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TMIT
February 16, 2017, 12:00 pm - 1:30 pm CT / 1:00 pm - 2:30 pm ET
Mortality Reviews: Great Learning from Our Early Journey
 Session Overview

Patty Atkins, RN, MS, CNS, CPPS, is responsible for Quality, Patient Safety and Lean Six Sigma for Sharp HealthCare, the largest healthcare system in San Diego, CA. She will share the terrific learning her organization has gleaned from mortality reviews, having worked with Dr. Jeanne Huddleston from the Mayo Clinic who are the leaders in this field. Her insights are just what our surveys have told us from frontline safety leaders in our National Research Test Bed.

Dr. Huddleston's work at the Mayo Clinic has generated one of the strongest positive reactions we have ever had in our nearly 100 monthly sequential webinars. The breakthrough work that can have enormous impact on the patient safety of healthcare institutions.

Following Patty's presentation, a reactor panel will discuss how the insights can be applied to frontline care.

To download the article recommended by Patty Atkins entitled: Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review by Gooske Douw et. al, click here.

We offer these online webinars at no cost to our participants.

Webinar Video and Downloads



Click here to download the National Survey Results.     

Speaker Slide Sets:

Click here to download the combined speakers' slide set in PDF format – one (1) slide 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.")
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:  February 16, 2017  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 the know how learned from collaborators who are early in the journey of Mortality Reviews.
  • Accountability: Participants will understand who is accountable for responding to, and prioritizing, the opportunities for improvement identified through Mortality Reviews in the early stages of adoption.
  • Ability: Participants will learn what they must be able to do to succeed when they undertake a mortality review program.
  • Action: Participants will learn what actions they may need to take in order to consider or adopt an approach to collaborating on Mortality Review programs.

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
C. R. Denham, II, MD
In the News, Recent Polling Responses and Med Tac Briefing

During Dr. Denham's 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.
Read more...

 Session Speaker
Patty Atkins, RN, MS, CNS, CPPS
Mortality Reviews: Great Learning from Our Early Journey

Patty Atkins, RN, MS, CNS, CPPS, is responsible for Quality, Patient Safety and Lean Six Sigma for Sharp HealthCare, the largest healthcare system in San Diego, CA. In 2016, Patty led a team to launch a mortality review process in collaboration with Dr. Jeanne Huddleston from the Mayo Clinic. She is a Certified Profession in Patient Safety by the National Patient Safety Foundation and has been a Critical Care Clinical Nurse Specialist.
Read more...

 Reaction Panelists
Jeanne M. Huddleston, MD, FACP, FHM
Discussion and Reaction to Presentation

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...

Mary E. Foley, PhD, RN, FAAN
Discussion and Reaction to Presentation AND The Voice of the Patient and Family

Mary E. Foley, PhD, RN, is a Clinical Professor at the University of California San Francisco (UCSF) School of Nursing and is the Director in the Center for Nursing Research and Innovation at UCSF. She is the Assistant Director for the Master’s Entry Program in Nursing at UCSF, and teaches in the Masters in Health Administration and Interprofessional Leadership (MS-HAIL) course at UCSF.
Read more...

Related Resources
  1. Douw G, Schoonhoven L, et al. Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review. Critical Care. 2015 May 20. Available at: https://ccforum.biomedcentral.com/articles/10.1186/s13054-015-0950-5  
  2. National Academies of Sciences, Engineering, and Medicine. A national trauma care system: Integrating military and civilian trauma systems to achieve zero preventable deaths after injury. Washington, DC: The National Academies Press. 2016 June 17.Available at: http://www.nationalacademies.org/hmd/Reports/2016/A-National-Trauma-Care-System-Integrating-Military-and-Civilian-Trauma-Systems.aspx  
  3. ECRI Institute. 2017 Top 10 Hospital C-Suite WATCH LIST. ECRI Institute. 2017. Available at: https://www.ecri.org/Pages/ECRI-Institute-2017-Top-10-Hospital-C-Suite-Watch-List.aspx  
  4. 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  
  5. 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  
  6. 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.  
  7. 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.  
  8. 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.  
  9. [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..  
  10. 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.  
  11. [No authors listed] “What Doctors Hate About Hospitals”. TIME. 2006 May 1.
  12. 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/.  
  13. 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.   
  14. 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.   
  15. 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.   
  16. 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.   
  17. 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. Lindstrom L. Officials: Ohio 'ground zero' in opioid epidemic. EMS1.com. 2017 Feb 8. Available at https://www.ems1.com/opioids/articles/191830048-Officials-Ohio-ground-zero-in-opioid-epidemic/.   
  2. Hill M. Ohio Coroner Has Processed Over 150 Opioid Related Deaths So Far in 2017. The Urban Twist. 2017 Feb 10. Available at http://theurbantwist.com/2017/02/10/ohio-coroner-processed-150-opioid-related-deaths-far-2017/   
  3. Business Wire. For the 1st Time, the Annual World Patient Safety, Science & Technology Summit Will Be Streamed Live in HD Outside of the United States. Yahoo Finance. 2017 J . Available at http://finance.yahoo.com/news/1st-time-annual-world-patient-162300107.html.   
  4. PRNewswire. Pharmaceutical company launches epinephrine access program. EMS1.com. 2017 Jan 27. Available at https://www.ems1.com/patient-safety/articles/185910048-Pharmaceutical-company-launches-epinephrine-access-program/.   
  5. Hilsendager I. Defibrillators proving to be invaluable assets. Community Voice. 2017 Feb 3. Available at http://www.thecommunityvoice.com/article/Defibrillators-proving-to-be-invaluable-assets.   
  6. Ostrom CM. Nurse’s suicide follows tragedy. The Seattle Times. 2011 April 21. Available at http://www.seattletimes.com/seattle-news/nurses-suicide-follows-tragedy/.   
  7. Barnett ML MD, Olenski AR BS, et al. Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use. NEJM. 2017 Feb 16. Available at http://www.nejm.org/doi/full/10.1056/NEJMsa1610524#t=articleTop/.   
  8. AHRQ. HOSPITAL SURVEY ON PATIENTSAFETY CULTURE 2016 User Comparative Database Report. AHRQ. 2016. Available at https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/2016/2016_hospitalsops_report_pt1.pdf.   
  9. Caplan AL PhD. The Problem of Publication-Pollution Denialism. Mayo Clinic Proceedings. 2015 May. Available at http://www.mayoclinicproceedings.org/article/S0025-6196%2815%2900190-1/abstract.   
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