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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.

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

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Webinar Video, and Downloads

Webinar Video:

National Survey Results:

Click here to download the National Survey Results.

Speaker Slide Set:

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.

Webinar date: October 20, 2016

Time:

  • 01:00 PM to 2:30 PM Eastern Daylight Time
  • 12:00 PM to 1:30 PM Central Daylight Time
  • 11:00 AM to 12:30 PM Mountain Daylight Time
  • 10:00 AM to 1:30 AM Pacific Daylight Time

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: Next Generation Safety Learning System
Bio
Hanan Foley, MSN, RN, CPHQ
Hanan Foley, MSN, RN, CPHQLearning from Collaboration on Mortality Reviews: The Journey
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 Presentation 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. 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.
  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
  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
  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
  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

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.