffering Melbourne Demons fan and proud ‘Mumma’ to Poppy (6 years) and Hamish (4 years), a career highlight and her greatest achievement so far. Despite expressing her concerns about research being a ‘waste of time’ as student ambulance paramedic in Melbourne , she has since changed her tune and developed research interests community paramedicine and paramedic education. She has a Master degree in Emergency Health and is currently undertaking her PhD and looks forward to dressing like a professor from Harry Potter when she graduates.

Mitch has been a paramedic with the Queensland Ambulance Service for the past 7 years in the Logan district of South East Queensland. He is currently working on the critical care paramedic pod out of Woodridge station. He has completed both a bachelor's degree in paramedic science and a graduate diploma in Critical Care Paramedicine with distinction. Most recently Mitch has had experience working in both continual education and paramedic inductions. Outside of QAS Mitch has significant experience working in both film and tv and festival medicine and has been involved in multiple special deployment opportunities including the gulf of Carpentaria during the 2018 floods and to northern NSW during the most recent floods

Rachael has worked for the Queensland Ambulance Service for eleven years, including as a Critical Care Paramedic for the last four years in Metropolitan Brisbane. She also has experience as an Acting Clinical Support Officer providing education and support for staff. She is most passionate about mentoring Critical Care Paramedic interns, clinical development and leadership.

Rory is a Critical Care Paramedic with the Queensland Ambulance Service where he has worked for the last 15 years. During his career he has worked as a Critical Care Flight Paramedic, a Clinical Support Officer and is currently the Senior Clinical Educator for the Darling Downs region. Rory has also taken some time to work as a Paramedic with the London Ambulance Service. During his career he has been involved in a lot of pre-hospital births, which led him to become a Registered Midwife. During his time as a Midwife, he has worked at Logan hospital, The Royal Brisbane Hospital and has recently returned from six months working as a Midwife at the University Hospital in Reykjavik, Iceland.

ct Associate Professor Alan Eade is the Chief Paramedic Officer for Victoria. He works alongside the other chief clinical officers based within Safer Care Victoria.

Alan believes the delivery of great care is all about collaboration and cooperation between professions, with recognition that great care is always delivered through a multidisciplinary partnership. He is focused on strengthening relationships between paramedics and other health professions in order to ensure integrated, optimal system performance is delivered for the best patient outcomes for all Victorians.

Alan is an experienced intensive care paramedic with a successful career in emergency ambulance settings, and event health and medical services. He is a Fellow of the Australasian College of Paramedicine and previously held the position of Chief Commissioner at St John Ambulance Australia. He has an adjunct academic appointment at Monash University.

Dr Ben Meadley is an Adjunct Senior Lecturer at Monash University in the Department of Paramedicine. Ben’s doctoral project investigated the physiological and metabolic health of paramedics, systems improvement and specialist paramedic task performance. Ben has more than 24 years’ experience, gaining expertise in prehospital critical care, paramedic education, paramedic health research, systems improvement and clinical guideline development. Ben currently works as the Operational Improvement Lead (MICA) and as a senior Intensive Care Flight Paramedic (MICA) at Ambulance Victoria, dividing his time between clinical, systems improvement and research roles.

Steph is an advanced care paramedic with QAS. She lives and works in a small rural town where she is an active member of the community. She has worked as a paramedic for the past 10 years after completing a Bachelor of Health Science (Paramedic) at QUT. She is now completing a Master of Paramedicine (Extended Care) at Charles Sturt University and looks forward to furthering her research pathway in the future.

Kenneth has been an operational paramedic operating with the Singapore Civil Defence Force (SCDF) Emergency Medical Services (EMS) for about 12 years. He holds a supervisory and operational role as a Station EMS OIC at Marina Bay Fire Station. He is also currently the vice-chairman of the SCDF’s Clinical Protocol Review and Standards Committee. He completed his Paramedic certification at the Justice Institute of British Columbia and Diploma in Paramedicine from Nanyang Polytechnic, Singapore. He is also an active NAEMT instructor of the disciplines of PHTLS and AMLS in Asia countries such as Taiwan, Malaysia, the Philippines and Singapore.

Paramedic Specialist with NSW Ambulance. Experience in a variety of clinical roles that include: Intensive Care Paramedic, Critical Care Paramedic, Special Operations, Rescue Paramedic and Flight Paramedic. Until 2021 worked as a Critical Care Paramedic Educator at the NSW Ambulance ACE Training Centre for five years. Now Associate Director of Clinical Practice. Devoted to furthering the paramedicine profession. This has led to roles on the colleges board of directors and as a member of the Paramedicine Accreditation Committee in Australia.

Natalie (PhD, MPH, BClinPrac (Paramedicine)) is a Senior Lecturer of Paramedicine in the School of Nursing, Midwifery and Paramedicine at UniSC. Natalie is an early career researcher with an interest in health behaviours (cancer screening), health professions communication, interprofessional education, student support, and wellbeing of paramedics. She has over $350,000 in grant funding and has fourteen peer-reviewed publications and commissioned reports. Natalie has worked in medical education for seven years, and coordinated a full-year level of the Doctor of Medicine, Griffith University, Sunshine Coast and taught communication skills using simulation. She also led the student support initiative. She is a registered paramedic with sixteen years of on-road experience with ASNSW.

Prior to moving to Australia Matt spent 10 years working in the London Ambulance Service NHS Trust as a paramedic. He was also the program leader for the undergraduate BSc (Hons) Paramedic Science (London) at the University of Greenwich, UK. At UniSC Matt leads the courses in the WIL space which relates to his research interests in wellbeing, coping and preceptorship. Matt has recently completed his PhD exploring how first year student paramedics experience stress on their first ambulance placement.

Dr Paul Simpson is an Associate Professor in Paramedicine at Western Sydney University. He is Editor in Chief of Paramedicine, the College’s international peer-reviewed journal, and a member of the ACP Research Advisory Committee. In his spare time Paul continues to practice as an Intensive Care Paramedic with NSW Ambulance and in the private sector, when not paddling his ski on the beautiful Port Hacking river.

John is a New Zealand trained medical doctor who enthusiastically specialises in primary care. His clinical career has included training and working in EDs and rural general practices. In recent years he has worked and taken leadership roles in a Superclinic, in a Bunnings sized general practice, in large corporates and in Urgent Care Clinics. His current roles are as the Australian Convenor for the RNZCUC, as an Adjunct Associate Professor at the University of the Sunshine Coast and as a Medical Director for a General Practice group in Southeast Queensland.

I have been lucky enough to be a paramedic for 16yrs. During this time I have been afforded some amazing development opportunities. By far one of the greatest opportunities I have had to date was to embark on the Community paramedic pathway with the completion of the LARU program in 2016. Since then I have completed 2 grad Cert’s and now completing a masters in Community paramedicine. Currently I am a Clinical Support Officer where I am able to assist in the learning and development of LARU officers both at a local and state level.

Sherlyn Hii is an undergraduate paramedic student based in Melbourne, Victoria. She is currently completing a Bachelor of Nursing / Bachelor of Paramedicine degree. Sherlyn was a professional filmmaker in a previous life, but she decided to leave the stage lights behind to pursue a more meaningful career in health care. Since commencing her studies in 2019, Sherlyn has worked in a variety of health roles including as a Registered Undergraduate Student of Nursing (RUSON) in a large tertiary hospital. Sherlyn also volunteers as an ambulance community officer, providing emergency first response in a rural setting.

Natasha Adams is a Senior Critical Care Paramedic (CCP) with the Queensland Ambulance Service, working on the Woodridge CCP POD and with the High Acuity Response Unit. Her clinical interests include progressive out of hospital care, clinical education and leadership development.

David is the Medical Director of Ambulance Victoria, an intensivist at The Alfred Hospital and an adjunct senior lecturer in the Department of Paramedicine at Monash University. He has trained and worked as a paramedic in Auckland and as a doctor in Auckland, Sydney and Toronto before settling in Melbourne. His clinical interests are prehospital and retrieval medicine, trauma, EMCO and bioethics. He has an embarrassingly large collection of Lego.

Sam is an ICP based in Eastern Rural Victoria, having been a paramedic for close to a decade, with previous emergency nursing experience. Sam holds a Bachelor of Nursing and a Master of Specialist Paramedic Practice both awarded by Monash University. He is passionate about prehospital ultrasound with recent publications discussing ultrasound guided cannulation and lung ultrasound.

Professor Brett Williams is the Head, Department of Paramedicine at Monash University. Brett has published over 330 peer-review publications with over 10,000 citations, and 3 edited textbooks. He is committed to professionalising paramedicine, and building capacity for paramedics nationally and internationally.

Daniel is a registered Paramedic and Chiropractor. He is currently a paramedicine lecturer and deputy clinical coordinator for paramedicine with the Australian Catholic University (ACU). He has worked in tertiary education since 2016 with both, Queensland University of Technology (QUT) and ACU. He has been employed as an ACP2 with the Queensland Ambulance Service since 2011 and before that as a medic in the Australian Army. He is a fellow of the higher education academy. He is a member of the Australasian College of Paramedicine, Australian Paramedics Association Queensland, and the Australian Chiropractic Association.

Derek is an experienced registered paramedic from Western Australia. He started his career in New Zealand as an EMT, before moving to Australia and completing his undergraduate degree at Curtin University in WA. Derek has since developed a keen interest in paramedic research and completed an honours programme at Monash University investigating how paramedics use their professional code of conduct. Derek is also a sessional lecturer and a HDR student at Curtin University.

Dr Simpiwe Sobuwa is a Senior Lecturer in the Department of Emergency Medical Sciences at the Durban University of Technology. He is also the Vice-President of the Health Professions Council of South Africa (HPCSA) for the 2020-25 term of office and the Chairperson of the Professional Board for Emergency Care of the HPCSA. He is also an associate editor for the South African Journal of Prehospital Emergency Care.

Sharon Duthie is a registered Critical Care Paramedic and works for St John Ambulance in Ashburton, New Zealand. As a large town serving the surrounding farming district, the ambulance service in Ashburton responds to both urban and rural areas. In her spare time, Sharon is a mixed sheep, cattle, and crop farmer. This gives her a practical understanding of the rural environment, and the mechanics of farming injuries. Sharon has a strong interest in research, education and sharing interesting cases to promote learning amongst her peers and has previously presented at ACP conferences.

Hugh is a Medical Officer at Queensland Health, currently working in Emergency Medicine at Logan Hospital. Prior to medicine, he worked as an Advanced Care Paramedic with Queensland Ambulance Service for eight years. His clinical interests are in patient safety and perioperative medicine. Outside of work, he enjoys spending time with friends and family, video games, cricket and horse racing.

Dean is a critical care paramedic with 27 years frontline experience in prehospital emergency ambulance service, including road based ambulances, HEMs, single crewed rapid response and remote/offshore experience. Dean has been involved in significant mass casualty incidents which has instilled a passion in him to find better ways to deal with the issues from these incidents and improve patient outcomes.