The OFR is a joint effort of the state's Departments of Justice and Public Health. Under the OFR, all of the stakeholders in an overdose case share specific case information that can assist in understanding factors in the drug overdose fatality, including the events that contributed to it and actions that might have prevented it and similar cases. The focus of the reviews is missed opportunities for intervention and prevention. Reviews also are compared with a series of case reviews, so as to identify patterns and trends that should be taken into account in designing broad intervention and prevention efforts. Professor O'Brien outlines the steps a state should consider in developing a similar review process. The first step is to identify the stakeholders with responsibilities for preventing and responding to drug abuse that can lead to overdose fatalities. The second step is to bring together representatives from these stakeholder agencies to discuss the importance of cooperation and the nature and usefulness of a cooperative reviews of overdose fatality cases. Following an agreement to proceed with such an effort, the stakeholder should develop a confidentiality agreement in sharing information, protocols for selecting and reviewing cases, and a means of ensuring accountability for implementing policies and procedures agreed upon in responding to the opioid crisis in the state.