Menu

April 20, 2017, 12:00 pm – 1:30 pm CT / 1:00 pm – 2:30 pm ET

​Failure to Rescue: Bedside Patient Rescue –  A Great Opportunity

Session Overview

Failure to Rescue, according to Dr. Jeanne Huddleston, the leading researcher in mortality reviews at the Mayo Clinic, is one of the most common “Opportunities for Improvement” and a great area to have impact. Opportunities of omission have been identified as a major interest area of our research test bed through multiple surveys. She will introduce the topic and lead our discussions.

Dr. Santiago Romero-Brufau of the Mayo Clinic, will present the Bedside Patient Rescue program developed from the information yielded by mortality reviews as a great opportunity for performance improvement.   A reactor panel of patient advocates and experts will react to the presentation.

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 now closed for this Webinar.  The video of the webinar can be viewed above.

  When:  April 20, 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 the details regarding “failure to rescue” of deteriorating patients from Mortality Reviews and be able to discuss strategies for improvement.
  • Accountability: Participants will understand who may be accountable for responding to, and prioritizing, the opportunities for improvement in failure to rescue.
  • Ability: Participants will learn about competencies important to failure to rescue and care of the deteriorating patient.
  • Action: Participants will learn what actions they may need to take in order to consider or adopt an approach to improvement of their own patients in their institutions.

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

Jeanne M. Huddleston, MD, FACP, FHM
Jeanne M. Huddleston, MD, FACP, FHM Failure to Rescue – What we Learned from Mortality Reviews
Bio
Santiago Romero-Brufau, M.D
Santiago Romero-Brufau, M.DBedside Patient Rescue at the Mayo Clinic
Bio
C. R. Denham, II, MD
C. R. Denham, II, MDIn the News and Recent Polling
Bio
Gregory H. Botz, M.D., FCCM
Gregory H. Botz, M.D., FCCMDiscussion and Reaction to Presentations
Bio
Jennifer Dingman
Jennifer DingmanDiscussion and Reaction to Presentations AND The Voice of Patient and Family
Bio

Related Resources

  1. ECRI Institute. PSO Deep Dive: Patient Identification: Executive Summary. ECRI Institute. 2016 Aug.
    Available at: https://www.ecri.org/Pages/Patient-Identification-Deep-Dive.aspx 
  2. CDC. National Healthcare Acquired Infections Progress Report (2014 data). CDC.2016.  Available at: https://www.cdc.gov/hai/surveillance/progress-report/index.html 
  3. Fikes BJ. First medical diagnosis often incomplete or plain wrong, study finds. The Mayo Clinic. 2017 April. Available at: http://www.sandiegouniontribune.com/business/biotech/sd-me-second-opinions-20170404-story.html 
  4. 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  
  5. 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 
  6. 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  
  7. 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  
  8. 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  
  9. 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  
  10. 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  
  11. 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  
  12. 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  
  13. 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.  
  14. 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.  
  15. 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.  
  16. 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.  
  17. 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/.  
  18. 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.   
  19. 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.   
  20. 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.   
  21. 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.   
  22. 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. Scientific American Editors. It’s Time to Get a Better Accounting of What Kills Us. Scientific American. 2017 April 1. Available at https://www.scientificamerican.com/article/it-rsquo-s-time-to-get-a-better-accounting-of-what-kills-us/    
  2. Miliard M. Top 10 patient safety concerns for 2017, according to ECRI. Healthcare IT News. 2017 March 14. Available at https://www.scientificamerican.com/article/it-rsquo-s-time-to-get-a-better-accounting-of-what-kills-us/    
  3. 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     
  4. Brilli RJ. National Survey Measures Parents’ Feelings About Hospital Safety. US News and World Report: Health Care News. 2017 Mar 14. Available at http://health.usnews.com/health-care/for-better/articles/2017-03-14/national-survey-measures-parents-feelings-about-hospital-safety     
  5. PR Newswire. HIT Linked to Nearly 900 Medication Errors in Pennsylvania Report. EMS World. 2017 Mar 15. Available at http://www.emsworld.com/news/12316084/hit-linked-to-nearly-900-medication-errors-in-pennsylvania-report    
  6. Almendrala A. This Prescription Drug Is Implicated In Almost A Third Of All Opioid Overdose Deaths. The Huffington Post. 2017 Mar 15. Available at http://www.huffingtonpost.com/entry/opioid-overdoses-combination-benzodiazepine_us_58c83e16e4b01c029d76f5ad     
  7. McClain M. What You Need to Know About Cardiac Arrest in Schools. Good4Utah.com. 2017 Mar 20. Available at http://www.good4utah.com/news/local-news/what-you-need-to-know-about-cardiac-arrest-in-schools/676069757    
  8. Rapaport L. Cafes, ATMs might be good places for emergency defibrillators. KFGO. 2017 Mar 21. Available at http://kfgo.com/news/articles/2017/mar/21/cafes-atms-might-be-good-places-for-emergency-defibrillators/9438    
  9. Singh J. Opioid & Heroin Overdose Antidote, Naloxone, To Be Sold Over-The-Counter In More States. The Science Times. 2017 Mar 21. http://www.sciencetimes.com/articles/10654/20170321/doctors-want-opioid-antidote-naloxone-to-be-sold-over-the-counter-in-more-states    
  10. Thinkstock. AARP Law Supports Family Caregiver Engagement in Discharge. Patient Engagement HIT. 2017 Mar 20. Available at http://healthitsecurity.com/news/79k-patients-affected-by-emory-healthcare-data-breach    
  11. Grygotis L. Opioid and benzodiazepine combination use significantly increases overdose risk. The Clinical Advisor. 2017 Mar 23. Available at http://www.clinicaladvisor.com/pain-management-information-center/opioid-and-benzodiazepine-combination-use-linked-to-overdose-risk/article/645902/    
  12. Lenovo Health. Securing data integrity at the ‘front door’ of care delivery. Healthcare IT News. 2017 Apr 3. Available at http://www.healthcareitnews.com/sponsored-content/securing-data-integrity-%E2%80%98front-door%E2%80%99-care-delivery    
  13. The National Academies of Sciences, Engineering, and Medicine. Fostering Integrity in Research. The National Academies Press. 2017. Available at: https://doi.org/10.17226/21896