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 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.

We offer these online webinars at no cost to our participants.

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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.”)

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Registration Information and CE Credit Information

Register:  The webinar has previously taken place. See webinar 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.

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Session Speakers and Panelists

Jeanne M. Huddleston, MD, FACP, FHM
Jeanne M. Huddleston, MD, FACP, FHM Learn from Mortality Review AND the Living
Bio
Christopher R. Peabody, MD, MPH
Christopher R. Peabody, MD, MPH Discussion and Reaction to Presentations
Bio
Gregory H. Botz, M.D., FCCM
Gregory H. Botz, M.D., FCCMDiscussion and Reaction to Presentations
Bio
Arlene Salamendra
Arlene SalamendraDiscussion and Reaction to Presentations AND The Voice of Patient and Family
Bio
C. R. Denham, II, MD
C. R. Denham, II, MDIn the News and Recent Polling
Bio

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   
  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   
  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  
  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   
  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  

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.