Our Safety Learning System® (a.k.a Interdisciplinary Learning Resources™) originated from lessons learned over the course of 14 years through the development and evolution of the Mayo Clinic Mortality Review System (MRS). After several years of frustration over the lack of change that arose from counting and trending adverse events using the Global Trigger Tool, our co-founder Jeanne Huddleston, MD, MS, and Mayo Clinic Colleagues started performing mortality reviews. They chose mortality under the presumption that if adverse events kill people therefore, death should be a richer source of learning. After reviewing 100 consecutive deaths, it was discovered that:


Patients suffered from a significant
adverse event.


Patient deaths were hastened by
care delivery.


Patients were believed to have been
outright killed.

These findings were meaningful in that the data was actionable, measurable, and improvable. A combination of actionable insights and meaningful data led to immediate action from leadership.

Over time, adverse events became issues that morphed into opportunities to improve (OFIs). Adverse events are considered failures but often these failures are out of our control as providers leading to the concept of OFIs. We moved away from the concept of intentional harm to discovering a wealth of omissions that we as providers want to see changed but accept them as part of the systems and processes of healthcare delivery.

What separates the Safety Learning System® from MRS is that SLS can be used to review any cohort of interest from readmission to sepsis. What remains the same is our guiding principle:

“No one should ever suffer or die as the result of system or process failures.”

By ‘no one’ we don’t just mean patients and their families but every care provider – the second victims of patient harm who have to cope with bad things happening that were out of their control.

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