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August 18, 2016, 12:00 pm - 1:30 pm CT/1:00 pm - 2:30 pm ET
Learn from Mortality Review AND the Living: Part 2 – A Deeper Dive
 Session Overview
In response to the overwhelmingly positive evaluations of our webinar last month addressing Learning from Mortality Reviews, we have asked Dr. Jeanne Huddleston to take a deeper dive into what can be learned from mortality reviews and how participants can start a program and learn from others.
Dr. Huddleston and her colleagues at the Mayo Clinic have undertaken breakthrough work that can have enormous impact on the patient safety of healthcare institutions. She will share learnings on their journey to analyze the stories of all patient deaths with a deep dive on specific and important topics. She will share the lessons learned through the development and evolution of the Mayo Clinic Mortality Review System.

Patient safety events are increasingly recognized as the 3rd leading cause of death including the typical adverse events we count and measure in patient safety. These existing measurement systems do not identify actionable opportunities for improvement nor provide obvious direction for next steps. The information Dr. Huddleston will share will help us understand areas of critical importance that will compliment what we do in prevention of adverse events. Following her presentation, a reactor panel will discuss the new information building on our July webinar shared by Dr. Huddleston.

Webinar Video and Downloads



Click here to download the Polling Data.     

Speaker Slide Sets:

Click here to download the combined speakers' slide set in PDF format – one (1) slide per page.     

Click here to download the combined speakers' slide set in PDF format – four (4) slides per page.     

To view the file, click the desired link (please note: the files may take several minutes to download). To save to your hard drive, right click on the link and choose "Save Target As." (In some browsers it might say "Save Link As.")

The slide set could take several minutes to download. The "four per page" slide set may download more efficiently.
Registration Information and CE Credit Information:
 Register:
Registration is closed for the 'live' online version of this webinar. You can view the entire webinar by watching the video above.

 When:  August 18, 2016  Time: 12:00 pm - 1:30 pm CT/1:00 pm - 2:30 pm ET
We are accepting questions now that relate to the session topics. Please e-mail any questions related to the specific session to webinars@safetyleaders.org with the session title in the e-mail message header.
  • Questions about the Webinar series?
    E-mail webinars@safetyleaders.org or call 512-473-2370 between 9:00 a.m. and 4:30 p.m. CT.
  • Need technical assistance with registration? Call 512-457-7605 between 9:00 a.m. and 4:30 p.m. CT.

Learning Objectives:

  • Awareness: Participants will understand and be able to communicate that multidisciplinary and multi specialty clinical involvement is critical for identification of opportunities for improvement and creating actionable information.
  • Accountability: Participants will understand who is accountable for responding to, and prioritizing, the opportunities for improvement identified during the Safety Learning System review process.
  • Ability: Participants will learn the principles of a Safety Learning System review and use of Chatham House Rules to reach consensus, across disciplines and departments, about the opportunities for improvement in any one patient care experience.
  • Action: Participants will learn which types of charts and reports carry the highest potential for securing meaningful leadership support and resources to mitigate future harm and make lasting change.

CE Participation Documentation

Texas Medical Institute of Technology, approved by the California Board of Registered Nursing, Provider Number 15996, will be issuing 1.5 contact hours for this webinar. TMIT is only providing nursing credit at this time.

To request a Participation Document, please click here.

 Introduction and Moderator
Charles R. Denham, MD
In the News and Recent Polling Responses

During Dr. Denham's business development career spanning 30 years, he and his organizations have served hundreds of innovation teams. While in practice as a radiation oncologist, he taught biomedical engineering and product development. He has taught innovation adoption, technology transfer, and commercialization in both academia and industry. He has been an adjunct Professor of Health Services Engineering at the...
Read more...

 Session Speaker
Jeanne M. Huddleston, MD, FACP, FHM
Learn from Mortality Review AND the Living: Next Generation Safety Learning System

Jeanne M. Huddleston, MD, FACP, FHM, is a past President of the Society of Hospital Medicine, the founder of Hospital Medicine and past Program Director of the Hospital Medicine Fellowship at Mayo Clinic, Rochester, MN. She is Chairperson of Mayo Clinic's Mortality Review Subcommittee, a multi-disciplinary group of providers that review every death in search of where the health care delivery system may have failed the providers and/or the patient.
Read more...

 Reaction Panelists
Dan Ford, MBA, LFACHE
Discussion and Reaction to Presentations AND The Voice of Patient and Family

Dan Ford, MBA, is a patient/patient safety advocate; retired Vice President of Furst Group, a healthcare executive search firm; nationally known speaker on patient safety, has served and is serving on a number of national and regional patient safety and quality, PFE and PFAC boards/committees, serves as a patient/family advisor on LEAN process improvement events at Spectrum Health, and is a writer on patient safety and leadership.
Read more...

Jennifer Dingman
Discussion and Reaction to Presentations

Jennifer Dingman realized, after her mother's death in 1995 due to errors in medical diagnoses and treatment, that there is little to no help available for patients and their families in similar situations. This life-changing experience left her feeling vulnerable, and she decided to dedicate her life to help prevent medical tragedies from happening to others.
Read more...

Related Resources
  1. Huddleston JM, Diedrich DA, Kinsey GC, Enzler MJ, Manning DM. Multi-Center Collaborative to Move Beyond Mortality Review and Create the Next Generation Safety Learning System. J Patient Saf. 2014 Mar;10(1). MultiCenter SLS Collaborative v17Aug2016.pdf  
  2. Huddleston JM, Diedrich DA, Kinsey GC, Enzler MJ, Manning DM. Learning from every death. J Patient Saf. 2014 Mar;10(1):6-12. doi: 10.1097/PTS.0000000000000053. Special Article. http://journals.lww.com/journalpatientsafety/Citation/2014/03000/Learning_From_Every_Death.2.aspx  
  3. Anderson J, Naonori K. Learning from patient safety incidents in incident review meetings: Organisational factors and indicators of analytic process effectiveness. Safety Science. 2015 Dec. Available at: http://www.sciencedirect.com/science/article/pii/S0925753515001769.  
  4. Martin JH, Taylor B, et al. A 100% Departmental Mortality Review Improves Observed-to-Expected Mortality Ratios and University HealthSystem Consortium Rankings. Safety Science. 2013 Dec 25. Available: http://www.ncbi.nlm.nih.gov/pubmed/24529804.  
  5. Barbieri, JS. Fuchs BD. The Mortality Review Committee: A Novel and Scalable Approach to Reducing Patient Mortality. The Joint Commission Journal on Quality and Patient Safety. 2013 Sep 1. Available at: http://www.ncbi.nlm.nih.gov/pubmed/24147350.  
  6. [No authors listed.] National Action Plan for Adverse Drug Event Prevention. Office of Disease Prevention and Health Promotion. Office of the Assistant Secretary for Health, Office of the Secretary. Washington, DC. 2014 Aug. Available at http://www.health.gov/hai/pdfs/ADE-Action-Plan-508c.pdf. Last accessed January 21, 2015..  
  7. Makary M and Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139. Available at: http://www.bmj.com/content/353/bmj.i2139.  
  8. [No authors listed] “What Doctors Hate About Hospitals”. TIME. 2006 May 1.
  9. James JT. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. J Patient Safety. 2013; 9:122-128. Available at: http://journals.lww.com/.  
  10. National Quality Forum. Safe Practice 1: Culture of Safety Leadership Structures and Systems. IN: Safe Practices for Better Healthcare – 2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010. Available at http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx.   
  11. National Quality Forum. Safe Practice 2: Culture Measurement, Feedback, and Intervention. IN: Safe Practices for Better Healthcare – 2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010. Available at http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx.   
  12. National Quality Forum. Safe Practice 3: Teamwork Training and Skill Building. IN: Safe Practices for Better Healthcare – 2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010. Available at http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx.   
  13. National Quality Forum. Safe Practice 4: Risks and Hazards. IN: Safe Practices for Better Healthcare – 2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010. Available at http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx.   
  14. National Quality Forum. Safe Practice 5: Informed Consent. IN: Safe Practices for Better Healthcare – 2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010. Available at http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx.   
  15. National Quality Forum. Chapter 9: Opportunities for Patient and Family Involvement. IN: Safe Practices for Better Healthcare – 2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010. Available at http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx.   
In the News
  1. Quick Safety Facts. The Joint Commission. Issue 24 June 2016. Available at https://www.jointcommission.org/quick_safety.aspx.  
  2. Levinson W MD, Yeung J MD, et al. Disclosure of Medical Error. JAMA. 2016 Aug 16. Available at: http://jama.jamanetwork.com/article.aspx?articleid=2544645.  
  3. Abbasi J. Headline Grabbing Study Brings Attention Back to Medical Errors. JAMA. 2016 Aug 16. Available at: http://jama.jamanetwork.com/article.aspx?articleid=2544638.  
  4. Nguyen OK MD MAS, Makam AN MD MAS, et al. Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse Outcomes. JGIM, 2016 Aug 8. Available at: https://link.springer.com/article/10.1007%2Fs11606-016-3826-8.  
  5. Whitman E. Best Practices: Addressing errors with Candor. Modern Healthcare, 2016 Aug 13. Available at: http://www.modernhealthcare.com/article/20160813/MAGAZINE/308139997.  
  6. Ghaferi, AA, Myers, CG, et al. The Next Wave of Hospital Innovation to Make Patients Safer. Harvard Business Review, 2016 Aug 8. Available at: https://hbr.org/2016/08/the-next-wave-of-hospital-innovation-to-make-patients-safer.  
  7. Price EL MD, Sewell JL MD MPH, et al. Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange. The Joint Commission Journal on Quality and Patient Safety. Volume 42, Number 8, August 2016, pp. 341-354(14). Available at: http://www.ingentaconnect.com/content/jcaho/jcjqs/2016/00000042/00000008/art00002.  
  8. National Safety Council. Injury Facts, 2015 Edition. Pages 30-31. Available at: http://www.nsc.org/Membership%20Site%20Document%20Library/2015%20Injury%20Facts/NSC_InjuryFacts2015Ed.pdf.  
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