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Fatality review teams that consistently achieve results share several characteristics that foster accountability and drive implementation.

I realized that letting go of control, fear, and attachment was not failure but was a risk worth taking. It was at this point that I knew I needed to bring her wisdom and understanding to others.

The CRM, developed by the Tri-Ethnic Center at Colorado State University, recognizes that effective strategies must match the community’s level of readiness as well as be culturally appropriate, realistically implementable to be accepted and sustained.

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.

The Cuyahoga County Medical Examiner's Office (CCMEO) co-leads the county OFR with Cuyahoga County Board of Health (CCBH) and has an in-house toxicology laboratory, forensic epidemiologists, and data dashboards.