1. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 PreMortem Follow-up Foreseeing 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? Armstrong Institute for Patient Safety and Quality 2 Adaptive CUSP Technical VAE

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

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

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

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 6