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TMIT
January 19, 2017, 12:00 pm - 1:30 pm CT / 1:00 pm - 2:30 pm ET
Saving Lives Putting Mortality Reviews to Work – It does pay off!
 Session Overview

Dr. Jeanne Huddleston from the Mayo Clinic generated one of the strongest positive reactions we have ever had in our nearly 100 monthly sequential webinars for her work in mortality reviews. She will now show how such information can be used to save lives.

She 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 how the learnings on their journey to analyze the stories of all patient deaths are being converted into results.

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 how the insights can be applied to frontline care.

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.     

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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:  January 19, 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 on Mortality Reviews.
  • Accountability: Participants will understand who is accountable for responding to, and prioritizing, the opportunities for improvement identified through Mortality Reviews.
  • Ability: Participants will learn what they must be able to do in order to join a collaborative program on mortality review.
  • 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
Jeanne M. Huddleston, MD, FACP, FHM
Learn from Mortality Review AND the Living

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

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...

Christopher R. Peabody, MD, MPH
Discussion and Reaction to Presentations

Christopher R. Peabody, MD, MPH, is a practicing Emergency Physician in California and Clinical Instructor at the University of California, San Francisco. He is also the Director of the UCSF Acute Care Innovation Center, an initiative of the UCSF Department of Emergency Medicine, which develops novel ways to deliver Emergency and Acute Care reliably and safely by developing new technology and validating best practices. He has a strong commitment to public service and healthcare delivery to vulnerable populations.
Read more...

Gregory H. Botz, M.D., FCCM
Discussion and Reaction to Presentations

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...

Related Resources
  1. 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  
  2. 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  
  3. 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  
  4. 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  
  5. 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.  
  6. 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.  
  7. 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.  
  8. [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..  
  9. 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.  
  10. [No authors listed] “What Doctors Hate About Hospitals”. TIME. 2006 May 1.
  11. 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/.  
  12. 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.   
  13. 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.   
  14. 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.   
  15. 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.   
  16. 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. Punke H. Incivility in the OR: How hospitals, nurse managers and frontline nurses should respond. Becker’s. 2017 Jan 4. Available at http://www.beckershospitalreview.com/quality/incivility-in-the-or-how-hospitals-nurse-managers-and-front-line-nurses-should-respond.htmlst.aspx.  
  2. Davis J. Top 10 healthcare technology advances for 2017, according to ECRI. Healthcare IT News. 2017 Jan 10. Available at: http://www.healthcareitnews.com/news/top-10-healthcare-technology-advances-2017-according-ecri.  
  3. Clark CM, PhD, RN, ANEF, FAAN. Promoting Civility in the OR: An Ethical Imperative. AAORN Journal. 2017 January. Available at: http://www.aornjournal.org/article/S0001-2092(16)30831-6/pdf.  
  4. Selby N. I’ve seen the opioid epidemic as a cop. Living it as a patient has been even worse. The Washington Post. 2017 Jan 11. Available at: https://www.washingtonpost.com/posteverything/wp/2017/01/11/ive-seen-the-opioid-epidemic-as-a-cop-living-it-as-a-patient-has-been-even-worse/?utm_term=.d5cb8852e31e.  
  5. European Resuscitation Council. Editorial Kids Save Lives – Training school children in cardiopulmonary resuscitation worldwide is now endorsed by the World Health Organization (WHO). European Resuscitation Council. 2015 July 5. Available at: http://www.resuscitationjournal.com/article/S0300-9572(15)00315-9/abstract.  
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