Global Patient Safety Forum

The GPSF is a convening alliance with a mission to save lives, save money, and build value in the community it serves.  The Forum was expressly founded to make available important content that the collaborators want to share more broadly. This website is not intended to compete with any other initiative and will meet its objectives if collaborators and those interested in the topics share the information with their communities. There are no financial requirements of users of the site. Certain communities are private in order to protect those we serve and those who serve. Those we serve are patients and their families. Those who serve are the caregivers, administrators, researchers, educators, and staff in the healthcare industry.

Global Innovators Network

We are a global network of leaders from academia, industry, government, NGOs, philanthropy, and faith-based organizations who are collaborating on best practices in leadership of innovation. Spawned to meet the global needs of innovators in healthcare and patient safety, our work has expanded to multiple sectors with a focus on mentorship and development of great leaders. There is no specific commercial purpose of this website and no required financial relationship between the collaborators. No direct, indirect, or affiliated financial support of any type from the healthcare industry has funded this site or communities of practice served here. The information available through this website is entirely free.

Global Webinars and Summits

TMIT Global has led a global community of practice of clinical, administrative, and patient safety leaders since the 1980s.  More than 130 monthly webinars and research and development have been delivered over more than a decade. They are served by 500 subject matter experts who have been speakers and advisors on a number of patient safety initiatives. The webinars are posted monthly at www.SafetyLeaders.org.

Title Date Resources
The 5 Rights of Emergency Care and SBAR for Patients November 19, 2020 Audio and Resources
Safety Plan Templates for Everyone:  A Survive & Thrive Guide™ November 5, 2020 Audio and Resources
Care of the Caregiver: Loved Ones Caring for Loved Ones October 15, 2020 Audio and Resources
Creating Your Family Safety Plan:  A Survive & Thrive Guide™ October 1, 2020 Audio and Resources
Drug Diversion 2020 & The 5 Rights of Pain Management September 17, 2020 Audio and Resources
Family Survive & Thrive Guide™: Keeping Our Kids Safe September 3, 2020 Audio and Resources
A Patient Safety Stress Test:  Coronavirus Crisis – Applying Just Culture August 20, 2020 Audio and Resources
Family Survive & Thrive Guide™: Coming Home Safely August 6, 2020 Audio and Resources
Pandemic Preparedness Part 2: Surfing the Next Wave with Security July 16, 2020 Audio and Resources
Family Survive & Thrive Guide™: The Latest Best Practices July 2, 2020 Audio and Resources
Pandemic Preparedness: Surfing the Next Wave June 18, 2020 Audio and Resources
Coronavirus Survive & Thrive Guide for Caregiver & Critical Worker Families May 21, 2020 Audio and Resources
Burnout and Crises: Joy in the Face of Chaos April 16, 2020 Audio and Resources
Just Culture: A 2020 Update and Case Studies March 19, 2020 Audio and Resources
Coronavirus – Protecting You & Your Family: First Responder & Family Briefing March 18, 2020 Audio and Resources
Mortality Reviews and Patient Safety: A 2020 Update February 20, 2020 Audio and Resources
Anticoagulation Safety: A 2020 Update January 16, 2020 Audio and Resources
Violence in Healthcare & Keeping Everyone Safe December 19, 2019 Audio and Resources
Leadership Tools, Performance Improvement, and 100 Day Plans November 21, 2019 Audio and Resources
A Perfect Storm: The Midcourse Correction for Patient Safety October 17, 2019 Audio and Resources
In-flight Emergencies: Good Samaritans at Altitude September 19, 2019 Audio and Resources
Workplace Violence: A Patient and Caregiver Safety Update August 15, 2019 Audio and Resources
The Quality Journey: The CEO and CMO View July 18, 2019 Audio and Resources
Mortality Reviews and Patient Safety: A 2019 Update June 20, 2019 Audio and Resources
Drug Diversion Scenarios & An Update on Patient Suicide May 16, 2019 Audio and Resources
5 Rights of Pain Care, Opioids and Diversion Update April 18, 2019 Audio and Resources
Serious Adverse Events and Engaging Your Governance Board March 21, 2019 Audio and Resources
From Burnout to Esprit de Corps and Safer Care February 21, 2019 Audio and Resources
Sepsis: A 2019 Update on Critical Issues January 17, 2019 Audio and Resources
Respectful Management of Serious Adverse Events: A 2018 Update December 18, 2018 Audio and Resources
Highlights of the Last Decade and High Impact
Issues for 2019 and Beyond
November 15, 2018 Audio and Resources
Dauntless Leaders in Nursing: Impacting Patient Safety October 18, 2018 Audio and Resources
Drug Diversion: The 2018 Crisis Update & Our Future September 20, 2018 Audio and Resources
The HR Department – Friend or Foe: Critical Patient & Caregiver Safety Events August 16, 2018 Audio and Resources
Healthcare Professional Burnout: A Critical Caregiver & Patient Safety Issue July 19, 2018 Audio and Resources
Workplace Violence: A Critical Patient and Caregiver Safety Issue June 21, 2018 Audio and Resources
Drug Shortages: A Critical Patient Safety Issue May 17, 2018 Audio and Resources
End of Life Care: Learning from Mortality Reviews April 19, 2018 Audio and Resources
Just Culture — High Impact Case Studies March 15, 2018 Audio and Resources
Just Culture — Voices from the Frontline February 15, 2018 Audio and Resources
Drug Diversion: A Drill Down Approach January 18, 2018 Audio and Resources
Just Culture in 2017 and Beyond December 21, 2017 Audio and Resources
Sepsis and Triage: Maximizing Safety of Incoming Patients November 16, 2017 Audio and Resources
Health Information Technology: Patient Safety Issues & Cybersecurity October 19, 2017 Audio and Resources
Drug Diversion and the Opioid Crisis September 21, 2017 Audio and Resources
Sepsis: Bringing it All Together Part 3 August 17, 2017 Audio and Resources
The Opioid Crisis: New Threats to Caregivers July 20, 2017 Audio and Resources
Sepsis: Acute Care Part 2 June 15, 2017 Audio and Resources
Sepsis: The Basics Part 1 May 18, 2017 Audio and Resources
Failure to Rescue: Bedside Patient Rescue – A Great Opportunity April 20, 2017 Audio and Resources
Mayo Clinic Mortality Review Presentations – at the Texas Medical Center Threat Safety R&D Community of Practice March 1, 2017 Audio and Resources
Mortality Reviews: Great Learning from Our Early Journey February 16, 2017 Audio and Resources
Saving Lives Putting Mortality Reviews to Work – It does pay off! January 19, 2017 Audio and Resources
The Opioid Crisis: An Update for Safety Leaders December 15, 2016 Audio and Resources
A Safety Leaders Update: Is H.I.T. Evidence Based? November 17, 2016 Audio and Resources
Learning from Collaboration on Mortality Reviews: The Journey October 20, 2016 Audio and Resources
Harmonizing Healthcare Emergency Codes September 15, 2016 Audio and Resources
Learn from Mortality Review AND the Living: Part 2 – A Deeper Dive August 18, 2016 Audio and Resources
Learn from Mortality Review AND the Living: Next Generation Safety Learning System July 21, 2016 Audio and Resources
New Oral Anticoagulants: New Patient Safety Challenges June 16, 2016 Audio and Resources
High Impact Care Hazards: Opioid OD, Anaphylaxis, Cardiac Arrest, Choking, and On-site Transportation Accidents May 19, 2016 Audio and Resources
The Opioid Patient Safety Crisis: Actions and Reactions April 28, 2016 Audio and Resources
Health Information Technology Safety Community of Practice January 21, 2016 Audio and Resources

November 19, 2020
The 5 Rights of Emergency Care and SBAR for Patients

Emergency care has become very challenging during the Coronavirus Crisis. The 5 Rights of Emergency Care was a framework designed for performance improvement prior to the coronavirus pandemic to prevent patient safety adverse events. Now that families cannot join patients who are seen for emergency care whether they have COVID-19 or not, the value of the framework has increased.  Dr. Christopher Peabody who was a lead collaborator with us in the development of the 5 Rights of Emergency Care is the Director of the UCSF Acute Care Innovation Center and is an Assistant Clinical Professor of Emergency Medicine at UCSF.  He will walk us through framework.  The original SBAR tool developed by Doug Bonacum, formerly of Kaiser Permanente was modified to be used by patients. It offers new value during the current crisis, especially in emergency care.  A reactor panel of leaders including Heather Foster, RN, a national award winning nurse and infection preventionist and emergency medicine caregivers will help reinforce the messages.

November 5, 2020
Safety Plan Templates for Everyone: A Survive & Thrive Guide™

We need to break family and living unit infection transmission chains to save our nations. A family safety plan can save our workers who are often more vulnerable at home than at work. The collective behaviors of our family members and those we live with will define the safety of each member individually. We all want to keep our children, teens, college students, and young adults as safe as possible. We are delighted to have national experts join us to help you take a step by step approach to build your plan and provide templates you can use. This program is for families of Essential Infrastructure Workers, teachers, scouts, faith-based leaders, and the general public.

                • WHO should create a Family Safety Plan?
                • WHAT should a Safety Plan include look like?
                • WHEN should a family build a plan?
                • HOW do I build a plan from scratch?
                • WHY does my plan need to be customized?

October 15, 2020
Care of the Caregiver: Loved Ones Caring for Loved Ones

John Nance, JD has been a tireless champion for proper care of our caregivers. He is a bestselling author, global safety leader, and governance expert. John brings forth a call to action with new energy and opportunities for governance, professional administrative, and management leaders to care for their caregivers. The Coronavirus Crisis has pulled back the curtain on our healthcare system. It has shown our greatness in technical care and the failure of our safety support systems…especially for taking care of our caregivers. This program provides real detail as to how to deal with the emerging threats to our teams. Richard Mereu, JD, the Chief Government Relations Officer for the Emergency Nurses Association and Professor Mary Foley, the former President of the American Nurses Association and national patient safety expert will share their messages.

A reactor panel of leaders including Heather Foster, RN, a national award winning nurse and infection preventionist will help reinforce the messages.

October 1, 2020
Creating Your Family Safety Plan: A Survive & Thrive Guide™

The collective behaviors of our family members will define the safety of each member individually. We all want to keep our children, teens, college students, and young adults as safe as possible. We are delighted to have national experts join us to help you take a step by step approach to developing your family safety plan in case a loved one gets infected with Coronavirus or the Flu.  This program is for families of Essential Infrastructure Workers, teachers, scouts, faith-based leaders, and the general public.

            • What is the science behind the risk to your family?
            • How can we improve our state of READINESS?
            • How do we best RESPOND when a loved is sick?  
            • How do we RESCUE someone with severe symptoms?  
            • What is the best RECOVERY plan after an infection?
            • How can we make our family more RESILIENT?
            • How do we get teens, those in their 20’s, and 30’s to take the lead in protecting our families?

September 17, 2020
Drug Diversion 2020 & The 5 Rights of Pain Management

Kim New, JD, BSN, RN, one of our most popular experts is back speaking about Drug Diversion in 2020 to update her powerful message of 2019. This is a growing problem and the evolving normal imposed by the Coronavirus Crisis has new implications.

Dr. Gladstone McDowell is a leading pain management expert who was a urological oncologist with extensive surgical experience. He will address the latest issues regarding pain management using our 5 Rights of Pain Management model.

September 3, 2020
Family Survive & Thrive Guide™: Keeping Our Kids Safe

Many of us are at risk for bringing the Coronavirus home. We are delighted to have national experts join us to answer the tough questions regarding keeping our families safe when our jobs and activities require us to be exposed.

  • What is the science behind the risk to your kids?
  • Does risk vary for kids under 10, teens, and youth?
  • What about our college students and young adults?
  • What are the CDC school and college guidelines?
  • What are the highest risk environments?
  • Why are the indoors riskier than the outdoors?
  • Are there best practices for play dates and sports?
  • How can we safely return to the beach and pool?
  • How do we get teens, those in their 20’s, and 30’s to take the lead in protecting our families?
  • What are the best practices to protect my family?
  • What if I am exposed to a COVID-19 patient at work?
  • How do I put together a Family Safety Program?
  • Can we have safe play dates?
  • Why are indoor activities riskier than those outdoors?
  • What Personal Protective Equipment do I need to care for a loved one at home?
  • How do we get teens and those in their 20’s and 30’s to take the lead in being safe and protecting families?

August 20, 2020
A Patient Safety Stress Test: Coronavirus Crisis – Applying Just Culture

David Marx, JD, is a true pioneer in the internationally recognized safety practice of Just Culture. Each time he speaks to our community of practice, he receives terrific reviews. The Coronavirus Crisis has dramatically stressed the healthcare system and increased the risk of patient safety incidents. It has generated new risks to patients and caregivers. We will address common challenging patient safety incidents and scenarios unique to caring for COVID-19 positive patients including the risk to caregivers. Our reactor panel including best-selling author, John Nance, JD and infection preventionist, Heather Foster, RN will discuss the update and implications of the case studies.

August 6, 2020
Family Survive & Thrive Guide™: Coming Home Safely

Many of us are at risk for bringing the Coronavirus home. We are delighted to have national experts join us to answer the tough questions regarding keeping our families safe when our jobs and activities require us to be exposed.

      • How do we keep from bringing the virus home?
      • What are the best practices to protect my family?
      • What if I am exposed to a COVID-19 patient at work?
      • How do I put together a Family Safety Program?
      • Can we have safe play dates?
      • Why are indoor activities riskier than those outdoors?
      • What Personal Protective Equipment do I need to care for a loved one at home?
      • How do we get teens and those in their 20’s and 30’s to take the lead in being safe and protecting families?

      Experts who are caring for patients now share their practices, the latest best practices, and practical tips to help you care for your families. Join us to learn from them and ask your most difficult questions.

July 16, 2020
Pandemic Preparedness Part 2: Surfing the Next Wave with Security

Vicki King is the Assistant Chief of Police at the police department at the MD Anderson Cancer Center. She is the team lead for Threat & Risk Protection for the center. She will be addressing critical issues such as screening, dealing with “mask deniers”, and separating research and administration areas from clinical spaces. Dr. Marian E. Von-Maszewski is the Emergency Readiness Officer for Anderson who plays a critical leadership role during the Coronavirus Crisis. She is Assistant Professor, Department of Critical Care, Division of Anesthesiology and Critical Care, The University of Texas. This “Part 2” section of readiness will build on the program Dr. Von-Maszewski presented in our last webinar.

July 2, 2020
Family Survive & Thrive Guide™: The Latest Best Practices for Caregiver & Critical Worker Families

We are launching a monthly webinar specifically for families from the general public and critical infrastructure worker families from 16 industry sectors. They include medical and security volunteers for faith-based organizations and community membership organizations such as scouts. In this first webinar we are addressing the latest science for practicing social distance, hand hygiene, high contact surfaces, and use of masks.

You will hear from emergency medicine, critical care, security leaders, and infectious disease experts from leading medical centers. We will present video and resources provided on the web that may be used to help care for COVID-19 patients.

June 18, 2020
Pandemic Preparedness: Surfing the Next Wave

Dr. Marian E. Von-Maszewski is the Emergency Readiness Officer for the MD Anderson Cancer Center having exhibited extraordinary leadership during hurricane Harvey. She is now playing another critical leadership role during the Coronavirus Crisis. She is Assistant Professor, Department of Critical Care, Division of Anesthesiology and Critical Care, The University of Texas. She and a panel of experts will help us understand the lessons we have learned about patient and caregiver safety that can be applied to a second wave, another pandemic, or another crisis requiring emergency preparedness.

May 21, 2020
Coronavirus Survive & Thrive Guide for Caregiver & Critical Worker Families

Dr. Gregory Botz, Heather Foster, RN, and a rapid response team of more than 30 clinical, operational, and community impact leaders contributed to this program. It is a multimedia platform for the critical infrastructure workers from 16 industry sectors. It has been designed for non-medical families who may have to prepare a care room for a loved one at home. We presented video and resources provided on the web that may be used to help care for COVID-19 patients in the homes of critical infrastructure workers including professional caregivers and professional first responders. You will hear from emergency medicine, critical care, and infectious disease experts from leading medical centers. They will be supported by a reactor panel of leading experts.

April 16, 2020
Burnout and Crises: Joy in the Face of Chaos

Dr. Stephen J. Swensen, a global expert on leadership and professional burnout, will be speaking on this critical topic. The COVID-19 crises has put enormous pressures on our caregivers. Dr. Swensen will give us hope through his world class work. For three decades he has served patients at the Mayo Clinic as its Director of Leadership and Organization Development, Director of Quality, and Chairman of Radiology. Dr. Swensen will address the practical aspects of professional burnout and performance improvement by developing Esprit de Corps. He is now a Professor Emeritus and is very focused on helping organizations develop a safer path for their caregivers and patients.

March 19, 2020
Just Culture:A 2020 Update and Case Studies

David Marx, JD, is a true pioneer in the internationally recognized safety practice of Just Culture. Each time he speaks to our community of practice, he receives terrific reviews. Our March webinar will provide a 2020 update on the Just Culture movement and case studies will be presented that illustrate practical challenges we face at the frontline. David Marx draws on experience that spans more than two decades of examining laws, regulations, and industry practices to help lawmakers, regulatory authorities, and organizational leaders fulfill their responsibilities to produce safer outcomes. Our reactor panel will discuss the update and implications of the case studies.

March 18, 2020
Coronavirus – Protecting You & Your Family: First Responder & Family Briefing

Dr. Gregory Botz and Chief William Adcox, our webinar speakers are world class experts in emerging threats and are frontline leaders in the fight against the Coronavirus – COVID-19. Both serve at MD Anderson Cancer Center and the University of Texas. Dr. Botz is a Professor of Critical Care and Anesthesia. Chief Adcox is the Chief Security Officer and Chief of Police. Dr. Botz is also an adjunct faculty member at the Stanford University Medical Center. They will be supported by a reactor panel of leading experts. The webinar will address the most common scenarios facing families, professional first responders, and volunteer medical and security responders in our communities. This emergency response initiative is part of the Global Med Tac Bystander Rescue Care program developed to help the general public save lives before professional first responders arrive on the scene and to support them when they do. In an emergency, everyone may become a first responder.

February 20, 2020
Mortality Reviews and Patient Safety: A 2020 Update


Dr. Jeanne Huddleston is the global pioneer in the use of mortality reviews to improve patient care. She will provide a 2020 update on what has been learned from the world-wide collaborative program she leads. She comes back to us based on popular demand from our patient safety community of practice and the great reviews of her prior presentations that have highlighted Opportunities for Improvement in issues of omission.

January 16, 2020
Anticoagulation Safety: A 2020 Update

Dr. Alan Jacobson is a pioneer and leader in the field of anticoagulation management, having implemented innovative strategies within the VA system to improve anticoagulation management and dramatically reducing risk with out-of-range INR and complications associated with anticoagulation therapy. He has been our leading speaker on anticoagulation safety and will bring the latest update on this daunting area of care.

December 19, 2019
Violence in Healthcare & Keeping Everyone Safe

Casey Clements, MD, PhD, is a renowned emergency medicine physician at the Mayo Clinic who has done a terrific job educating our audience in past webinars. He will educating us on one of the most daunting crises in healthcare – workplace violence. Dr. Clements always delivers very practical and actionable information when he speaks.

November 21, 2019
Leadership Tools, Performance Improvement, and 100 Day Plans

Dr. J. Michael Henderson and CEO Kevin Cook received rave reviews for their presentation on their quality journey of the Chief Medical Officer at the University of Mississippi Medical Center. Our audience survey revealed you wanted more from them regarding their tools such as their 100 Day Plans. They will be joined by Dr. Shannon Pittman, their chair of Family Medicine and Candice Whitfield, the Administrator of their CMO office who will discuss the work. Dr. Henderson is the former Chief Quality Officer of the Cleveland Clinic and has a long history of work in performance improvement. Kevin Cook is responsible for the strategic leadership of the UMMC Health System, including University Hospital, Wiser Women and Infants Hospital, Conerly Critical Care Hospital, Children’s of Mississippi, UMMC Holmes County and UMMC Grenada, and all UMMC-owned ambulatory clinics.

October 17, 2019
A Perfect Storm: The Midcourse Correction for Patient Safety

John Nance, JD, the bestselling author of Why Hospitals Should Fly and Charting the Course: Launching Patient-Centric Healthcare, and global patient safety leader who has inspired us for years, will speak regarding new emerging issues impacting patient safety related to caregiver satisfaction. He will preview some of the very important topics that he will cover in his next book. A frequent international speaker and advisor to leading medical centers, John has terrific insights into emerging threats challenging our industry. The ABC commentator for safety, he is a former airline captain, holds a law degree, and is expert on ethics in corporate governance. His leadership experience makes him one of the best advisors to healthcare.

September 19, 2019
In-flight Emergencies: Good Samaritans at Altitude

There are more than 44,000 commercial flights tracked per day by air traffic controllers. Many caregivers and healthcare workers have had the experience of a flight attendant calling for help while in the air. Dr. Robert Katzer will be delivering a world class presentation on what we need to know about caring for the public during an in-flight emergency. He is an Emergency Medicine physician, educator, and medical director for a busy fire and rescue program. Having heard him speak, our TMIT team gives him our highest recommendation.  Dr. Gregory Botz, the co-founder of the Med Tac Bystander Care program who also teaches in-flight emergency care, will provide his perspective along with reactions from our patient advocate representative.

August 15, 2019
Workplace Violence: A Patient and Caregiver Safety Update

 Workplace violence continues to be a critical Patient Safety AND Caregiver issue. Our industry has 4-5 times the frequency of other sectors. Richard Mereu, Chief Government Relations Officer of Government Relations for the Emergency Nurses Association, will address the key issues in their domain. Chief William Adcox and his colleagues at MD Anderson Cancer Center are global experts in Threat Safety Science that includes workplace violence.

July 18, 2019
The Quality Journey: The CEO and CMO View

Dr. J. Michael Henderson and CEO Kevin Cook will address the quality journey of the Chief Medical Officer at the University of Mississippi Medical Center. Dr. Henderson is the former Chief Quality Officer of the Cleveland Clinic and has a long history of work in performance improvement. Kevin Cook is responsible for the strategic leadership of the UMMC Health System, including University Hospital, Wiser Women and Infants Hospital, Conerly Critical Care Hospital, Children’s of Mississippi, UMMC Holmes County and UMMC Grenada, and all UMMC-owned ambulatory clinics.

June 20, 2019
Mortality Reviews and Patient Safety: A 2019 Update


Dr. Jeanne Huddleston is the global pioneer in the use of mortality reviews to improve patient care. She will provide a 2019 update on what has been learned from the world-wide collaborative program she leads. She comes back to us based on popular demand from our patient safety community of practice and the great reviews of her prior presentations that have highlighted Opportunities for Improvement in issues of omission.

May 16, 2019
Drug Diversion Scenarios & An Update on Patient Suicide

Kim New, JD, BSN, RN, is back speaking about Drug Diversion scenarios to address the growing problem and in response to her extraordinary reviews and number of requests from our community of practice to have her continue to teach and inspire us.

Vicki King is the Assistant Chief of Police at the MD Anderson Cancer Center and UT Health Science Center, UT Police at Houston. She is one of the pioneers of Threat Safety Science and leads a Threat Management team. She will address the latest issues regarding patient suicide prevention.

April 18, 2019
5 Rights of Pain Care, Opioids and Diversion Update

Dr. Gladstone McDowell is a global leader in pain management who will provide the latest perspective on how best practices in pain management can impact opioid addiction using the 5 Rights of Pain Care framework model.

Kim New, JD, BSN, RN, will be a reactor and provide a short update on the drug diversion issues. David Marx, JD, the founder of the Just Culture movement, will provide his view of the recent Vanderbilt medical error and indictment of a nurse.

March 21, 2019
Serious Adverse Events and Engaging Your Governance Board


Tom Van Dawark has been a tremendous contributor to healthcare governance. He has been on community and business boards throughout his business career. He has been both a member of the Virginia Mason Hospital and Healthcare System Board Chair, and participated in work with the CEO which resulted in Virginia Mason being recognized today as a top 100 hospital. He is now working closely with boards and championing leadership, patient safety, and governance best practices.

February 21, 2019
From Burnout to Esprit de Corps and Safer Care


Dr. Stephen J. Swensen, a global expert on leadership and professional burnout, will be speaking on this critical topic. For three decades he has served patients at the Mayo Clinic as its Director of Leadership and Organization Development, Director of Quality, and Chairman of Radiology. Dr. Swensen will address the practical aspects of professional burnout and performance improvement by developing Esprit de Corps. He is now a Professor Emeritus and is very focused on helping organizations develop a safer path for their caregivers and patients.

January 17, 2019
Sepsis: A 2019 Update on Critical Issues

Casey Clements, MD, PhD, is a renowned emergency medicine physician at the Mayo Clinic who has done a terrific job educating our audience in past webinars. He will update us as of 2019 on the state of the art and care of sepsis. This remains to be one of our most sought after topics and Dr. Clements delivers very practical and actionable information every time he speaks.

December 20, 2018
Respectful Management of Serious Adverse Events: A 2018 Update


Jim Conway has been a tremendous contributor to what we know about how to handle serious adverse events. An IHI Senior Fellow and frequent speaker on the topic over the years, Jim will provide a 2018 update to the challenges to handling serious adverse events. Heather Foster RN, a frontline nurse who has championed the cause of “taking the high road” will provide her perspective and serve as a reactor.

November 15, 2018
Highlights of the Last Decade and High Impact Issues for 2019 and Beyond


John Nance, JD, and a group of safety leaders will help us celebrate this our 120th webinar of our high performer series marking our 10th anniversary. We will be addressing what we have learned from the high impact patient safety target areas of the past and how we can drive accountability for the changes we need in 2019 and beyond as we target issues of Threat Safety Science.

October 18, 2018
Dauntless Leaders in Nursing: Impacting Patient Safety

Kathleen Bartholomew, RN, MN is an accomplished author in patient safety with breakthrough professional books such as “Ending Nurse-to-Nurse Hostility” and “Charting the Course” (co-written with John Nance). From the bedside to the boardroom she challenges health care leaders to protect patients with research based presentations woven with narratives that resonate strongly with her audiences. She will address key issues in her latest book “The Dauntless Nurse: Communication Confidence Builder” and how they may empower us our patient safety mission.

September 20, 2018
Drug Diversion: The 2018 Crisis Update & Our Future

Kimberly New has been a terrific speaker for us on drug diversion who is back by popular demand. She is a specialist in controlled substance security and DEA regulatory compliance and consults with healthcare facilities across the country. She is an attorney and an RN who will provide a 2018 update on practical and powerful insights to the exploding drug diversion problem. She is widely published and advises a number of leading medical centers. The webinar for this month is an update to the drug diversion crisis following the excellent and informative programs she led January 18th of 2018 and September 21st of 2017.

August 16, 2018
The HR Department – Friend or Foe: Critical Patient & Caregiver Safety Events

The Human Resources department at many healthcare organizations have evolved from employee advocacy and concierge functions to becoming an employer’s “defense department”. In some cases HR has become weaponized against the very employees who trust them. The trend can put patient safety and quality leaders in a position of distrust with frontline staff. Cynthia Shapiro, a former HR leader and bestselling author of Corporate Confidential will be interviewed and react to caregiver patient safety cases and apply the “50 Secrets” of her book to the healthcare environment. We will discuss the positive ways of ensuring your HR department behaves in a proper manner after an adverse event.

July 19, 2018
Healthcare Professional Burnout: A Critical Caregiver & Patient Safety Issue

Professional Burnout is epidemic in Healthcare Professionals. It negatively impacts both caregivers and patients. Dr. Swensen will present an evidence-based and validated strategy to move from Burnout to Esprit de Corps. Esprit is camaraderie, passion, and engagement wrapped in loyalty to the mission…it recreates fulfillment and joy in practice. Esprit is the single most impactful leading indicator (within our control) of patient experience, outcomes and safety, and driver of organizational effectiveness. Our second speaker, Nancy Conrad, the founder of the Conrad Foundation in honor of Pete Conrad, the astronaut and national hero who died the preventable death of a healthcare systems failure. She will announce the 2018 Global Pete Conrad Patient Safety Award winners.

June 21, 2018
Workplace Violence: A Critical Patient and Caregiver Safety Issue

Workplace violence has become a critical Patient Safety AND Caregiver issue. Our industry has 4-5 times the frequency of other sectors. Chief William Adcox and his colleagues at MD Anderson Cancer Center are global experts in Threat Safety Science that includes workplace violence. He shared the virtual podium with leaders from the healthcare community who will frame the problem and address some of the solutions in the pipeline. Rob Kramer, Director of Government Relations for the Emergency Nurses Association, addressed the key issues in their domain.

May 17, 2018
Drug Shortages: A Critical Patient Safety Issue

Drug shortages have become a critical patient safety issue and will continue to be a daunting challenge. Dr. Gregory Botz, Professor of Anesthesia and Critical Care at the MD Anderson Cancer Center and adjunct faculty at Stanford University School of Medicine, is a national patient safety champion who will frame the issue for us. Adriana Rivera, PharmD, will present key strategies and tactics to address this problem. She is a Clinical Pharmacy Specialist at MD Anderson and leader in Pharmacy Medication Management & Analytics.

April 19, 2018
End of Life Care: Learning from Mortality Reviews

The Opportunities for Improvement (OFI’s) are enormous when it comes to end of life issues. Our audience continuously requests more learning from mortality reviews pioneered by the Mayo Clinic and led by Dr. Jeanne Huddleston. Her emphasis along with other speakers from her research collaborative this month will be on Opportunities for Improvement for the end of life care.

Patty Atkins, MS, RN, FACHE, CPPS, who is Vice President of Quality and Patient Safety at Sharp HealthCare, will discuss this important topic with attention to end of life goals in the ED, a nurse-led approach to end of life issues, and the barriers to nurse-led Advanced Illness Management (AIM) programs.

March 15, 2018
Just Culture – High Impact Case Studies

In prior webinars, David Marx, JD, established the principles of Just Culture, brought voices from frontline leaders to our audience, and will now present case studies that apply the concepts to real-life scenarios. David Marx draws on experience that spans more than two decades of examining laws, regulations, and industry practices to help lawmakers, regulatory authorities, and organizational leaders fulfill their responsibilities to produce safer outcomes. Our speakers and reactors will discuss applying Just Culture in the real world.

February 15, 2018
Just Culture – Voices from the Frontline

David Marx, JD, is a true pioneer in the internationally recognized safety practice of Just Culture. He spoke to our audience in December of 2017 and when we surveyed them, we received an extraordinary response requesting more speakers addressing implementation at the frontline. Our webinar this month fulfills that desire with frontline leaders who will talk about the practical issues of adoption. David Marx draws on experience that spans more than two decades of examining laws, regulations, and industry practices to help lawmakers, regulatory authorities, and organizational leaders fulfill their responsibilities to produce safer outcomes. His colleagues and our reactor panel will explore the drill down issues of adopting and sustaining a truly just culture.

January 18, 2018
Drug Diversion: A Drill Down Approach

The webinar for this month is a follow up and detailed approach to the exploding drug diversion problem following an excellent and informative program September 21 of 2017 by Kimberly New. She will drill down on tactical detail regarding how an organization needs to deal with this issue.

Kimberly New is a specialist in controlled substance security and DEA regulatory compliance and consults with healthcare facilities across the country. She is an attorney and an RN who will provide practical and powerful insights to the exploding drug diversion problem. She is widely published and advises a number of leading medical centers.

December 21, 2017
Just Culture in 2017 and Beyond

David Marx, JD, is a true pioneer in the internationally recognized safety practice of Just Culture. He draws on experience that spans more than two decades of examining laws, regulations, and industry practices to help lawmakers, regulatory authorities, and organizational leaders fulfill their responsibilities to produce safer outcomes. David will bring us up to date on the state of Just Culture in 2017 and the future as it pertains to patient safety leaders.

John Nance, an internationally recognized safety expert in healthcare and aviation who is an award winning author, journalist, attorney, and patient safety advocate will be a reactor to David Marx’s presentation. John is the developer of Red Cover Reports, an NTSB-like approach to analyzing patient safety accidents. William Adcox, the Chief Security Officer for MD Anderson Cancer Center who is also the Chief of Police for the UT Health Science Center and a pioneer of Threat Safety Science will also be a reactor.

November 16, 2017
Sepsis and Triage: Maximizing Safety of Incoming Patients

Our audience continuously requests more on sepsis. Dr. Jeanne Huddleston, our lead speaker this month, will address this topic to complement our prior sepsis webinars. Her emphasis will be on the triage and safety of incoming patients and the safety of patients being transferred out to other centers. She has led the breakthrough mortality review work at the Mayo Clinic that identified both sepsis and triage as two very important Opportunities for Improvement.

Dr. Greg Botz and Chief Bill Adcox, both of MD Anderson Cancer Center, and Vicki King of the University of Texas Police at Houston, will provide an update on the Med Tac bystander care program that is focused on patient safety during emergencies threatening the lives of previously healthy children, youth, and adults in their workforce years.

September 21, 2017
Drug Diversion and the Opioid Crisis

The opioid crisis is touching everyone in our caregiver community. Through multiple recent research surveys, we have found our audience has realized that drug diversion is a patient safety crisis and that we need help at the frontline.

Kimberly New is a specialist in controlled substance security and DEA regulatory compliance and consults with healthcare facilities across the country. She is an attorney and an RN who will provide practical and powerful insights to the exploding drug diversion problem. She is widely published and advises a number of leading medical centers.

August 17, 2017
Sepsis: Bringing it All Together Part 3

This is the third webinar our sepsis series. Sepsis, according to Dr. Jeanne Huddleston our lead speaker this month, is one of the most common “Opportunities for Improvement” and a great area to have impact. Dr. Huddleston is the leading researcher in mortality reviews at the Mayo Clinic. Our national surveys have revealed that opportunities of omission and sepsis in particular have been identified as a major interest area of our research test bed.

Dr. Huddleston will sum up the terrific presentations in Part 1 and Part 2 and tie what we have learned to what has been gleaned from the Mayo Mortality Review process.

July 20, 2017
The Opioid Crisis: New Threats to Caregivers

Dr. Gladstone McDowell is one of our nation’s leading pain management experts who has practiced as a urologic oncologist, anesthesiologist, and pain management physician. He frequently speaks to caregivers as well as youth on the dangers of pain medicines and our current opioid crisis. He will address the latest life threatening developments from the introduction of Fentanyl additives to street drugs that are now threatening our first responders, emergency caregivers, and our patients.

June 15, 2017
Sepsis: Acute Care Part 2

This is our second webinar in a series on sepsis. Sepsis, 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. Our national surveys have revealed that opportunities of omission and sepsis in particular have been identified as a major interest area of our research test bed.

Dr. Huddleston will introduce the topic with a review of the new sepsis related knowledge that has been gleaned from the Mayo Mortality Review process. Casey Clements, MD, PhD, is a renowned emergency medicine physician at the Mayo Clinic who will build on our prior webinar in this second installment on the state of the art care of sepsis.

May 18, 2017
Sepsis: The Basics Part 2

Sepsis, 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. Our national surveys have revealed that opportunities of omission and sepsis in particular have been identified as a major interest area of our research test bed.

Dr. Ryan Arnold is an emergency medicine physician at Christiana Care Health System and is the Director of Research participating in over 60 different research projects, which include several multi-center clinical trials and investigator-initiated studies. He will be the speaker of the first part of a three part series on sepsis and will provide foundational approach to the issue including important definitions and an evidence based introduction to the topic. A reactor panel of patient advocates and experts will react to the presentation.

April 20, 2017
Failure to Rescue: Bedside Patient Rescue – A Great Opportunity

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.

March 1, 2017
Mayo Clinic Mortality Review Presentations at the Texas Medical Center Threat Safety R&D Community of Practice

Dr. Jeanne Huddleston presents two back to back sessions regarding the breakthrough work she and her colleagues at the Mayo Clinic have that have had enormous impact on improving quality across their system. She shared learnings on their journey of a detailed data analysis and stories of more than sequential 10,000 patient deaths. She shared the lessons learned through the development and evolution of the Mayo Clinic Mortality Review System and the opportunities to address issues of omission.

Mayo Mortality Reviews: Next Generation Patient Safety – The presentation will provides a detailed look at how the Mayo Mortality Review System evolved, their findings, and how barriers were overcome to develop it.

Putting Mortality Reviews to Work – The Enormous Payoff! – The presentation provides a detailed outline and roadmap of how mortality reviews have been put to work at the Mayo Clinic and how other systems in Dr. Huddleston’s national collaborative are undertaking their journeys. The impact of the approach was presented using a comprehensive measurement and improvement approach.

February 16, 2017
Mortality Reviews: Great Learning from Our Early Journey

Patty Atkins, RN, MS, CNS, CPPS, is responsible for Quality, Patient Safety and Lean Six Sigma for Sharp HealthCare, the largest healthcare system in San Diego, CA. She will share the terrific learning her organization has gleaned from mortality reviews, having worked with Dr. Jeanne Huddleston from the Mayo Clinic who are the leaders in this field. Her insights are just what our surveys have told us from frontline safety leaders in our National Research Test Bed.

Dr. Huddleston’s work at the Mayo Clinic has generated one of the strongest positive reactions we have ever had in our nearly 100 monthly sequential webinars. The breakthrough work that can have enormous impact on the patient safety of healthcare institutions.

January 19, 2017
Saving Lives Putting Mortality Reviews to Work – It does pay off!

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 shares helps 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

December 15, 2016
The Opioid Crisis: An Update for Safety Leaders

The opioid crisis in America is breathtaking and demands our attention. Dr. Gladstone McDowell is a global leader in pain management who is the Medical Director of Integrated Pain Solutions. He is a trained specialist in Urology, Urologic Oncology, Anesthesiology, Pain Management, and Patient Safety. Dr. McDowell will address the current opioid crisis and updated numbers just reported by the DEA. He will address the issue of gateway drugs and how our healthcare staff, patients, and families are at risk. We will discuss the latest in drug diversion and what safety leaders need to know and watch for in 2017.

November 17, 2016
A Safety Leaders Update: Is H.I.T. Evidence Based?

Ross Koppel, PhD, Adjunct Professor of Sociology, University of Pennsylvania in Philadelphia, has provided tremendous insight to our TMIT audience in the area of E.H.R. patient safety in multiple webinars. He is a leading scholar of healthcare IT, and of the interactions of people, computers, and workplaces. His articles in JAMA, JAMIA, Annals of Internal Medicine, NEJM, Health Affairs, Journal of Patient Safety, the Journal of Clinical Care, Journal of Managed Care, Chest, and AHRQ-M&Ms, et cetera, are considered seminal works.

Dr. Koppel will address a great question: Is Health Information Technology evidence based and what do we need to know?

October 20, 2016
Learning from Collaboration on Mortality Reviews: The Journey

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.

September 15, 2016
Harmonizing Healthcare Emergency Codes

Leaders who have successfully harmonized their emergency codes will speak on lessons learned from this vital issue. With the frequency and severity of active shooter events, healthcare facility terrorism, and natural disasters striking healthcare institutions, coordination of the communication of emergency codes is critical. The discussion of the “how to” harmonize emergency codes and implementing plain language and simple text principles to improve effectiveness will be discussed. Stories illustrating how confusion regarding codes can lead to preventable deaths will be shared.

Dr. Bill Scharf and his colleagues at OSF have successfully accomplished harmonization of emergency codes across their health system and will share their experience. James Mitchell and Aaron Freedkin of Texas Children’s Hospital will describe their journey to harmonizing their emergency codes and moving to plain language for the world’s largest children’s hospital.

In our reactor panel, Chief Bill Adcox, Inspector Vickie King, and Dr. Greg Botz of MD Anderson Cancer Center will discuss the importance of standardization at major medical centers where multiple institutions share common sky walkways and common areas as well as have caregivers and staff who rotate through multiple areas where differing emergency codes are used. Jennifer Dingman will discuss the perspectives of the patient and the family.

August 18, 2016
Learn from Mortality Review AND the Living: Part 2 – A Deeper Dive

In response to the overwhelmingly positive evaluations of our webinar last month addressing Learning from Mortality Reviews, we have asked Dr. Jeanne Huddleston to take a deeper dive into what can be learned from mortality reviews and how participants can start a program and learn from others. Following her presentation, a reactor panel will discuss the new information building on our July webinar shared by Dr. Huddleston.

July 21, 2016
Learn from Mortality Review AND the Living: Next Generation Safety Learning System

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 share learnings on their journey to analyze the stories of all patient deaths. She will share the lessons learned through the development and evolution of the Mayo Clinic Mortality Review System.

Patient safety events are increasingly recognized as the 3rd leading cause of death including the typical adverse events we count and measure in patient safety. These existing measurement systems do not identify actionable opportunities for improvement nor provide obvious direction for next steps. 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 the new information shared by Dr. Huddleston.

June 16, 2016
New Oral Anticoagulants: New Patient Safety Challenges

Dr. Alan Jacobson is a pioneer and leader in the field of anticoagulation management, having implemented innovative strategies within the VA system to improve anticoagulation management and dramatically reducing risk with out-of-range INR and complications associated with anticoagulation therapy.

Dr. Jacobson addressed the challenges associated with the new therapeutic drugs, which require less monitoring, but bring new risks. There are new lessons being learned that can help keep patients safer when these innovative new medications are being used.

May 19, 2016
High Impact Care Hazards: Opioid OD, Anaphylaxis, Cardiac Arrest, Choking, and On-site Transportation AccidentsPatient Safety Challenges

The May webinar addressed other leading causes of death of students K-12, colleges, and young employees. The topics include practical issues addressing Opioid Overdose, Anaphylaxis, Cardiac Arrest, Choking, On-site Transportation accidents, Bullying and Abuse of Power that can lead to workplace and school violence, active shooter events, and the value of a Rapid Response Team approach in schools and institutions. Our audience response to the May webinar covering Opioid related adverse events was terrific and led us to take a deep dive on the leading causes of death of young people – students at schools, colleges, and on the job.

We were proud to have Dr. Greg Botz, a national Intensive Care and patient safety leader, address the High Impact Care Hazards facing schools, colleges, and healthcare institutions. He will address the critical knowledge, lifeline behaviors or competencies that must be learned, and how assessment of such competencies may be undertaken. We introduced a new Medical-Tactical Certificate program that students can help lead in their school, college, or medical school.

Dr. Toff Peabody, a leading Emergency Medicine physician, updated us on the Dream Team concept successfully used in graduate training programs to combat burn out and introduce a new program being launched for Pre-med students. Students from leading Texas universities will reacted to the discussions as well as leading patient advocates.

April 28, 2016
The Opioid Patient Safety Crisis: Actions and Reactions

Opioid related adverse events have become a critical patient safety issue as evidenced by actions taken last month by the FDA (see link: http://www.fda.gov/NewsEvents/Newsroom/FactSheets/ucm484714.htm) and CDC (see link: http://www.cdc.gov/drugoverdose/prescribing/guideline.html).

We were proud to have Dr. Gladstone McDowell as our speaker; Dr. McDowell spoke extensively on the topic of pain management and the use and misuse of opioid medications. He discussed the latest patient safety developments and current strategies to optimize opioid use in the context of the “5 Rights of Pain Care®.” After his presentation, Dr. McDowell was joined by members of a reactor panel who discussed the key takeaways with our experts, and responded to questions from our webinar participants.

January 21, 2016
Health Information Technology Safety Community of Practice

TMIT was delighted to have Ross Koppel, PhD, Adjunct Professor of Sociology, University of Pennsylvania in Philadelphia. His presentation “From MU to MUch less? What is CMS telling us?” We were also delighted to have Christopher Peabody, MD, MPH, Assistant Clinical Professor of the Department of Emergency Medicine, University of California in San Francisco, lead the launch of our Community of Practice. He presented “Health IT: Front-line Problems and Solutions.” John Nance, a world-class speaker, joined these presenters covering “HIT Accidents and Cybercrime Issues,” along with Dan Ford, one of our nation’s leading patient advocates, who gave his talk on “Reflections on Visioning E.H.R. Vendor Transition and Including Patient Advocates.”

Prior Global Summits

We have held a number of global summits and national meetings of leaders who are focused on high impact innovations. Videos of these meetings may be viewed below. The meetings were also broadcasted over the internet.

Title Date Resources
Greenlight Meeting – Washington, DC October 27, 2010 Video & Resources
Patient Safety and High Performance Leadership Summit: Issues in Governance, National Collaboratives, and HIT – Washington, DC April 27, 2012 Video & Resources
Board Engagement and the 5 Rights of Imaging™ – Austin, TX May 3, 2012 More info
Patient Safety and High Performance Leadership Summit:
Issues in Governance, National Collaboratives, and HIT

Friday, April 27, 2012
The following presenters participated in a fast-paced day of multimedia presentations, front-line success stories, and interactive panels. Click on the links for their bios to get more detail about their backgrounds and expertise.
Charles Denham, MD: TMIT; Harvard ALI
David Hunt, MD, FACS: U.S. Department of Health & Human Services
Dana Rohrabacher, MA: U.S. House of Representatives, R-CA
Dennis Wagner, MPA: Centers for Medicare & Medicaid Services
Chesley B. (Sully) Sullenberger III: Pilot, U.S. Airways (Retired)
John Nance, JD: Best-selling Author and Pilot
James Bagian, MD, PE: University of Michigan
David W. Bates, MD, MSc: Brigham and Women’s Hospital
David Classen, MD, MS: University of Utah
Paul McGann, MD: Centers for Medicare & Medicaid Services
Samantha M. Chao, MPH: Institute of Medicine
Leah Binder, MA, MGA: The Leapfrog Group
Perry Bechtle, DO: Mayo Clinic, Jacksonville, FL
William Munier, MD, MBA: U.S. Department of Health & Human Services
Arjun Srinivasan, MD: Centers for Disease Control and Prevention
Jean D. Moody-Williams, RN, MPP: Centers for Medicare & Medicaid Services
Farzad Mostashari, MD, ScM: U.S. Department of Health & Human Services
Stephen Swensen, MD, MMM, FACR: Mayo Clinic College of Medicine
J. Michael Henderson, MD: Cleveland Clinic Health System
Mike Williams, MD, MBA: Hill Country Memorial Hospital
Robert Chapman, MBA: Barry-Wehmiller Companies, Inc.
Regina Holliday: Patient Rights Arts Advocate
Trisha Torrey: Patient Advocate
Lygeia Ricciardi, EdM: U.S. Dept. of Health & Human Services
Mary Foley, RN, PhD: University of California
Nancy Conrad: Conrad Foundation
Sharon Rossmark, MBA: Zayos Global Ventures, LLC
David Parda, MD, FACP: Allegheny General Hospital
Ellen Canepa Brzytwa, RN, MSN, MPH: Ellen Brzytwa and Associates
Gladstone C. McDowell, II, MD: Integrated Pain Solutions; TMIT
Franck Guilloteau: Texas Medical Institute of Technology (TMIT)
Thomas Zeltner, MD: Fondation Science et Cité, Switzerland
Edward Kelley, PhD: World Health Organization, Switzerland