 Hello. Good afternoon. I'm in the precarious position of standing between you and lunch. So, but I am very, very pleased to be here representing Dartmouth-Hitchcock as we announce our patient safety movement foundation commitment focused on eliminating failure to rescue deaths. Dartmouth-Hitchcock has been actively committed to addressing failure to rescue as a major driver of inpatient mortality for more than a decade, most notably with our implementation of continuous monitoring in the general care setting, which we also call surveillance monitoring back in 2007. The seminal event that initiated our increased attention to failure to rescue events involved a patient in their 30s who was admitted to the general care unit for a minor surgical procedure. The patient had a history of anxiety and pre-existing conditions that were assessed and determined to represent little perioperative risk. The patient was given medication for anxiety and opioids for pain. Post-op physiologic assessments during the first few hours of inpatient admission were normal, but just hours later, the patient was found dead by a nurse who entered the room for routine vital signs assessment. Shortly after the review of this event, Dartmouth-Hitchcock committed to seeking additional ways to prevent patient harm from unwitnessed arrests due to a failure to recognize and rescue patients with serious but treatable complications with a goal of complete elimination of such events. Implementation of our patient surveillance system, which employs pulse oximetry, resulted in a 48 percent decrease in transfers to higher level of care and a 65 percent reduction in rapid response team activations. Additionally, a chart review of the five years after the implementation found that there had been no cases of unwitnessed respiratory arrest in the original pilot unit during that time. It's quite remarkable. And although we have made great strides in addressing unwitnessed respiratory arrest in our hospital, we recognize there's more work to do to address the many other serious but treatable conditions currently associated with failure to rescue deaths. Our experience and the evidence that is currently available suggests that early recognition of patient deterioration and rapid intervention represent key opportunities for improvement in rescue systems at this point in time. At Dartmouth-Hitchcock, our recent efforts have focused on systems-level analysis conducted through our patient safety learning laboratory, which is supported in part by the Agency for Healthcare Research and Quality. Over the next three years, our organization will systematically identify and evaluate gaps in our rescue system and will design, prototype, and deploy interventions, including unit and hospital-level patient complication assessment tools to enhance patient placement and clinical resource allocation, individual patient assessment tools to improve early recognition of deterioration at the bedside, and communication systems to improve shared mental models across clinical teams to promote intervention and rescue activation when patient deterioration due to an unrecognized serious but treatable complication is detected. Through our commitment with the Patient Safety Movement Foundation, we've set a goal of reducing deaths by 25% per year over two years after we implement our latest interventions, which means that we expect to save approximately 30 lives during this time period. We also plan to help other health care systems achieve significant reduction in failure-to-rescue event rates through publications and outreach activities designed to highlight the key characteristics of successful interventions and methods of implementing operational clinical settings. I'll close with another patient story, one of my favorites. In 2012, just months after we implemented surveillance monitoring in our pediatric unit, the unit nurse educator sought me out with tears in her eyes and explained how the system the previous night had just saved the life of a 12-year-old girl by alarming just five minutes after the completion of the vital science check that was scheduled to be done every four hours. It occurred to me recently that that young lady is applying for college right now and the belief that every patient deserves the same outcome as that young woman is why our team is committed to continuing our journey to eliminate failure-to-rescue deaths in hospitalized patients. Thank you.