Overdose Fatality Review

Overdose

Fatality Review

A Practitioner’s Guide to Implementation

Acknowledgment

This document was authored by Melissa Heinen and

Mallory O’Brien, Institute for Intergovernmental

Research.

Financial support for this toolkit was provided by the

Bureau of Justice Assistance, Ofce of Justice Programs,

U.S. Department of Justice and the U.S. Centers for

Disease Control and Prevention.

Released: July 2020

Learn more about the Overdose Fatality Review at www.cossapresources.org.

About BJA

The Bureau of Justice Assistance (BJA) provides leadership and services in grant administration and criminal justice policy

development to support local, state, and tribal law enforcement in achieving safer communities. To learn more about BJA,

visit www.bja.gov and follow us on Facebook (www.facebook.com/DOJBJA) and Twitter (@DOJBJA). BJA is part of the

U.S. Department of Justice’s Ofﬁce of Justice Programs.

This project is supported by the Bureau of Justice Assistance (BJA), Ofﬁce of Justice Programs, U.S. Department of Justice, and the U.S. Centers for

Disease Control and Prevention by Grant No. 2017-AR-BX-K003 awarded by BJA. The contents of this document were developed by the Institute

for Intergovernmental Research and do not represent the ofﬁcial position or policies of the U.S. Department of Justice or the U.S. Centers for

Disease Control and Prevention.

Table of Contents

Overview...................................................................................................................................1

What Is the Overdose Epidemic?.....................................................................................................................................2

Are Overdose Deaths Preventable?.................................................................................................................................2

What Is an Overdose Fatality Review (OFR)? ...................................................................................................................2

Why Are OFRs a Useful Strategy for Preventing Overdose Deaths .................................................................................2

Toolkit Design...................................................................................................................................................................3

Module 1. Recruit Your OFR Members .....................................................................................4

1A. OFR Team.................................................................................................................................................................5

1B. OFR Leadership Roles and Structure .......................................................................................................................8

1C. OFR Team Facilitation Role......................................................................................................................................8

1D. OFR Team Coordination Role ................................................................................................................................11

1E. OFR Data Manager Role ........................................................................................................................................11

1F. OFR Subcommittees ..............................................................................................................................................11

1G. Governing Committee ...........................................................................................................................................12

1H. OFR Overall Structure ............................................................................................................................................12

Module 2. Plan Your OFR Meeting ..........................................................................................13

2A. Meeting Logistics ...................................................................................................................................................14

2B. Meeting Preparation: Coordinator’s Activities ......................................................................................................15

2C. Meeting Preparation: Members’ Activities............................................................................................................17

Module 3. Facilitate Your OFR Meeting..................................................................................19

3A. Facilitator’s Role .....................................................................................................................................................20

3B. Guiding Principles ..................................................................................................................................................20

3C. Meeting Agenda ....................................................................................................................................................21

3D. Meeting Facilitation Strategies ..............................................................................................................................23

3E. Managing Difﬁcult Conversations ..........................................................................................................................25

3F. Measuring Meeting Success...................................................................................................................................26

3G. Meeting Notes .......................................................................................................................................................26

3H. Post-Meeting Tasks ................................................................................................................................................26

3I. Updating the Governing Committee .....................................................................................................................27

3J. Preventing Case Review Burnout ...........................................................................................................................27

Overdose Fatality Review: A Practitioner’s Guide to Implementation / iii

Module 4. Collect Your OFR Data ...........................................................................................28

4A. Conﬁdentiality........................................................................................................................................................29

4B. Data Collection Process .........................................................................................................................................30

4C. OFR Database........................................................................................................................................................31

Module 5. Build a Recommendation Plan................................................................................32

5A. Identifying Recommendations During the OFR Review.........................................................................................33

5B. Documenting Recommendations...........................................................................................................................34

5C. Forming a Subcommittee to Develop Recommendations.....................................................................................35

5D. Subcommittee Roles and Responsibilities .............................................................................................................36

5E. Implementing a Recommendation.........................................................................................................................37

5F. Assessing and Monitoring Recommendations.......................................................................................................37

Appendix A: Resources for Model 1. Recruit Your OFR Members.........................................39

Sample: OFR Recruiting Letter......................................................................................................................................40

Sample List: Facilitator Qualities...................................................................................................................................41

Sample Checklist: OFR Launch .....................................................................................................................................42

Appendix B: Resources for Model 2. Plan Your OFR Meeting ...............................................43

Coordinator’s Meeting Preparation Checklist ................................................................................................................44

Sample: OFR Agenda ...................................................................................................................................................45

Sample: OFR Case Email ..............................................................................................................................................46

Sample: Member’s Guide to Collecting Case Information............................................................................................47

Sample: Agency-Speciﬁc Data Elements ......................................................................................................................48

Sample: OFR Two-Week Reminder Email .....................................................................................................................49

Sample: Case Summary Outline....................................................................................................................................50

Sample: Summary Data Report.....................................................................................................................................50

Sample: Meeting Ground Rules ....................................................................................................................................51

Appendix C: Resources for Model 3. Facilitate Your OFR Meeting .......................................52

Sample Template: Meeting Minutes .............................................................................................................................53

Sample: Governing Committee Report Outline............................................................................................................54

Appendix D: Resources for Model 4. Collect Your OFR Data ................................................55

Sample: Interagency Data Sharing Agreement.............................................................................................................56

Sample: Conﬁdentiality Agreement..............................................................................................................................58

Sample: Conﬁdentiality Agreement and Review Sign-In Sheet ....................................................................................59

Template: OFR Data Sharing Protocol ..........................................................................................................................60

Appendix E: Resources for Model 5. Build a Recommendation Plan .....................................61

Sample: Recommendation Work Plan...........................................................................................................................62

iv / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Overview

What Is the Overdose Epidemic?

Drug overdoses are a leading cause of death in the

United States. From 1999 to 2017, more than 702,000

people died from a drug overdose in America; 67,000

died in 2018.

Pointing to progress in addressing the epidemic, there

were 4 percent fewer overdose deaths in 2018 compared

with 2017.

Are Overdose Deaths Preventable?

Yes. Overdose deaths can be prevented with coordinated

prevention strategies, timely implementation of evidence-

based interventions, community mobilization, and

supportive families and friends.

The shared understanding that overdose deaths

are preventable guides the entire overdose fatality

review (OFR) process. Federal agencies, such as the

Bureau of Justice Assistance (BJA) and the Centers for

Disease Control and Prevention (CDC), are strategically

coordinating to mobilize local communities to develop

and implement OFRs.

What Is an Overdose Fatality Review

(OFR)?

The purpose of an OFR is to effectively identify system

gaps and innovative community-speciﬁc overdose

prevention and intervention strategies.

In practice, OFRs involve a series of conﬁdential individual

death reviews by a multidisciplinary team. A death review

Overview

(also referred to as a “case review”) examines a decedent’s

life cycle in terms of drug use history, comorbidity, major

health events, social-emotional trauma (including adverse

childhood experiences), encounters with law enforcement

and the criminal justice system, treatment history, and

other factors, including local conditions, to facilitate a

deeper understanding of the missed opportunities for

prevention and intervention that may have prevented an

overdose death.

By conducting a series of OFRs, jurisdictions begin to see

patterns of need and opportunity, not only within speciﬁc

agencies but across systems.

Blending input from public health, public safety, providers,

and the community, OFR teams develop program

and policy recommendations to improve coordination

and collaboration between agencies and community

conditions to prevent future overdose deaths.

These recommendations are presented to a governing

committee that supports and provides resources for

implementation and a framework for accountability for

action. Examples of successful recommendations include

the integration of peer recovery specialists into new

settings, targeted naloxone distribution, and improved

coordination of public safety and public health.

Why Are OFRs a Useful Strategy for

Preventing Overdose Deaths?

Fatality reviews are used to address several complex

public health issues. Reviews such as homicide, child

death, maternal mortality, critical incidents, suicide, and

2 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

overdose deaths share many common components such

as a focus on prevention, convening of multidisciplinary

teams to do a series of case reviews, identiﬁcation of

missed opportunities for prevention and intervention,

and development and implementation of data-driven

prevention and intervention strategies.

The OFR process generates information about the

decedent and his or her interactions with services

and systems. This information is used to craft

recommendations to prevent future similar deaths.

Toolkit Design

As a nationally recognized model, OFR is being used by

a growing number of communities to strengthen their

community-based responses to the opioid overdose

epidemic. This toolkit is a companion document to the

CDC Foundation’s Public Health and Safety Team (PHAST)

Toolkit and was created to help communities plan,

implement, and evaluate OFRs. It is designed for multiple

audiences including public health, public safety, criminal

justice, drug treatment, and social services.

The goal of the toolkit is to provide the reader with the

needed information to build a successful OFR process

with a strong foundation in coalition, data collection, and

prevention. The toolkit content draws on other fatality

reviews and the authors’ practice-based knowledge. It is

organized into ﬁve modules:

Modules

Module 1. Recruit Your OFR Members

Module 2. Plan Your OFR Meeting

Module 3. Facilitate Your OFR Meeting

Module 4. Collect Your OFR Data

Module 5. Build a Recommendation Plan

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 3

Module 1. Recruit Your OFR Members

Recruit Your

OFR Members

Module

This module covers the overdose fatality review (OFR)

team leadership roles and members, as well as how to

recruit to ensure active participation by multidisciplinary

members. It also covers how the OFR team ﬁts into a

larger infrastructure, including subcommittees and a

governing committee.

1A. OFR Team

OFR teams are multidisciplinary and include individuals

who can share information about a decedent or contribute

to the analysis of available data to make recommendations

that will prevent future overdose deaths.

Like the CDC Foundation’s Public Health and Safety Team

(PHAST) framework, an OFR encourages multisector

collaboration by using the data-driven “SOS” process.

In this context, SOS stands for shared understanding,

optimized capacity, and shared accountability.

OFR Team Members

Overdoses affect a variety of populations, neighborhoods,

and communities. To effectively function and work toward

the goal of preventing overdose deaths, OFR teams need

a diverse set of members from disciplines and sectors that

represent the community.

Shared understanding. OFRs increase

members’ understanding of area

agencies’ roles and services as well as the

community’s assets and needs, substance

use and overdose trends, current

prevention activities, and system gaps.

Optimized capacity. OFRs increase the

community’s overall capacity to prevent

future overdose deaths by leveraging

resources from multiple agencies and

sectors to increase system-level response.

Shared accountability. OFRs continually

monitor local substance use and overdose

death data as well as recommendation

implementation activities. Status updates

on recommendations are shared at each

OFR team meeting and with a governing

committee, reinforcing accountability for

action.

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 5

Finding the appropriate partner agencies and

professionals to become OFR team members is essential

in establishing an effective OFR. It is important to partner

with agencies willing to:

• Provide quality services.

• Develop successful partnerships.

• Maintain consistent engagement.

• Be good stewards of data—following conﬁdentiality.

• Engage in public policy or advocacy.

Each partner agency should identify staff members

(frontline staff, mid-level supervisors, or executives) who

have the most appropriate roles within in the agency to

be OFR team members and who regularly attend and

contribute to the OFR. All stafﬁng levels are important

and needed on a review team to ensure the most

complete understanding of how agencies and systems

work together, including what gaps exist and what steps

may be needed to implement identiﬁed prevention

recommendations. This level of engagement ensures

that at least one person from each agency can be

present at each meeting and helps build internal agency

relationships and champions for change.

OFR team members are dedicated professionals who

believe that overdoses are preventable, are well-regarded

in the ﬁeld, and have time to attend regular meetings and

participate in follow-up activities. Effective OFR teams

have 15-35 members. A list of typical OFR team members

is available in Figure 2.1.

Some sectors, such as law enforcement agencies, may

have more than one representative on OFR teams.

For instance, if there are multiple law enforcement

agencies (sheriff’s ofﬁce, police department, etc.) in your

jurisdiction, you may have both a sheriff’s ofﬁce and a local

law enforcement representative.

For some cases, OFR team members may have had

previous contact with a decedent or the decedent’s family

or social network. They may also represent an agency

Figure 2.1 Typical OFR Team Members

• Local health department ofﬁcial

• Local law enforcement representative

• Medical examiner/coroner

• Prosecutor

• Local human services department ofﬁcial

• Substance use treatment provider

• Medication for opioid use disorder (MOUD)*

provider*

• Mental health social worker

• Pain management clinician

• Emergency department physician

• Primary care provider

• Pharmacist/toxicologist

• High Intensity Drug Trafﬁcking Area (HIDTA)

public health analyst

• Sheriff

• Probation and parole ofﬁce

• Emergency medical service provider

• Drug treatment court representative

• Patient advocate

• Child protective services representative

• Substance use prevention professional

• School counselor

• Tribal elder, traditional leader

• Community leader

• Housing authority representative

• Harm-reduction outreach professional

* formerly known as medication-assisted treatment (MAT)

6 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

that provided services to the decedent or where the

decedent lived, or where the overdose incident occurred.

The OFR team members provide essential information

about the conditions or environments in which the

decedent was born, lived, worked, and aged and what

may have contributed to the decedent’s overdose death.

Some Environmental and Social Determinants

Contributing to Fatal Overdose

• Environmental factors that may have contributed

to the overdose incident. For example, the

decedent may have lived in a home with violence

and drug use, or police ofﬁcers had responded

multiple times to the decedent’s apartment building

regarding complaints of drug dealing and loitering.

• Social determinants of health, which are the social

and community networks and the socioeconomic,

cultural, and environmental conditions in which

residents live, as well as the health and social

systems available. Every community has assets and

needs that impact the health status of its residents.

• Community assets that promote social

inclusion and that may improve the community’s

health and well-being to help prevent future

overdose deaths, such as a robust public

transportation system, adequate housing

for low-income households, and transitional

housing and shelters available without a long

wait to those in need.

• Community disadvantages that increase

the community’s risk for substance use and

overdose deaths, such as a high unemployment

rate, systemic racism, lack of substance use

treatment providers, and frequent drug arrests

and drug-related crime.

Tip:

Consistent attendance builds trust among

participants.

Conditions in the environments

in which people are born, live,

learn, work, play, worship, and age

that affect a wide range of health,

functioning, and quality-of-life

outcomes and risks.

Social

determinants

of health

– Healthy People 2020

In addition to possibly providing services to the

community and to the decedent, an effective OFR team

member will also have:

• An understanding of the impact of the overdose

epidemic in his or her community.

• The ability to assess problems at the macro or

system level and assess organizational practices or

communitywide initiatives.

• Authority to make decisions for the agency he or

she represents or direct access to decision makers.

• The ability to critique work of other agencies and

raise questions without passing judgment.

OFR Team Member Attendance

Encouraging OFR team members to attend each OFR is

important, even if a fatality is not from their geographic

territories, populations, or issues of focus. It helps to build

rapport and builds trust within the team. This trust allows

for more open dialogue about each case and increases

commitment to recommendations. In addition, members

often have critical knowledge outside their geographic

areas or substantive focus where decedents and their

social networks may travel across jurisdictions.

Missing even one meeting can impact the team dynamics

and members’ understanding of the overdose issues and

prevention strategies. If a member cannot attend, he or

she may send a pre-approved designee.

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 7

administrative agency has an institutional commitment to

preventing overdose deaths and providing resources, and

staff to support the initiative. It is seen by the community

as a trustworthy and collaborative agency.

An OFR lead agency can be the local health department,

human services department, prevention coalition, or other

local agency and is seen as a neutral agency; typically, this

agency is already involved as a leader in responding to

the overdose epidemic.

The OFR lead agency oversees the OFR team by

providing administrative support to fulﬁll three key

leadership roles:

• Facilitator

• Coordinator

• Data manager

The OFR team leadership structure and roles depend on

the jurisdiction. Jurisdictions with signiﬁcant ﬁnancial

and political support may have up to three separate

funded staff positions. In other jurisdictions, one person

completes the roles.

1C. OFR Team Facilitation Role

A representative from the lead agency should serve the

facilitation role. The OFR team facilitator is responsible

for activities such as:

• Facilitating OFR meetings

• Recruiting OFR team members

• Building and maintaining relationships with OFR

team members

• Orienting new OFR team members

Facilitating OFR Meetings

OFR team meetings are facilitated using a problem-

solving process to identify recommendations and

to track and oversee implementation of developed

recommendations. More information about the OFR team

facilitation role is available in Module 3. Facilitate Your

OFR Meeting.

OFR teams may beneﬁt from inviting guest

Tip:

participants to contribute information to speciﬁc

cases; such participants are known as OFR guest

members.

OFR Guest Members

An OFR meeting may focus on cases from a speciﬁc area

in a geographic region where nonproﬁt agencies, faith-

based organizations, and other community leadership

or service agencies that are not consistent OFR team

members can inform problem-solving-discussions and

formulate realistic and community-speciﬁc prevention

recommendations. These OFR members are known as

guest members.

In addition, agencies that, and individuals who, have

directly or indirectly served an overdose decedent

may have valuable information. As such, they may be

invited to attend as guest members. Guest members

representing agencies with information about the

decedent may be identiﬁed from news coverage about

the death or from medical examiner/coroner reports.

Participants from smaller nonproﬁt organizations or

understaffed organizations may have less time to

prepare for reviews, have fewer staff members to send

if key staff members are unable to attend, require more

reminders of meetings and tasks, and need more support

implementing recommendations targeting their agencies.

You may consider asking such members to serve as guest

members only for speciﬁc cases to ensure that they obtain

the maximum beneﬁt possible.

Another example of a guest member is an elected ofﬁcial

or someone who wants to observe and learn more about

the OFR process.

1B. OFR Leadership Roles and

Structure

Every OFR team has a lead agency that oversees the

OFR team and provides administrative support. The lead

8 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Figure 2.2 Key Leadership Roles and Responsibilities

Recruiting OFR Team Members

Facilitator

• Facilitate OFR meetings

• Recruit OFR team members

• Build and maintain relationships with

OFR team members

• Orient new OFR team members

Coordinator

• Obtain and share case information

with team members

• Review data and reports from team

members

• Research information about cases

that may not be provided by OFR

members, such as reviewing social

media, obituaries, media coverage,

etc.

• Draft OFR meeting agendas, in

partnership with the OFR team

facilitator

• Manage meeting logistics (such

as date and time, location, and

technology support)

• Take minutes during each meeting

• Document activities since the last

OFR meeting

• Update the governing committee

• Support and communicate with

subcommittees

Data

Manager

• Enter case information and

recommendations into OFR database

• Write data or summary reports for

sharing with the OFR team and the

governing committee

• Analyze OFR data

OFR teams beneﬁt from ongoing recruitment of new

members to address staff turnover, address gaps in their

membership, or identify new trends.

Members may need to be recruited and engaged

before being requested to provide data, participate in

a review, or assist with developing or implementing a

recommendation. Their perspectives and input will be

valuable even if their organizations did not have direct

contact with the decedent or service area related to the

case. For example, a drug treatment provider has a

valuable perspective on standards of care even if it did not

provide services to the speciﬁc individual being reviewed.

A toxicologist or pharmacist may assist with understanding

the prescription drugs provided to the decedent even if

he or she did not interact with that individual.

Effective recruitment is all in the details. Ideally, the OFR

team facilitator will meet one on one with new recruits to

prepare members for what to expect when participating

on a review team by:

• Explaining the OFR goals and reviewing overall

structure.

• Sharing stated and unstated group rules/norms.

• Emphasizing that the purpose of the meeting is not

to point ﬁngers at other participants.

• Addressing any data sharing or conﬁdentiality

concerns and having them sign a conﬁdentiality

agreement. A sample conﬁdentiality agreement is

included in Appendix D.

Tip:

Partnerships are fundamental to the

success of the OFR. Visit the CDC

Foundation’s PHAST Toolkit to learn

more about building multi-sector

partnerships.

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 9

A more formal way to help build team cohesion is to

provide general agency or member updates at the

beginning or end of the meeting that may result in

partnerships during and outside of the fatality review

experience.

Keep in mind that if the relationship with the agency is

new, attending agency events and asking to observe the

program may help you to get a sense for what the agency

does and will build rapport.

Orienting New OFR Team Members

Every team member will come to the table with different

experiences, knowledge, prejudices, and ideas about

substance use and its impact on his or her work and the

community. It will be the facilitator’s responsibility to

lead meetings in a way that elevates all voices, addresses

stigma or misinformation, and neutralizes tensions. To

prepare for this task, the team facilitator may expect each

member to obtain certain knowledge or training ahead of

participating in an OFR team meeting.

Recommended trainings include the following:

• “Partnerships for Prevention: OFR 101” webinar

(link to COAP resource)

• “Overcoming Stigma, Ending Discrimination”

(https://www.samhsa.gov/power-perceptions-

understanding/webcasts)

• “Why Addiction Is a ‘Disease’ and Why It’s

Important” (https://www.samhsa.gov/power-

perceptions- understanding/webcasts)

• “Social Determinants of Health: Know What Affects

Health” (https://www.cdc.gov/socialdeterminants/

index.htm)

The OFR team facilitator needs to

attend and support partners’ events

and initiatives.

Tip:

• Summarizing past and current recommendations

relevant to their organization or area of work.

• Suggesting immediate ways they can participate in

developing and implementing a recommendation.

Drafting an OFR recruitment email with the above

infor

mation, a meeting schedule, and a clear list of partner

expectations will help communicate and recruit new active

members.

A sample OFR recruitment letter is included in

Appendix A.

Before recruited members can participate on the review,

they will need senior leadership to sign an interagency

agreement. A sample interagency agreement is included

in Appendix D.

Depending on whether your state has

OFR-speciﬁc legislation, memoranda of understanding

(MOUs) from data providing members may be needed.

Building and Maintaining Relationships

Building and maintaining relationships can be achieved

several ways. For example, the OFR team can use

meeting breaks as an opportunity to incorporate team

building.

This may involve as little as pulling aside a couple of

participants and introducing them to each other and

bringing up a shared inter

est or connection they may

not be aware of. Encouraging members to stay after the

meeting to network is another effective way to build trust

and relationships.

10 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

• “Words Matter: How Language Choices

Can Reduce Stigma” (http://latwc.org/

uploads/3/4/8/2/34828545/session_101_ho3_

words_matter_tot_binder.pdf)

Since death investigations vary by jurisdiction, it may be

beneﬁcial for OFR team members to learn more about the

local death investigation process and the roles they play

with information available from the medical examiner’s/

coroner’s ofﬁce and local law enforcement agencies.

1D. OFR Team Coordination Role

A representative from the lead agency should serve

the coordination role. The OFR team coordinator is

responsible for activities such as:

• Obtaining and sharing case information with team

members

• Receiving data and reports from team members

• Researching information about cases that may not

be provided by OFR members, such as reviewing

social media, obituaries, media coverage, etc.

• Drafting OFR meeting agendas, in partnership with

the OFR team facilitator

• Managing meeting logistics (such as date and time,

location, and technology support)

• Taking minutes during each meeting

• Documenting activities since the last OFR meeting

• Updating the governing committee

• Supporting and communicating with subcommittees

More information about the OFR team coordination role is

available in Module 2. Plan Your OFR Meeting.

1E. OFR Data Manager Role

A representative from the lead agency should serve in

the data manager role. The OFR team data manager is

primarily responsible for entering case information and

recommendations into the OFR database.

The governing committee

Governing

provides direction to

Committee:

the OFR team and

resources to implement

the recommendations

generated.

More information about the OFR data manager role is

available in Module 4. Collect Your OFR Data and Module

5. Build a Recommendation Plan.

In addition to entering data, there may be a need for

analyzing data from other data sources and/or the OFR

case data for OFR team meetings, governing committee

updates, and annual reports.

1F. OFR Subcommittees

The bulk of the work of an OFR may occur between

meetings at the subcommittee level. Subcommittees

may determine case selection criteria or how a

recommendation may achieve a policy change. For

example, if an OFR review identiﬁed improving care

coordination among inpatient and outpatient treatment

providers as a need, a subcommittee of local treatment

providers, social workers, and patient advocates might

convene to discuss gaps in care; identify partner agencies;

and develop recommendations, an implementation plan,

and a timeline for completion.

Subcommittee membership may include members of

the governing committee, the OFR team, and outside

experts (e.g., experts related to addiction, homelessness,

veterans’ affairs, or family survivors).

Subcommittees meet separately from the OFR team

and report to other members at case review meetings

on their aims and progress. Subcommittees are formed

and disbanded as needed, so they may serve an

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 11

ongoing or a temporary purpose. To learn more about

forming a subcommittee to develop a recommendation,

review Section 5C. Form a Subcommittee to Develop

Recommendations.

1G. Governing Committee

In addition to the lead agency and subcommittees, the

OFR team needs a committee to provide leadership

and support for implementing recommendations it has

identiﬁed. This committee is referred to as a governing

committee.

Depending on the jurisdiction, the governing committee

may be an already existing local drug prevention task

force or may be formed solely to support the OFR

initiative.

The governing committee is composed of senior-level

representatives of city, county, and state agencies and

community partner organizations. Table 1.1 lists possible

governing committee members for a local OFR team. To

learn more about how the OFR team interacts with the

governing committee, review Section 3I. Updating the

Governing Committee.

Table 1.1 Example of Governing Committee Members

Chief of police

Chief executive ofﬁcers at

Mayor

local hospitals

Commissioner of health

County sheriff

Researchers at a local

Attorney General

university

Secretary of Department of

Corrections

District attorney

Behavioral health

School superintendent

administrator

Medical examiner/coroner

1H. OFR Overall Structure

Lead Agency

Governing

Committee

OFR

Team

Subcommittee A

Subcommittee B

12 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 13

Module 2. Plan Your OFR Meeting

Plan Your

OFR Meeting

displaying the created timeline of signiﬁcant life events

leading up to the decedent’s overdose death.

Closed-Meeting Format

Given the sensitive nature of the information shared and

the need to build trusted relationships, the OFR meetings

are closed and not open to the public.

Sometimes, invited guests will participate or observe

to learn more about OFRs. Most often, the invited

professionals have information speciﬁc to the case and are

called guest members.

Each meeting attendee, including

guest members or invited guests/

observers, needs to review and

sign appropriate conﬁdentiality

forms to attend.

Remember:

Module

This module will assist overdose fatality review (OFR)

coordinators in planning OFR meetings and prepare

partners to actively and thoughtfully participate in

meetings.

2A. Meeting Logistics

Meeting Schedule

The meetings are held when and where most members

can attend. The schedules and locations of the entire

year’s meetings should be developed at the beginning of

the year so that OFR team members can plan accordingly.

A typical meeting will be two to three hours in length

and each case will take about an hour, depending on the

complexity of the case and the review team’s experience.

Meeting Room Layout

The meeting room layout is important for group dynamics

and inclusion. Hosting the OFR team meeting in a

circle or a hollow rectangle layout gives everyone an

equal position at the table and allows for face-to-face

interactions by all participants. In addition to having

adequate space for desired layout, it is ideal to have a

whiteboard in the meeting room for taking notes and

Having timely data is critical for a

Tip:

successful OFR initiative.

14 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

2B. Meeting Preparation:

Coordinator’s Activities

Successful OFR case reviews depend on thoughtful

preparation by the OFR coordinator, beginning a month

or two before an OFR case review meeting. A list of

coordinator activities and a timeline is provided below

and in the Coordinator’s Meeting Preparation Checklist

provided in Appendix B.

1. Select cases

Beginning two months before the meeting, the cases

to be reviewed at the upcoming meeting need to be

selected.

Having timely data is critical for a successful OFR initiative.

The medical examiner’s/coroner’s ofﬁce can be an

excellent source for identifying overdose cases and initial

case information. If possible, have someone with access

to the medical examiner’s/coroner’s data on the case

selection subcommittee and the OFR team. Ideally, this

person will gather information about overdose fatalities as

they occur.

Once cases are identiﬁed by the medical examiner/

coroner, allow enough time for toxicology results to be

known and police ofﬁcers to investigate an overdose

before selecting the case for review. This will enable the

data to be collected and organized for a more complete

case review.

2. Case selection criteria

It may not be feasible for every OFR team to review

every death in its jurisdiction. In this situation, the

coordinator may task a subcommittee with developing

case selection criteria and/or selecting cases.

To help select cases, the following may need to be

decided:

• Jurisdiction inclusion—residents from the

jurisdiction or deaths within the jurisdiction

• Substances involved—all overdose deaths or only

deaths from a speciﬁc substance will be included,

for example, opioid-involved deaths

• Cause of death—only unintentional overdoses;

include all (suicides and undetermined deaths)

overdoses, or drug-related injuries, such as car

crashes or hypothermia complicated by opioid use

• Cases under investigation—exclude cases in which

there is an open law enforcement investigation

Once the core case criteria are determined, further case

selection criteria may be needed to narrow the selection

of cases to a feasible number. Criteria may include the

following:

• Geographical neighborhoods with high rates (e.g.,

cases from the northside neighborhood)

• Populations with recent increases in deaths (e.g.,

young adult white females)

• Substances involved in most recent overdose deaths

(e.g., fentanyl)

• Populations with known system interactions that

may beneﬁt from review (e.g., overdose deaths after

recent release from incarceration or treatment)

3. Recruit guest OFR members

Beginning six weeks before the meeting, the

coordinator needs to identify guest members, in

addition to OFR team members, that he or she needs to

recruit.

Agencies that are not already OFR members and that

may have provided services to the decedent (such as a

behavioral health provider) or that serve the community

in which the decedent lived, such as social services or

housing and employment supports, may be recruited

to participate in a speciﬁc case review. The agencies

to participate may be identiﬁed from the medical

examiner’s/coroner’s report or from news coverage

about the death.

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 15

An email and follow-up phone call to discuss the OFR

process and purpose can be an effective method for

getting participation. It is important to share and

review interagency and conﬁdentiality agreements.

Have the agreements signed before discussing details

of the case or requesting case information. Sample

recruitment letter and agreements are included in

Appendix A and D.

4. Request case information

Once interagency agreements are in place and around

a month before the meeting, case-speciﬁc information

should be requested of all team members. The

information should be protected in accordance with

conﬁdentiality standards. If possible, use an encrypted

email to request information about the case.

The email requesting case information should include

the decedent’s information listed below and guidance

on what information is requested from members,

including what speciﬁc data members should report

out. A sample OFR case email, a member’s guide

to collecting case information, and a list of agency-

speciﬁc data elements is included in Appendix B.

Decedent information:

• Name, aliases

• Date of birth, date of death

• Demographics (age, race, sex)

• Address of residence

• Incident location, date, and time

5. Send meeting reminder email

Two weeks prior to the review, an email including the

following should be sent to OFR members:

• Brief summaries of cases

• List of meeting participants

• Meeting agenda

• Meeting date, time, and location

A sample two-week reminder email is included in

Appendix B.

Summarize case(s)

Prior to the meeting, the coordinator will want to

summarize in a PowerPoint presentation or handout

additional information identiﬁed by reading the

obituary, news coverage, or social media posts or

by interviewing family members or social contacts to

present during the case review. A template for

creating and presenting a case summary is included in

Appendix B.

7. Document activities since last meeting

Two weeks prior to the meeting, reach out and follow up

with partner agencies that were responsible for previous

action items or recommendations to get a status update

to share during the OFR meeting.

OFR teams should consider having a standing agenda

item to provide updates on action or tasks completed

since the last meeting. Documenting and sharing this

information helps build in accountability of all members

and subcommittees.

8. Print agendas and meeting materials

The coordinator is responsible for developing the

meeting agenda with input from the OFR facilitator,

if this is a different person. More information on

developing an OFR meeting agenda is located in

Section 3C, and a sample meeting agenda is included in

Appendix C.

The coordinator will print and bring agendas, handouts,

data use agreements, and any other materials needed

during the OFR meeting.

16 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Reminder:

agencies and for public policies affecting speciﬁc target

populations, neighborhoods or communities, and/

or topic areas (such as co-occurring mental illness and

substance abuse).

Documents need to be saved in a

secure, restricted-access folder. If

copies of the summary information

are distributed at the meeting, the

facilitator is responsible for collecting

them at the end of the meeting to

ensure security and conﬁdentiality.

Identify agency’s contact

Members will need to determine whether their

organizations or agencies had contact with the

decedents, decedents’ families, or social networks, or

whether they provided services to the neighborhoods

where the decedents lived or where the incidents

occurred.

2C. Meeting Preparation: Members’

Activities

Follow up with the OFR coordinator if more information

is needed to determine whether your organization or

agency had contact with or provided services to the

decedent(s).

OFR members include OFR core team members and

invited guests. Members may begin preparing a month

prior to the review meeting.

The more prepared the members are, the more

engaged they will be, resulting in a more comprehensive

understanding of the incident and what could have been

done to prevent it.

Prepare a summary

If a member’s organization or agency had contact with

someone involved in the case or the incident area, he or

she should prepare a summary to verbally share during

the OFR discussion.

Receive and review the case information

Members will receive an email one month prior to the

meeting containing the basic decedent information

listed below. Most OFR meetings will cover more than

one case.

There are no hard-and-fast rules about what information

will be useful in identifying a problem and possible

solutions to prevent similar overdose deaths from a

systems perspective. However, preparing for the review

by answering the questions provided by the coordinator,

along with reading the basic decedent case information,

is a good starting point.

Decedent information:

• Name, aliases

• Date of birth, date of death

• Demographics (age, race, sex)

• Address of residence

• Incident location, date, and time

Before you draft a summary, review the

signed data sharing agreement and

conﬁdentiality forms, as well as your

organization’s conﬁdentiality policies.

Important:

Consider implications

Members will want to think about each case and any

implications it might have for their organizations or

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 17

A member’s guide to collecting case information and

agency-speciﬁc data element recommendations are

available in Appendix B.

Some members may choose to read a prepared

summary and others may choose to read from available

case ﬁle. Ideally, OFR team members will bring their

summary and records to be able to reference back

to during the meeting to allow additional details to

become available as the discussion progresses.

5. Participate in group discussion

At the review meeting, members will want to ask

questions to clarify information and timeline, identify

missed opportunities or gaps in services, and suggest

strategies to prevent future deaths.”

6. Take notes during the meeting

At the review meeting, it is ﬁne to take notes of the

discussion, observations, prevention activities, or

strategies you want to remember for your agency. Do

not document any identifying information about a case

that would be considered conﬁdential.

7. Invest in networking

Schedule your day so you can arrive early and stay a few

minutes after the review to meet other team members.

It is a good networking opportunity and a great way to

continue the discussion with other colleagues.

18 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

our OFR Meeting Module 3. Facilitate Y

Facilitate Your

OFR Meeting

This module will assist overdose fatality review (OFR)

facilitators in effectively facilitating review meetings to

build trust and identify recommendations to prevent

future overdose deaths.

3A. Facilitator’s Role

An effective facilitator is a neutral convener who is a good

listener, develops trust with partners, encourages group

participation and engagement, leads but does not direct

discussion, and guides the group towards collective

problem solving to craft recommendations.

Ideally, to maintain objectivity and a sense of equality

among partnering agencies and members, the facilitator

should be a representative from a neutral lead agency,

such as local public health or community coalition, and

will not report to a principal agency such as the police

department, the mayor’s ofﬁce, or a behavioral health

service agency.

The OFR team facilitator is a

“neutral convener” who oversees

facilitation of team meetings to

collectively problem solve and

identify recommendations to

prevent future overdose deaths.

Denition:

Module

Including discussion about the

decedent’s associates and social

connections can provide a more

contextual understanding of the

circumstances surrounding the

overdose death.

Tip:

3B. Guiding Principles

The facilitator is responsible for ensuring that members

agree with the following guiding principles:

• The “North Star” (a shared goal of reducing

overdose deaths)

• Overdose deaths are preventable

• Substance use disorder is a chronic, treatable

disease

• Use of multisector data to inform response

strategies

• Continually improve the OFR process and

prevention activities

Visit the CDC Foundation’s Public Health and Safety

Team (PHAST) Toolkit to learn more about these guiding

principles.

20 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

3C. Meeting Agenda

A successful OFR meeting will cover the following nine

steps. A sample agenda can be found in Appendix B.

1. Opening remarks and introduction

This step should include member introductions, updates

from previous meetings, upcoming events, data

presentation, review case selection criteria, and other

announcements.

• Member introductions: Attendees share their

names, titles and their agencies’ names and roles in

preventing overdose fatalities.

• Updates from previous meetings: Members share

status updates on any delegated action items or

recommendations from previous meetings.

• Data presentation: At the beginning of the year,

present an overview of the prior year’s fatal and

nonfatal overdose deaths. At each subsequent

meeting, present the year-to-date number of

overdose fatalities and any noticeable trends

(e.g., changes by overall numbers, demographics,

or substance type). Understanding overdose

fatalities (e.g., who is at risk for an overdose and

where overdose deaths are happening) requires

an ongoing and real-time analysis of overdose

trends. Using a standard report will help partners

understand long-term trends in fatalities and

allow them to plan and develop new strategies or

modify existing ones. Data and analysis from these

reports can also be invaluable for promoting public

awareness and outreach, as well as for applying

for grant funding. A sample summary data report

is included in Appendix B. Also, refer to the CDC

Foundation’s PHAST for more guidance about

presenting data at an OFR meeting.

• Review case selection criteria: If not all overdose

deaths within a jurisdiction are being reviewed,

remind the review committee about which criteria

were used to select the case.

2. Goals and ground rules

The facilitator reads aloud the meeting goal(s), guiding

principles, and ground rules included on the agenda

handout. Ask participants whether they want to add any

new ground rules.

• A sample list of ground rules is included in

Appendix B.

• Guiding principles listed in Section 3B.

Conﬁdentiality

The facilitator or coordinator collects members’

reviewed and signed conﬁdentiality forms and answers

any related questions. Conﬁdentiality is discussed in

more detail in Module 4. Collect Your OFR Data.

• Conﬁdentiality agreement: This essential form

needs to be signed at the beginning of each review

by the members present. A sample conﬁdentiality

agreement is included in Appendix D.

• If more than one case is reviewed at a meeting and

some members arrive mid-meeting, the facilitator

needs to make sure that they sign and submit the

conﬁdentiality agreement when they arrive.

• Interagency agreement: This agreement needs to

be signed by senior leadership of each participating

agency (including any ad hoc agencies) before they

participate in any reviews. The agreement states

the role of the agency in the reviews. A sample

interagency data sharing agreement is included in

Appendix D.

• The facilitator is responsible for reminding team

members that the meeting is closed and that the

information shared in the meeting shall not be

discussed outside the meeting, as outlined in the

agreements they have signed.

4. Case presentation

The facilitator presents the decedent’s basic case

information.

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 21

• The facilitator presents the case summary

developed by the coordinator, as outlined in Section

2B. Coordinator’s Activities, Step 6. Summarize

Case(s).

• If each member is given a summary document, all

documents should be collected at the end of the

meeting.

5. Member report-outs

The facilitator calls on each member to share what

he or she knows about the decedent, his or her

social connections, and the overdose incident. The

information shared helps members understand more

about where the decedent lived, socialized, worked,

and played to help identify risk factors and missed

opportunities for prevention and intervention that may

have contributed to the overdose death.

The facilitator calls on members to share their summary

reports, as discussed in Section 2C. Members’ Activity,

Step 4. Prepare a Summary, starting with the medical

examiner and ﬁrst-responder agencies, to report out

in reverse chronological order, for assistance with

developing an incident timeline. The facilitator will then

determine the best approach to receive report outs from

the remaining members, based on the speciﬁc case.

6. Group discussion

The facilitator actively guides the group discussion by

encouraging members to ask questions. The group

discussion will clarify the timeline of signiﬁcant life

events and identify missed opportunities for prevention

and intervention. The facilitator may want to use the

strategies outline in Section 3D. Meeting Facilitation

Strategies.

7. Case and timeline summarized

The facilitator summarizes signiﬁcant case information

and draws a timeline of key activities, ideally on a

whiteboard.

8. Formulate recommendations

The facilitator leads a problem-solving discussion as

outlined in Figure 2.1 to identify recommendations

for change in practices or policies that may have

prevented this overdose death and may prevent those

in the future.

Summarize and adjourn

The facilitator reviews and clariﬁes actionable

recommendations, assigns individuals responsible for

any action items, reﬂects on the meeting’s process

and ﬁndings, and collects any participants’ handouts

containing case information.

• The facilitator recaps how the meeting went and

relates today’s review to other cases or to a larger

context, such as by saying, “Today’s case involved

a heroin-laced fentanyl, and there has been an

increase in such reported cases in recent months

from this area of the city.”

• The team determines whether the investigation is

complete or whether more information is needed.

• Remind members of conﬁdentiality and collect any

papers with conﬁdential information.

• Remind members of the time and location of the

next meeting.

Figure 2.1 Problem-Solving Process to Identify

Recommendations

What are the

missed

opportunities?

What are the

system gaps?

What can be

done to improve

service delivery

or intervention?

How would

this be

implemented

and in what

settings?

22 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

To have the most signiﬁcant impact,

recommendations should focus on:

Tip:

• Improving service delivery and

investigation.

• Changing agency policies and

practices.

• Revising local ordinance or state

legislation.

• Initiating or modifying community

prevention strategies.

3D. Meeting Facilitation Strategies

An OFR meeting is a combination of information

sharing, group brainstorming and problem solving,

strategic planning, and decision making. The meeting

facilitator actively participates in the discussion, moving

it from information sharing to problem solving using the

following strategies.

1. Thank members

Thanking members for their input and suggestions

encourages participation by all who have relevant

information.

2. Encourage person-ﬁrst language and

respect for the decedent and survivors

OFR teams have a responsibility to honor the decedent’s

life and to respect surviving family members and loved

ones. This can be accomplished by:

• Protecting conﬁdentiality of the case review

proceedings.

• Using appropriate and sensitive language when

discussing the case.

• Avoiding judgment of the decedent’s decisions.

• Considering all factors that contributed to the

decedent’s substance use and overdose.

• Trying to understand the decedent’s experience

through his or her eyes.

• Holding a place at the table for the decedent or

taking a moment of silence.

Summarize members’ comments

To ensure that main points are heard, the facilitator

may restate or summarize members’ comments, when

possible, making connections clearer and stronger

between members’ points and potential implications for

changing a system.

Solicit a variety of solutions/

recommendations

Actively encouraging strategies beyond standard

enforcement and intervention-centered approaches

will steer the group towards more upstream or primary

prevention activities.

5. Address misinformation

While the facilitator does not need to be an expert, he

or she should identify and correct misinformation when

apparent. If there is disagreement over the accuracy

of a statement, it can be paused for further research

after the meeting to shift the focus back to the task at

hand. Attention to accurate information will inspire

standards of information quality. This is important for

the development of meaningful recommendations and

can reduce stigma that is based on misinformation.

6. Acknowledge all potential solutions

The facilitator remains neutral by acknowledging and

giving equal consideration to all suggested solutions

and demonstrating how each suggestion is part of a

continuum of response to prevent overdose.

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 23

7. Ask open-ended questions

Asking open-ended questions helps participants (1)

understand the “bigger picture,” (2) examine the

underlying issue, and (3) develop their own solutions.

8. Ask clarifying questions

The facilitator may ask members to explain agency-

speciﬁc or sector-speciﬁc acronyms or labels so that

everyone understands the material being presented.

It is best not to assume that people already know or

understand information. Asking clarifying questions

helps team members become familiar with the internal

processes of different organizations.

9. Ask reﬂective questions

Pausing and asking reﬂective questions allows members

to look at the case and information shared and to

identify missing information or partners.

Questions that may be useful include “Do we have all

the information we need to identify the problem or

solution?” and “Are there any organizations missing

from this discussion?”

10. Encourage all to participate

To reinforce that all members have equal value and

voice regardless of title or professional experience,

the facilitator may want to refer to everyone by their

ﬁrst names. In addition, the facilitator should call on

members who are less engaged or who do not readily

speak up during the meeting.

11. Ask for help

Encourage persons who or agencies that specialize

in an area to help direct a discussion. They may help

by framing the nature of the problem, summarizing

the results of past initiatives, explaining a new

concept or practice, or proposing possible future

recommendations.

12. Encourage team building

The OFR team should use meeting breaks as an

opportunity to incorporate team building. This may

involve as little as pulling aside a couple of members

and introducing them to each other, bringing up a

shared interest or connection they may not be aware

of. Another way to build team cohesion is to provide

general agency or member updates at the beginning

or end of the meeting that may result in partnerships

during and outside of the fatality review experience.

13. Anticipate possible areas of tension or bias

Including in the ground rules how the team will address

unprofessional or disparaging statements from others

will build trust. It is important that everyone understand

the need to stay focused on working together to identify

possible strategies for preventing future overdoses.

14. Politely redirect members

If the conversation becomes repetitive or irrelevant,

the facilitator should ask questions or change focus to

keep the conversation moving forward. For example,

if a member makes a comment such as “This overdose

could never have been prevented,” the facilitator

should politely redirect members in a direction towards

prevention. This may be as simple as saying, “While

this case may be difﬁcult to review, we have identiﬁed a

few service gaps. Let’s start with one of those and think

about what improvements may beneﬁt others.”

15. Remind members of the “North Star” and

guiding principles

For some members, considering an overdose death a

preventable event may be a signiﬁcant cultural shift.

Reminding members to commit to a common goal

or “North Star” to reduce overdose deaths can help

ground all OFR team members. More information

about guiding principles can be found in the CDC

Foundation’s PHAST Toolkit.

24 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

3E. Managing Difcult Conversations

Disagreements, arguments, competing agency interests,

and other personal and professional conﬂicts need to be

anticipated and resolved prior to or during the meeting so

the discussion can feel safe and fruitful for everyone.

As with much of the OFR process, much of the work

happens outside of the review meeting. It is often

necessary for the facilitator to reach out to members

Remind members of guiding principles:

Tip:

• The “North Star” (shared goal of

reducing overdose deaths)

• Overdose deaths are preventable

• Substance use disorder is a chronic,

treatable disease

• Use of multisector data will inform

response strategies

• Continually improve OFR process and

prevention activities

after a meeting to address any conﬂicts that arise during

the review process and, when the facilitator anticipates

conﬂicts, to reach out ahead of the meeting to mitigate

any possible conﬂicts.

To help limit and manage difﬁcult conversations, the

facilitator may also want to:

Limit tension between partners

To help members collaborate, the facilitator may want to

make such suggestions as, “Let’s try to build a solution

together that will meet everyone’s needs.” If there is

competition between service agencies, it can be useful

to highlight the value each organization brings to the

table.

Notice possible political issues

In researching a case for the review meeting, the

facilitator may notice something that could result in one

agency being under ﬁre. The facilitator should give the

agency a heads-up prior to the meeting, setting up the

conversation and expectations in a way that allows for

respectful, honest transparent discussion to identify and

correct any issues to mitigate future problems.

Be on alert for individual member triggers

If a member of the meeting said something that was

obviously disrespectful, the facilitator will need to

remind members to be respectful. If the statement

was stated respectfully, but another member took

offense or is sensitive to the statement, the facilitator

might restate the comment in a way that decreases the

negative impact and encourages problem solving and

collaboration.

Put a conversation on hold until after a

meeting/create a “parking lot”

Acknowledge when a conversation is drifting or

irrelevant and ask that members put it on hold until after

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 25

the meeting. Sometimes, disagreements beneﬁt from

a pause, which provides an opportunity for additional

research to inform conﬂict resolution. The facilitator can

tactfully ask the members to pause the discussion and

move on to the next case or agenda item.

Remain neutral and objective

It is very important that the facilitator remain neutral and

objective. Do not take sides in the dispute. Instead,

ask members to focus on the facts of the case and the

goal of the review—to prevent future overdose deaths.

The facilitator may need to end a possible escalating

discussion by making a statement such as,

“It appears we have reached a stalemate. Let’s move

on and discuss other issues that were identiﬁed.”

3F. Measuring Meeting Success

The facilitator wants to make sure that meetings are

as successful as possible. The OFR process is always

evolving in response to members’ needs and changes in

data trends. In addition, the identiﬁed recommendations

impact large system issues, and it may take time to

effectively make noticeable improvements. Therefore,

it may be helpful to have some short-term measures to

determine whether the OFRs are successful.

How do you know if an OFR is successful?

• Agencies continue to send staff members to the

reviews.

• Members contribute to the discussion.

• Members are open to feedback and are not

defensive.

• Members come more prepared for each meeting.

• Members linger after the meeting has formally

ended to network with other members.

• Members begin to see connections between

seemingly unrelated overdose deaths and develop

a shared analysis.

• Agencies report that the information is useful to

their daily work.

• Each agency is working on at least one

recommendation during the year.

In addition to the above measures of success, the

facilitator will want to connect with members between

meetings to get feedback on the overall OFR process and

meetings and identify strategies for improvement.

3G. Meeting Notes

The coordinator typically takes notes during the review.

If the OFR team does not have both a coordinator and

a meeting facilitator, the facilitator will want to delegate

someone to take notes during the OFR meeting.

Notes help to document tasks that need follow-up

and to track recommendations. Sometimes, notes are

summarized and included in future meeting handouts or

meeting minutes.

3H. Post-Meeting Tasks

While the OFR meeting forms the foundation of the

process, follow-up events are equally important. The

meeting discussion, case information, and identiﬁed

recommendations must be documented and momentum

maintained.

Immediate post-meeting activities (on the same or next

day) include the following:

1. Preparing meeting minutes and securely storing

them electronically with the other case records. A

meeting minute template is included in Appendix C.

2. Capturing the OFR case information that was

shared and collected at the review meeting, often

26 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

using an OFR database. Learn more about the OFR

database in Module 4. Collect Your OFR Data.

3. Working on follow-up activities and reaching out to

any identiﬁed partner agencies.

4. Drafting and sending updates to the governing

committee, as requested. More information about

this task can be found in Section 3I.

3I. Updating the Governing Committee

Summarizing review activities to update the governing

committee should be done after each review meeting.

Most often, the OFR coordinator is responsible for

communicating with the chair of the governing committee

to determine what is expected from a report-out from the

OFR team.

Depending on the jurisdiction’s OFR structure, some

governing committees receive updates annually on

priority recommendations and implementation status of

prior recommendations. Other governing committees

may request more frequent updates on review activity and

ﬁndings; for instance, on a quarterly basis.

An update may be a short summary on a standing

agenda or a full-length presentation or report. A sample

governing committee report is included in Appendix C.

3J. Preventing Case Review Burnout

Reviewing overdose fatalities can affect review team

members emotionally and psychologically. These effects

are known as secondary trauma. The effects can be

reduced by:

• Inviting experts in secondary trauma to present to

the team.

• Identifying and understanding attendee reactions to

potentially upsetting information.

• Acknowledging that everyone experiences stress

from reviewing overdose fatalities.

• Sharing professional self-care resources and

strategies with team members.

• Reporting on and celebrating successes such as

implemented recommendations generated by the

OFR process.

• Reminding members of the purpose and

effectiveness of OFRs.

• Allowing members to rotate out after a period of

service to the team if requested.

• Recognizing many members of the OFR team are

ﬁrst responders, behavioral health, and health care

providers and may have compassion fatigue.

Compassion fatigue is the emotional strain of working

with those suffering from the consequences of traumatic

events. First responders may experience compassion

fatigue as a result of encountering repeated overdose

cases.

Consider using “The Vicarious Trauma Toolkit”

(U.S. Ofﬁce of Justice Programs, Ofﬁce for Victims

of Crime) to address and prevent secondary trauma.

(Source: https:// vtt.ovc.ojp.gov/what-is-vicarious-trauma)

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 27

our OFR Data Module 4. Collect Y

Collect Your

OFR Data

Module

This module will assist the overdose fatality review (OFR)

data manager in securely collecting and storing relevant

case review data.

4A. Condentiality

Conﬁdentiality is essential for successful overdose

fatality reviews. It maintains the trust of participating

members and of the community in the OFR process.

The lead agency should check state law and consult its

legal authority before starting an OFR process. All team

members (including guest members and observers) must

sign a conﬁdentiality agreement to attend.

Relevant federal laws that affect data

protections

OFR teams must understand and adhere to the Health

Insurance Portability and Accountability Act (HIPAA) and

the Family Educational Rights and Privacy Act (FERPA;

and 42 CFR) in addition to the conﬁdentiality policies of

other government-private institutions that serve children

and other vulnerable populations to protect decedent

information. Refer to the agency’s record retention

policy—what types of documents need to be retained and

for what length of time.

Relevant state privacy laws

Many states have statutes and legislation supporting and

guiding the OFR process and conﬁdentiality, and every

year more states introduce legislation to support and

guide the review process.

Some states may have additional privacy laws for medical,

substance use, and mental health records.

Interagency data sharing agreement

An interagency data sharing agreement is signed by the

senior leadership of each participating agency/members

(including any one-time members) that outlines the

responsibilities of each party. In an interagency data

sharing agreement, all parties agree to share certain

information on an established timeline, adhere to certain

data protection standards, and identify communication

expectations. A sample interagency data sharing

agreement is included in Appendix D. Interagency data

sharing agreements should be updated annually and

amended as new members are added to the OFR team.

Conﬁdentiality agreement

A conﬁdentiality agreement needs to be signed

by members at the beginning of each review. This

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 29

agreement is at the person/participant level and includes

the objectives of the OFR. It prohibits dissemination of

information beyond the purpose of the review. A sample

conﬁdentiality agreement is included in Appendix D.

In addition to understanding federal and state laws

around OFR and signing data sharing and conﬁdentiality

agreements, there are other steps needed to maintain

conﬁdentiality. It is recommended that you create a data

sharing protocol for the distribution of case information

and record-keeping expectations. A sample data sharing

protocol is included in Appendix D.

When sharing any sensitive case-speciﬁc information

outside of the meetings with any members, encrypt the

emails or protect them with passwords. Hand delivery

also maintains conﬁdentiality.

4B. Data Collection Process

Before the Meeting: Data Collection Steps

The data collection process begins before the OFR

meeting and is a key responsibility of the OFR coordinator.

In addition to steps 4 and 6 (request case information

and summarize case) of Section 2B. Meeting Preparation:

Coordinator’s Activities, the coordinator will want to be

familiar with the type of information captured in the OFR

database.

As documents and information are received, organize and

save all ﬁles on a secure computer with restricted access.

Examples of these data ﬁles may include the medical

examiner’s/coroner’s report, the decedent’s criminal

history, signed conﬁdentiality forms (collected from

Save all case-related

documents and information

on a secure computer with

restricted access.

Important:

Summarizing key activities along a

timeline, ideally on a whiteboard,

is a great way to focus the OFR

team’s discussion.

Tip:

participants at the meeting), and all data collected prior to

or at the review meeting.

As mentioned in step 4 of Section 2C. Meeting

Preparation: Members’ Activities (Prepare a summary),

members will need to prepare a summary to verbally

share during the OFR discussion. A member’s guide to

collecting case information and agency-speciﬁc data

element recommendations are available in Appendix B.

During the Meeting: Data Collection Steps

The data collection process during the OFR meeting

happens as the members report out and ask questions.

The designated note taker (often the coordinator) will

want to be familiar with the OFR database to make sure to

capture pertinent information discussed in the meeting.

The facilitator summarizes in chronological order any

signiﬁcant case details shared in the meeting and

elicits a discussion to focus participants on identifying

30 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

4C. OFR Database

The OFR database collects information about the cases

reviewed and the recommendations developed. The

OFR database needs to be secure and stored at a neutral

agency. For consistency across cases and OFR teams,

OFR teams may want to use the OFR database developed

by the OFR National Data Workgroup. The OFR database

is a REDCap database available to all OFR teams and

contains four main sections:

1. OFR team meeting details

2. Decedent case information

• Demographics

• Cause of death

• Overdose and death-scene investigation

• Interventions following the overdose

• History of life circumstances and immediate

stressors before the overdose

3. Community context

4. Recommendations

To access and learn

more about the

OFR database, visit

www.cossapresources.org.

At the beginning of every OFR

meeting, ask all members to sign and

submit the conﬁdentiality agreement,

and remind team members that

the meeting is closed and prohibits

dissemination of information beyond

the purposes of the review.

Reminder:

missed opportunities for prevention and intervention.

Section 3C. Meeting Agenda provides details on the types

of information shared and discussed in the OFR meeting.

After the Meeting: Data Collection Steps

The OFR team data manager is responsible for managing

the collection and entry of the data on reviewed cases and

developed recommendations. Depending on the size

of the jurisdiction and the resources available, the OFR

facilitator or coordinator may be responsible for this task.

The individual responsible for entering data needs to

ensure that the data is entered consistently and accurately.

After the meeting, all the data from the meeting needs to

be entered into the OFR database; learn more about the

database in Section 4C. OFR Database. The facilitator or

data manager may need to follow up with members to

get missing data or information that needs more research

outside of the review meeting. Any additional information

provided will need to be entered into the OFR database.

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 31

Module 5. Build a Recommendation Plan

Build a

Recommendation

Module

This section summarizes the types of recommendations

that may be developed through the overdose

fatality review process; provides an overview of the

recommendation process, from developing to sustaining

recommendations; and offers a method to track, monitor,

and assess the implementation of recommendations.

Figure 5.1 Building a Recommendation Plan

1. Identify

recommendation

during review

2. Form a subcommittee

to develop

recommendation,

if needed

3. Implement

recommendation

4. Assess

recommendation

5. Monitor

recommendation

Plan

5A. Identifying Recommendations

During the OFR Review

The overdose fatality review (OFR) process is driven by an

action-oriented partnership. Data comes from members

representing multiple agencies. Each member gathers

and provides potentially sensitive information to the team

that informs the understanding of the overdose problem

and potential solutions.

Successful OFRs rely on active engagement by

members beyond the detailed case discussions,

including formation, implementation, assessment, and

continuation of prevention strategies. It is important

that the OFR facilitator reinforce that recommendations

can be identiﬁed and implemented through the OFR’s

collaborative, data-driven, problem-solving process.

Learn more about this process in Section 3C. Meeting

Agenda, Step 8. Formulate Recommendations.

Problem solving occurs during a collaborative process

that fosters accountability and transparency. Identiﬁed

solutions usually involve a cross-agency response that

reduces duplication and information silos. The process is

best served if it prioritizes addressing system issues and

making recommendations for improvement.

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 33

Table 5.1 Recommendation Type

Recommendations

Target Audience Denition Example

Systemic Professionals, agencies,

and organizations

Addresses a gap,

weakness, or problem

within a system or across

systems

Improve communication between inpatient

treatment providers upon discharge to an

outpatient, medication for opioid use disorder

(MOUD)—formerly known as medication-

assisted treatment (MAT)—provider by

establishing an automated alert system.

Agency-

Specic

Only one sector or

partner agency

Addresses a service gap or

failure

Give naloxone to people who have been

released from incarceration.

Local health department to provide training to

all hotel staff members on how to administer

naloxone.

Research Academic organizations

and agencies that

research overdose

deaths or evaluate

programs or policies

Recommendation to

research a topic or issue

area

Determine the number of deaths from

prescription opioids for those who had a

prescription for an opioid

Establish a process for case review outcomes to

inform research priorities.

OFR Quality

Assurance

OFR team Strengthen or improve the

OFR process

Increase the length of meetings to allow for

more time developing recommendations.

Population-

Specic

Individuals and groups at

increased risk

Evidence-based

intervention that will

reduce a speciﬁc risk factor

for overdose

Increase access to buprenorphine among

incarcerated populations.

Types of Recommendations

OFR teams may generate a variety of recommendation

types across the continuum of care or systems as

outlined in Table 5.1 Recommendation Type.

5B. Documenting Recommendations

The OFR initial recommendations are captured in the

meeting minutes and in the recommendations section

of the OFR database. More detailed recommendation-

related information captured in the OFR database

includes:

• A public summary of the recommendation

• A working summary of the recommendation

• Date recommendation identiﬁed

• Cases related to the recommendation

• Data sources shared at the review meeting

• OFR members present at the review meeting

• Type of recommendation (e.g., agency-speciﬁc or

research-related)

• Level of prevention

• Population or issue of focus

• Jurisdiction level responsible for implementing the

recommendation

• Agency responsible for implementing the

recommendation and contact information

• Status of the recommendation

• Recommendation strategies (short-, medium-, and

long-term)

• Recommendation implementation accomplishments

• Notes regarding any media coverage

34 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

5C. Forming a Subcommittee to

Develop Recommendations

Recommendations can be diverse, and some are easier

to implement than others. Planning and implementing

recommendations is a very rewarding process that

can have immediate and tangible results. Some

recommendations maintain momentum, and others may

slowly lose support. The process can be challenging when

factors outside of the OFR team’s control impact progress.

Creating subcommittees to focus and implement speciﬁc

recommendations can maintain momentum by building

sustained internal and external support for the strategy.

Figure 5.2 Forming a Subcommittee

Subcommittees assigned to lead the development

and implementation of a recommendation will want

to follow the steps outlined in Figure 5.2 Forming a

Subcommittee:

Subcommittees meet separately

from the OFR team and report

out at case review meetings

on their aims and progress.

Subcommittees are formed and

disbanded as needed, serving

temporarily or on an ongoing

basis.

Reminder:

Identify a subcommittee lead

The overdose fatality review coordinator will designate

a lead for the subcommittee. The subcommittee

lead needs to be a neutral convener, to avoid

possible competition among agencies for future grant

opportunities or services provided, and in a leadership

position that will ensure progress in implementing

the recommendation.

Identify and recruit

key partner agencies

The success and momentum of recommendation

development rests largely on who is participating on

the subcommittee. Each subcommittee will want a

champion who provides energy around the focused

problem or solution. Subcommittee membership may

include members from the governing committee, the

OFR team, and outside experts.

Assign roles and responsibilities

As with any workgroup, there a several roles to be

ﬁlled. Some common formal and informal roles include

lead, researcher, support, monitor, and champion. A

description of each role is provided in Module 5D.

Subcommittee Roles and Responsibilities.

Host meetings

One or several meetings may need to be scheduled.

Ideally, meetings will happen in person versus over the

phone and at times and locations that work best for

subcommittee members.

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 35

5D. Subcommittee Roles and

Responsibilities

It takes multiple stakeholders to effectively develop,

implement, and monitor recommendations. This

section reviews the OFR coordinator’s, facilitator’s, and

subcommittee members’ roles and responsibilities

regarding recommendations.

OFR coordinator and facilitator roles and

responsibilities

The process for developing and implementing

recommendations is collaborative and ﬂuid. Success

is possible only with open communication, timely

information sharing, and trust building. Trust must be

established in both the process and the other agencies

involved.

The OFR coordinator must be able to manage competing

agendas, interagency conﬂicts, and unpopular or criticized

recommendations and to ensure partners that the process

is fair, data-driven, and likely to produce results.

The OFR coordinator is responsible for designating the

subcommittee lead, recruiting participants, supporting

the subcommittee as needed, and checking regularly with

the subcommittee on the status of the development and

implementation of recommendations.

The OFR facilitator is responsible for developing trust and

collaboration through the entire OFR process; both are

crucial to successfully implementing recommendations.

Subcommittee members’ roles and

responsibilities

• Lead—The OFR coordinator assigns the

subcommittee lead. The lead is responsible for

setting the agenda, facilitating subcommittee

meetings, taking notes, sending reminders,

monitoring activities, and reporting to the OFR

facilitator and others as identiﬁed (such as the

governing committee or the OFR team).

• Researcher—The OFR coordinator designates

a team member to present data trends such as

overdose deaths, substances, hot spots, and

related prevention and risk factors, as well as policy,

practices, or procedures for a system or agency.

This information helps inform decisions and guide

the implementation of recommendations.

• Supporter—The OFR coordinator designates a

supporter to provide minimal informal support as

requested from the subcommittee. Examples of

support may be connecting the subcommittee with

an individual or an agency, ﬁnding meeting space,

or reviewing draft materials.

• Monitor—The OFR coordinator works with the

subcommittee lead to systematically monitor the

implementation of a recommendation, ensure

that it is addressing the problem it was intended

to resolve, suggest reﬁnements, ensure the status

of the recommendation is tracked in the OFR

database, and periodically report results to the OFR

team and/or the governing committee.

• Champion—Any member who provides motivation,

political will, and energy around the focused

problem or solution is a champion.

36 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

5E. Implementing a Recommendation

Once the subcommittee has developed a

recommendation, it needs to be implemented. It is

important to do so strategically. The subcommittee lead

may consider sharing recommendation materials with

persons not on the subcommittee for their review and

feedback.

The subcommittee must develop a work plan for

implementing the recommendation.

Develop a work plan

The subcommittee is responsible for developing a work

plan that:

• Identiﬁes key action steps needed to implement

and monitor the recommendation.

• Assigns r

esponsibility to members and partners.

• Determines intermediate measures of success.

• Establishes a realistic timeline for completion.

A sample recommendation work plan is included in

Appendix E.

5F. Assessing and Monitoring

Recommendations

Plans for assessing and monitoring recommendations

need to be developed at the beginning of the initiative.

Steps for regularly updating and tracking the status of

recommendations include the following:

Giving status updates

The subcommittee lead will check regularly with

subcommittee members on the status of assigned tasks

and implementation.

Reporting to the OFR coordinator

Prior to each fatality review and scheduled governing

committee meetings, the subcommittee lead will

provide the OFR coordinator with status updates

on the implementation as well as ongoing plans

to monitor and support recommendations. The

subcommittee lead will likely provide a verbal progress

report during OFR case review meetings.

3. Tracking the status of a recommendation

Documenting the implementation status of a

recommendation is encouraged. The OFR coordinator,

in partnership with the subcommittee monitor role,

is responsible for systematically monitoring the

status of recommendations. If the OFR coordinator

is not involved throughout the recommendation

implementation process, he or she will need to follow

up with partners (for example, the subcommittee lead

or monitor) to learn the status of the recommendation.

The OFR coordinator will work with the OFR data

manager to ensure the status of the recommendation

is tracked in the OFR database. Recommendation data

elements are included in the OFR database discussed

in Module 4E. Data Collection System.

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 37

Appendices

Appendix A

Resources for Model 1.

Recruit Your OFR Members

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 39

Sample: OFR Recruiting Letter

[Insert agency letterhead]

[date]

[Name]

[Address]

[City, state, ZIP code]

Dear Colleague/Partner:

You are invited to participate in overdose fatality review (OFR), an innovative data-sharing process to address drug-

related overdoses in our community.

OFR involves a case review process that generates information about decedents and their interactions with our services

and systems. This information will be used to craft recommendations to prevent future similar deaths. This process has

been effective for reviewing homicides, child fatalities, and maternal deaths and is now a nationally recognized model.

The OFR team will meet [monthly, quarterly] at the [location] from [time]. Members must commit to regular attendance,

providing data about the decedent, and contributing to the discussion.

The authority to conduct case review through data sharing is detailed [information here] in [statute, MOU, regulations].

Attached is an interagency agreement and a conﬁdentiality agreement that need to be signed prior to your participation

on the OFR team.

Thank you for your consideration. Please direct any questions about the program to me. I look forward to working with

you.

Sincerely,

[your name here]

40 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Sample List: Facilitator Qualities

The facilitator of a fatality review team holds a special position. Preferred qualities that contribute to effective

management of the team include the following:

• Good, active listener

• Communicates clearly

• Encourages open conversation

• Connects with the group and is trusted by partners

• Reads group’s body language and dynamics

• Creates an inclusive environment: brings partners together, encourages sharing of information and views, and

creates a safe place to share

• Sees all members as providing equal value

• Balances conversation to encourage less-vocal members to participate

• Navigates difﬁcult conversations

• Professional

• Summarizes, pauses, and checks with the group before making decisions

One tool that can be helpful to facilitators is the APPLE technique:

Ask the question

Pause for members to think

Pick a member to answer/respond if no one is volunteering

Listen to the response

Expound or elaborate on what was said and relate it to the rest of the discussion

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 41

Sample Checklist: OFR Launch

 Identify the governance committee and the administrative lead agency

 Identify who will be responsible for the coordinator, facilitator, and data manager roles

 Establish interagency data sharing and conﬁdentiality agreements

 Recruit case review team members

 Ask member agencies and members to sign an interagency data sharing agreement and conﬁdentiality

agreements

 Set OFR ground rules and expectations

 Review data and determine case selection criteria

 Develop protocols for secure data access

 Provide team member training

 Set the meeting schedule

42 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Appendix B

Resources for Model 2.

Plan Your OFR Meeting

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 43

Coordinator’s Meeting Preparation Checklist

 Cases selected

 Guest members recruited

 Case information requested

 Meeting reminder email sent to members

 Case information summarized

 Activities since last meeting documented for sharing at meeting

 Agendas and other meeting materials printed

44 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Sample: OFR Agenda

OFR Meeting Agenda

Date, Time,

Location

1. Opening Remarks and Introduction

a. Members’ introduction

b. Updates from previous meeting

c. Upcoming events

d. Data presentation

e. Review case selection criteria

f. Other announcements

2. Goals and Ground Rules

a. Read goals and ground rules

b. Ask for any additional ground rules

3. Conﬁdentiality

a. Read conﬁdentiality statement

b. Collect signed forms

4. Case Presentation

5. Member Report-Outs (reverse chronological)

6. Group Discussion

7. Case and Timeline Summarized

8. Formulate Recommendations

9. Summarize and Adjourn

a. Members reﬂect on how the meeting went

b. Collect any paperwork with conﬁdential information

c. Remind members of conﬁdentiality

d. Encourage members to take time for self-care

Next meeting: date, time, and location

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 45

Sample: OFR Case Email

[Insert agency letterhead]

[date]

Dear Colleague/Partner,

You are invited to participate in the next OFR meeting on [date and time] at the [location].

The authority to conduct case review through data sharing is detailed [information here] in [statute, MOU, regulations].

Attached are the interagency agreement your agency has signed and a copy of the conﬁdentiality agreement that

must be signed and collected at the beginning of the meeting. Copies will be made available for your signature at the

meeting.

We will be reviewing the following case(s) at the review. Keep this and all information you prepare about the case

conﬁdential.

Case 1.

Case 2.

• Name, aliases

• Date of birth, date of death

• Demographics (age, race, sex)

• Address of residence

• Incident location, date, and time

• Name, aliases

• Date of birth, date of death

• Demographics (age, race, sex)

• Address of residence

• Incident location, date, and time

Please be prepared to share any information you have about the individual, the community, and your services as it relates

to the overdose death. See the attached guide to collecting case information and agency-speciﬁc data elements to

summarize the information.

If you need additional information about the decedent for identiﬁcation in your records, feel free to contact me at [phone

number].

Sincerely,

[your name here]

46 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Sample: Member’s Guide

to Collecting Case Information

Guiding questions for collecting information about the case:

• What was the nature and timing of your agency’s contact with the decedent in the overdose death?

• What interactions did your organization or agency have with the decedent, and when?

• What services, if any, was the decedent accessing around the time of his or her death?

• What services, if any, were provided to the decedent’s family members? What can we learn about the

decedent’s life through the agency’s interaction with the family?

• Did the decedent transition between service providers? Did any gaps in service occur, or were any service

needs unmet? What were the reasons for those gaps? Were referrals made? What communication occurred

among providers?

• What were some missed opportunities in intervening or providing services?

• What were the anticipated beneﬁts of those services?

• How did the decedent/family/neighborhood respond to services?

• Was an intervention completed or in progress at the time of the death?

• What were the outcomes of the interaction(s)?

• What were the strengths or protective factors of the decedent, the decedent’s family/social network, or

environmental context at the time of your agency’s interaction?

• Neighborhood, support system, social network, family, peer support, access to services, employment history,

housing history, health insurance, environmental safety, education

• What were the risk factors of the decedent, the decedent’s family/social network, or environmental context at the

time of your agency’s interaction?

• Neighborhood, environment, exposure to violence, trauma or abuse, discrimination, injustice, criminal activity,

loss of employment, abandonment, acute or chronic illness, injury, disability, transience

• What services or programs were being offered in the area during the incident? Were they available to the

decedent?

• What public policies (such as criminal justice, health, economic, and social welfare) were most likely impacting the

individuals and neighborhoods involved in the overdose death at the time of the incident?

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 47

Sample: Agency-Specic Data Elements

• Medical examiner/coroner

• Autopsy results

• Death scene investigation

• Toxicology report

• Law enforcement (decedent and/or suspect)

• Drug involvement

• Gang, group, crew involvement

• Criminal history

• Treatment history

• Location of incident

• Department of corrections (DOC)

• Current DOC status

• History of supervision

• Drug and gang involvement

• Treatment history

• Mental health history

• Medications

• Treatment providers

• Treatment history—substance use and/or mental health

• Medications

• Trauma

48 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Sample: OFR Two-Week Reminder Email

[Insert agency letterhead]

[date]

Dear Colleague/Partner,

Reminder: You are invited to participate in the next OFR meeting on [date and time] at the [location]. See attached

agenda, and list of invited meeting members.

The authority to conduct case review through data sharing is detailed [information here] in [statute, MOU, regulations].

Attached are the interagency agreement your agency has signed and a copy of the conﬁdentiality agreement that

must be signed and collected at the beginning of the meeting. Copies will be made available for your signature at the

meeting.

We will be reviewing the following case(s) at the review. Keep this and all information you prepare about the case

conﬁdential.

Case 1.

• Name, aliases

• Date of birth, date of death

• Demographics (age, race, sex)

• Address of residence

• Incident location, date, and time

Case 2.

• Name, aliases

• Date of birth, date of death

• Demographics (age, race, sex)

• Address of residence

• Incident location, date and time,

Please be prepared to share any information you have about the individual, the community, and your services as

it relates to the overdose death. See the attached guide to collecting case information and agency-speciﬁc data

elements to summarize the information.

If you need additional information about the decedent for identiﬁcation in your records, feel free to contact me at

[phone number].

Sincerely,

[your name here]

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 49

Sample: Case Summary Outline

Presentation/Handout of Case Summary

• Name, aliases

• Date of birth, date of death

• Demographics (age, race, sex)

• Address of residence

• Incident location, date, and time

• Obituary summary information

• Pertinent news coverage information

• Relevant social media posts

• Details from interviews with the decedent’s family members and social contacts

Sample: Summary Data Report

Summary data:

Medical examiner’s/coroner’s ofﬁce: Year to date, we had [number] overdoses, [number] of which met our case selection

criteria. Since our last review, there have been [number] overdose deaths. Compared to the same time last year, the

cases are [compare number, substances, demographics].

EMS data: Year to date they responded to [number] overdoses, and since our last review, they responded to [number]

overdoses. Compared to the same time last year, the cases are [compare number, substances, demographics].

50 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Sample: Meeting Ground Rules

• Be on time—at the beginning of the meeting and coming back from breaks.

• Raise your hand if you have something to say. Only one person speaks at a time.

• Listen actively to what other people are saying.

• Be respectful—no mocking or attacking other people’s ideas.

• See all members as equal. Avoid favoring members with leadership titles.

• Maintain and protect conﬁdentiality.

• Use appropriate and sensitive language when discussing the case.

• Use person-ﬁrst language, such as “a person addicted to drugs” versus “a drug addict.”

• Avoid judging the decedent’s decisions. Try to understand the decedent’s experience through his or her eyes.

• Consider all factors that contributed to the decedent’s substance use and overdose.

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 51

Appendix C

Resources for Model 3.

Facilitate Your OFR Meeting

52 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Sample Template: Meeting Minutes

OFR Meeting

Date:

Present: [Name, Agency]

Updates:

Incident#:

Date: Time: Address: District:

Case narrative:

Partner/agency reports (add/remove partners listed as appropriate):

• Medical examiner’s/coroner’s ofﬁce:

• Emergency medical services:

• Police department:

• Department of corrections:

• Health department:

• Drug treatment provider(s):

• Hospital:

Themes:

Recommendations:

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 53

Sample: Governing Committee Report Outline

• General statistics report-out

• Year-to-date, number of deaths

• Since last meeting, number of deaths

• Prior year same time frame, number of deaths

• (Any other aggregate data available)

• Activities since last meeting

• OFR review team meeting schedule and attendance

• Number and types of cases reviewed

• Any planned new work

• Recommendations

• Recruiting new members

• Case selection criteria change

54 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Appendix D

Resources for Model 4.

Collect Your OFR Data

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 55

Sample: Interagency Data Sharing Agreement

Interagency Data Sharing Agreement

This cooperative agreement is made on this ______day of _______ among the following agencies:

Ofﬁce of the Medical Examiner/Coroner

County Child Protective Services

Ofﬁce of the Prosecuting Attorney

Sheriff’s Department

Police Department

County Health Department

(Others as Needed)

WHEREAS, the parties are vested with the authority to promote and protect the public health and safety and to provide

services which will improve the well-being of children and their families.

WHEREAS, the parties agree that they are mutually served by the establishment of a multiagency, multiprofessional

overdose fatality review team, and the outcomes of the reviews will be the identiﬁcation of preventable overdose deaths

and recommendations for interventions and prevention strategies.

WHEREAS, the objectives of an overdose fatality review team are agreed to be:

Accurate identiﬁcation and uniform reporting of the cause, manner, and relevant circumstances of every overdose death

with special emphasis on those features that relate to potential preventability.

Improved communication and coordination of agency responses to overdose deaths in the investigation and delivery of

services.

Design and implementation of cooperative, standardized guidelines for the investigation of certain categories of overdose

death.

Identiﬁcation of needed changes in legislation, policy and practices, and expanded efforts to prevent overdose deaths.

56 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

WHEREAS, the parties agree that all members signing this agreement are essential to an effective review.

WHEREAS, the parties agree that the review process requires case-speciﬁc sharing of records, and that conﬁdentiality is

inherent in many of the involved reports so that there will be clear measures taken to protect conﬁdentiality, and no case

review will occur without all present abiding by the conﬁdentiality agreement.

NOW THEREFORE, it is agreed that all team members and others present at a review will sign a conﬁdentiality

agreement which prohibits any unauthorized dissemination of information beyond the purpose of the review process.

The review team will not create any ﬁles with case-speciﬁc identifying data. Case identiﬁcation will be utilized only to

enlist interagency cooperation in the investigation, delivery of services, and development of prevention initiatives. It

is further understood that there may be an individual case which requires that a particular agency be asked to take the

lead in addressing a systemic or quality of care issue based on the agency’s clear connection with the issue at hand.

It is further understood that a participating agency may use information obtained at the review in accordance with

the mandated responsibilities of that agency. It is also understood that team review data may be entered into [OFR

database], where it will be maintained for the purpose of establishing a state central registry for overdose death data.

This data will not include case-speciﬁc names. The registry will include standardized data from overdose fatality review

teams throughout [state].

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 57

Sample: Condentiality Agreement

Condentiality Statement

The purpose of the overdose fatality review (OFR) team is to conduct a thorough review of preventable overdose deaths

in [county] to better understand how and why an individual dies as a result of an overdose and to act to prevent other

deaths.

To ensure a coordinated response that fully addresses all systemic concerns surrounding overdose deaths, all relevant

data should be shared and reviewed by the team, as permitted by law, including historical information concerning the

decedent, his or her family, and the circumstances surrounding the death. Much of this information is protected from

public disclosure by law.

[State statutes] allow for overdose fatality reviews to remain conﬁdential and can be exempt from the open meeting

law. In no case will any team member disclose any information regarding team discussion outside of the meeting other

than pursuant to the mandated agency responsibilities of that individual. Failure to observe this procedure may violate

various conﬁdentiality statutes that contain penalty. Public statements about the general purpose of the overdose fatality

review process may be made, as long as they are not identiﬁed with any speciﬁc case.

The undersigned agrees to abide by the terms of this conﬁdentiality policy.

Name:

Agency:

Signature:

Date:

58 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Sample: Condentiality Agreement

and Review Sign-In Sheet

OFR Condentiality Agreement

The purpose of the overdose fatality review team (OFR) is to conduct a thorough review of all preventable overdose

deaths in [county] in order to better understand the circumstances of overdose deaths and how to act to prevent future

similar deaths.

To ensure a coordinated response that fully addresses all systemic concerns surrounding overdose deaths, all relevant

data should be shared and reviewed by the team, as permitted by law, including historical information concerning the

decedent, his or her family, and the circumstances surrounding the death. Much of this information is protected from

public disclosure by law.

[state statutes] allow for overdose fatality reviews to remain conﬁdential and can be exempt from the open meeting

law. In no case will any team member disclose any information regarding team discussion outside of the meeting other

than pursuant to the mandated agency responsibilities of that individual. Failure to observe this procedure may violate

various conﬁdentiality statutes that contain penalty. Public statements about the general purpose of the overdose

fatality review process may be made, as long as they are not identiﬁed with any speciﬁc case.

Dated [date] the undersigned agree to abide by the terms of this conﬁdentiality policy.

Name Agency

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 59

Template: OFR Data Sharing Protocol

1. Data Storage

Upon receipt of the OFR data from OFR team members, how will the data be stored and for what period of time?

2. Data Transfer

What information will be transferred to team members and in what format (email, letter, etc.)?

3. Data Security

How will conﬁdential information be protected during transfer to team members?

4. Data Sharing

How will team members share information? If sharing prior to the review, how will information and records be

transferred to the team coordinator and how will they be protected? If sharing at the reviewing, what format will the

data be in and will it be kept by the team coordinator after the meeting?

60 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Appendix E

Resources for Model 5.

Build a Recommendation Plan

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 61

Sample: Recommendation Work Plan

Lead Agencies/

Supporting Agencies

Recommendation Activity/Action Steps Timeline

62 / Overdose Fatality Review: A Practitioner’s Guide to Implementation

Overdose Fatality Review: A Practitioner’s Guide to Implementation / 63

Recruit

Your OFR

Members

Plan

Your OFR

Meeting

Facilitate

Your OFR

Meeting

Collect

Your OFR

Data

Build a

Recommendation

Plan

Overdose

Fatality

Review

For more information about Overdose Fatality Reviews, visit