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.    

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

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 with the session title in the e-mail message header.

  • Questions about the Webinar series?
    E-mail 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.


Session Speakers and Panelists

C. R. Denham, II, MD
C. R. Denham, II, MDIn the News, Recent Polling and 100 Webinars in Review
John J. Nance, JD
John J. Nance, JDThreats in 2017 and Red Cover Report
Jeanne M. Huddleston, MD, FACP, FHM
Jeanne M. Huddleston, MD, FACP, FHM Mortality Reviews: Looking Forward in '17
Liana Orsolini, Ph.D., RN, ANEF, FAAN
Liana Orsolini, Ph.D., RN, ANEF, FAAN Our Mortality Review Journey
Gregory H. Botz, M.D., FCCM
Gregory H. Botz, M.D., FCCM Medical Tactical (Med Tac) Program & Healthcare Workplace Violence
William H. Adcox, MBA
William H. Adcox, MBAMedical Tactical (Med Tac) Program & Healthcare Workplace Violence
Arlene Salamendra
Arlene Salamendra The Voice of Patient and Family AND Discussion and Reaction to Presentations
Hilary J. Schmidt, PhD
Hilary J. Schmidt, PhD Discussion and Reaction to Presentations
Jennifer Dingman
Jennifer Dingman Discussion and Reaction to Presentations
Dan Ford, MBA, LFACHEDiscussion and Reaction to Presentations
Becky Martins
Becky MartinsDiscussion and Reaction to Presentations

Related Resources

  1. ECRI Institute. Top 10 Patient Safety Concerns for Healthcare Organizations 2017. ECRI Institute 2017 March 15. Available at:  
  2. Zimmerman B. Hospitals fail to document nearly half of all family-reported medical errors, study finds. Becker’s. 2017 Feb 28. Available at  
  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  
  4. Lipitz-Snyderman A PhD, Korenstein D PhD. Reducing Overuse—Is Patient Safety the Answer? JAMA. 2017 Feb 28. Available at  
  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:  
  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:  
  7. ECRI Institute. 2017 Top 10 Hospital C-Suite WATCH LIST. ECRI Institute. 2017. Available at:  
  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.  
  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:  
  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:  
  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:  
  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 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:  
  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:  
  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