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March 16, 2017, 12:00 pm - 1:30 pm CT / 1:00 pm - 2:30 pm ET
2017 Threats & Safety
Why Hospitals Should Fly: Mortality Reviews and
Harm from Omission, Med Tac, and Healthcare Violence
 Session Overview

This is our 100th sequential monthly webinar delivered to our National Research Test Bed. It is only fitting that we have a super star speaker line up for you.

John Nance is one of our nation's greatest patient safety experts and advocates. He is nationally-known author of 19 major books, five non-fiction, plus 13 fiction bestsellers. His books Why Hospitals Should Fly and Charting the Course are both must reads for patient safety leaders. He will give us a head's up on threats and Red Cover Report case studies will help you serve.

Dr. Jeanne 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 tie together opportunities for improvement in 2017.

Liana Orsolini, PhD., RN, ANEF, FAAN, the Care Delivery and Advanced Practice System Consultant for Clinical Excellence and Innovation for Bon Secours Health System, will join to discuss the Mortality Review Journey.

Dr. Greg Botz and Chief Bill Adcox, two of our nation's leading threat scientists will address the progress on bystander care for the most common causes of death in the healthy and new insights on healthcare workplace violence.

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.     

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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:  March 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, understand important life-saving issues for healthy children and adults, and be introduced to issues regarding healthcare workplace violence.
  • 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, intervention opportunities to save lives in the general public, and understand accountability issues pertaining to healthcare workplace violence.
  • Ability: Participants will learn about competencies important to mortality reviews, medical tactical interventions for common causes of death, and prevention strategies to prevent harm from healthcare workplace violence.
  • 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, adoption of medical tactical lifesaving techniques, and consideration of actions toward reducing workplace violence.

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 and 100 Webinars in Review

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 Speakers
John J. Nance, JD
Threats in 2017 and Red Cover Report

One of the key thought leaders to emerge in American healthcare in the past decade, John J. Nance brings a rich and varied professional background to the task of helping doctors, administrators, boards, and front-line staff alike survive and prosper during the most profoundly challenging upheaval in the history of modern medicine. Having helped pioneer the renaissance in patient safety as one of the founders of the National Patient Safety Foundation in 1997, his efforts (and healthcare publications) are dedicated to reforming American healthcare from a reactive cottage industry to an effective and safe system of prevention and wellness.
Read more...

Jeanne M. Huddleston, MD, FACP, FHM
Mortality Reviews – Looking Forward in 2017

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...

Liana Orsolini, Ph.D., RN, ANEF, FAAN
Our Mortality Review Journey

Liana Orsolini, Ph.D., RN, ANEF, FAAN, is the Care Delivery and Advanced Practice System Consultant for Clinical Excellence and Innovation for Bon Secours Health System, a role she has held since July, 2013. Dr. Orsolini leads all advanced practice clinician (APC) initiatives across several states in order to liberate their potential to work to the fullest extent of their education, training and state scope of practice. She is the system lead for mortality and especially Value Based Purchasing mortality using a centralized interprofessional review process to standardize care  for greater safety and reliability.
Read more...

Gregory H. Botz, M.D., FCCM
Medical Tactical (Med Tac) Program & Healthcare Workplace Violence

Gregory H. Botz, MD, FCCM, is a professor in the Department of Critical Care at the UT MD Anderson Cancer Center. He received his medical degree from George Washington University School of Medicine in Washington, DC. He completed an internship in internal medicine at Huntington Memorial Hospital and then completed a residency in anesthesiology and a fellowship in critical care medicine at Stanford University in California. He also completed a medical simulation fellowship at Stanford with Dr. David Gaba and the Laboratory for Human Performance in Healthcare. Dr. Botz is board-certified in anesthesiology and critical care medicine. He is a Fellow of the American College of Critical Care Medicine.
Read more...

William H. Adcox, MBA
Medical Tactical (Med Tac) Program & Healthcare Workplace Violence

With 37 years in municipal and campus policing, William H. Adcox serves as the Chief of Police and CSO at The University of Texas MD Anderson Cancer Center and The University of Texas Health Science Center. Chief Adcox holds an MBA degree from UTEP and is a graduate of the PERF's Senior Management Institute for Police and the Wharton School ASIS Program for Security Executives.
Read more...

Arlene Salamendra
The Voice of Patient and Family AND Discussion and Reaction to Presentations

Arlene Salamendra is a former Board member and Staff Coordinator of Families Advocating Injury Reduction (FAIR). A number of years ago, she was the subject of a preventable medical error. Since that time, she has devoted a portion of her time to giving support to other patients...
Read more...

 Reaction Panelists
Hilary J. Schmidt, PhD
Discussion and Reaction to Presentations

Hilary J. Schmidt, PhD, is an advanced education expert with extensive experience in strategic planning and change management within both the pharmaceutical industry and Academic Medical Centers.
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...

Dan Ford, MBA, LFACHE
Discussion and Reaction to Presentations

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 boards/committees, serves as a patient/family advisor at Spectrum Health, and is a writer on patient safety and leadership.
Read more...

Becky Martins
Discussion and Reaction to Presentations

Becky Martins' advocacy spirit derives from the days when she was driving a family member 150 miles round-trip, three days a week, to dialysis treatments. She spent countless hours at the unit visiting with patients and their families. It was through their stories that she learned of the many challenges faced by patients living with chronic illness. It was by their example that she learned of the resilience of the human spirit to face health and health-related challenges head-on.
Read more...

Related Resources
  1. ECRI Institute. Top 10 Patient Safety Concerns for Healthcare Organizations 2017. ECRI Institute 2017 March 15. Available at: https://www.ecri.org/EmailResources/PSRQ/Top10/2017_PSTop10_ExecutiveBrief.pdf  
  2. Zimmerman B. Hospitals fail to document nearly half of all family-reported medical errors, study finds. Becker’s. 2017 Feb 28. Available at http://www.beckershospitalreview.com/quality/hospitals-fail-to-document-nearly-half-of-all-family-reported-medical-errors-study-finds.html  
  3. Khan A MD, MPH. Coffrey M MD, FRCPC, et al. Families as Partners in Hospital Error and Adverse Event Surveillance. JAMA Pediatrics. 2017 Feb 27. Available at http://jamanetwork.com/journals/jamapediatrics/article-abstract/2604750  
  4. Lipitz-Snyderman A PhD, Korenstein D PhD. Reducing Overuse—Is Patient Safety the Answer? JAMA. 2017 Feb 28. Available at http://jamanetwork.com/journals/jama/fullarticle/2605779  
  5. 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  
  6. 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  
  7. 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  
  8. 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  
  9. 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  
  10. 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.  
  11. 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.  
  12. 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.  
  13. [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..  
  14. 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.  
  15. [No authors listed] “What Doctors Hate About Hospitals”. TIME. 2006 May 1.
  16. 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/.  
  17. 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.   
  18. 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.   
  19. 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.   
  20. 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.   
  21. 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. Conn J. Lawsuit alleges patient was charged $2,694 for release of medical records. Modern Healthcare. 2017 Mar 2. Available at http://www.modernhealthcare.com/article/20170302/NEWS/170309978.   
  2. Jaspers AW BS, Cox LJ JD, et al. Copy Fees and Limitation of Patients’ Access to Their Own Medical Records. JAMA. 2017 Jan 30. Available at http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2599438   
  3. HealthDay News. Supreme Court Rules Patient Safety Data Subject to Litigation. Doctors Lounge. 2017 Feb 27. Available at http://www.doctorslounge.com/index.php/news/pb/70283.   
  4. Parks T. Court rules patient-safety info subject to litigation discovery. AMA Wire. 2017 Feb 27. Available at https://wire.ama-assn.org/practice-management/court-rules-patient-safety-info-subject-litigation-discovery.   
  5. Thinkstock. 79K Patients Affected by Emory Healthcare Data Breach. Health IT Security. 2017 Mar 2. Available at http://healthitsecurity.com/news/79k-patients-affected-by-emory-healthcare-data-breach.   
  6. Arndt R. Emory Healthcare cyberattack affects 80,000 patient records. Modern Healthcare. 2017 Mar 2. Available at http://www.modernhealthcare.com/article/20170302/NEWS/170309983.   
  7. Slater TP. Medical errors rise, but malpractice lawsuits fall cords. The Des Moines Register (part of the USA Today network). 2017 Feb 26. Available at http://www.desmoinesregister.com/story/opinion/columnists/iowa-view/2017/02/26/medical-errors-rise-but-malpractice-lawsuits-fall/98363556/.   
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