PreMortem Follow-up Foreseeing and achieving your goals for CUSP & VAP

1. PreMortem Follow-upForeseeing and achieving your goals for CUSP & VAP Armstrong Institute for Patient Safety and Quality Presented by: Kristina Weeks, MHS, DrPh(c) Research Associate

2. Adaptive or technical? Adaptive CUSP Technical VAE Armstrong Institute for Patient Safety and Quality

3. PreMortem Greatest Hits 1 • Lack of engagement • By whom? • Tune in to WIFM • SOS • Action Plan? Armstrong Institute for Patient Safety and Quality

4. PreMortem Greatest Hits 2 • Lack of Education • Action Plan? Armstrong Institute for Patient Safety and Quality

5. Rank Order of 
Error Reduction Strategies Armstrong Institute for Patient Safety and Quality

6. Next Steps • Please conduct a PreMortem on your Unit • Please return the results to your Coordinating Entity by January 12, 2014 Armstrong Institute for Patient Safety and Quality