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TMIT
October 20, 2016, 12:00 pm - 1:30 pm CT / 1:00 pm - 2:30 pm ET
Learning from Collaboration on Mortality Reviews: The Journey
 Session Overview
In response to the overwhelmingly positive evaluations of our webinars on Learning from Mortality Reviews by Dr. Jeanne Huddleston of the Mayo Clinic, we have engaged leading organizations who have joined the collaborative efforts.
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. In our July and August webinars, she shared the lessons learned through the development and evolution of the Mayo Clinic Mortality Review System, and will be our introduction speaker for our webinar this month.

Our audience was polled and asked if they wanted to hear from groups at the front line who have learned from the Mayo Clinic work and are actively studying and collaborating on mortality reviews. Hanan Foley, MSN, RN, CPHQ, the Director of Quality and Safety at MedStar Georgetown University Hospital, will share their experience on the journey.

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.     

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:  September 20, 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 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
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...
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 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...

Hanan Foley, MSN, RN, CPHQ
Learning from Collaboration on Mortality Reviews: The Journey

Hanan Foley, MSN, RN, CPHQ, is the Director of Quality and Safety at MedStar Georgetown University Hospital. Her healthcare career spans over 35 years most of which were spent in Critical Care Nursing and Quality Improvement. She has also functioned as an adjunct faculty in the Department of Health Systems Administration at Georgetown University School of Nursing and Health Studies and as an advisor to the IHI Open School students.
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 Reaction Panelists
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.
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Jennifer Dingman
Discussion and Reaction to Presentations AND The Voice of the Patient and Family

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. 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. Rechtoris M. Investigation uncovers US fails to report infection-related death toll — 5 things to know. Becker’s 2016; Sep 26. Available at http://www.beckersasc.com/asc-quality-infection-control/investigation-uncovers-us-fails-to-report-infection-related-death-toll-5-things-to-know.html.   
  2. Finnigan L and Donnelly L. Junior doctors call off planned five day NHS walkouts . The Telegraph News. 2016 Sep 24. Available at http://www.telegraph.co.uk/news/2016/09/24/junior-doctors-call-off-planned-five-day-nhs-walkouts/.   
  3. Beck M. Medical Record Mix-Ups a Common Problems, Study Finds. The Wall Street Journal. 2016 Sep 25. Available at http://www.wsj.com/articles/medical-record-mix-ups-a-common-problem-study-finds-1474844404.   
  4. Whitman E. When doctors get the wrong patient. Modern Healthcare. 2016 Sep 25. Available at http://www.modernhealthcare.com/article/20160925/NEWS/160929937.   
  5. Associated Press. Medicare sets new patient safety goals for hospitals. Business Insider. 2016 Sep 29. Available at http://www.businessinsider.com/ap-medicare-sets-new-patient-safety-goals-for-hospitals-2016-9.   
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