Increasing Reporting of Adverse Events to Improve the Educational Value of the Morbidity and Mortality Conference

Psychological Safety Competency Training During the Clinical Internship From the Perspective of Health Care Trainee Mentors in 11 Pan-European Countries: Mixed Methods Observational Study

BACKGROUND

In the field of research, psychological safety has been widely recognized as a contributing factor to improving the quality of care and patient safety. However, its consideration in the curricula and traineeship pathways of residents and health care students is scarce.

OBJECTIVE

This study aims to determine the extent to which health care trainees acquire psychological safety competencies during their internships in clinical settings and identify what measures can be taken to promote their learning.

METHODS

A mixed methods observational study based on a consensus conference and an open-ended survey among a sample of health care trainee mentors from health care institutions in a pan-European context was conducted. First, we administered an ad hoc questionnaire to assess the perceived degree of acquisition or implementation and significance of competencies (knowledge, attitudes, and skills) and institutional interventions in psychological safety. Second, we asked mentors to propose measures to foster among trainees those competencies that, in the first phase of the study, obtained an average acquisition score of <3.4 (scale of 1-5). A content analysis of the information collected was carried out, and the spontaneity of each category and theme was determined.

RESULTS

In total, 173 mentors from 11 pan-European countries completed the first questionnaire (response rate: 173/256, 67.6%), of which 63 (36.4%) participated in the second consultation. The competencies with the lowest acquisition level were related to warning a professional that their behavior posed a risk to the patient, managing their possible bad reaction, and offering support to a colleague who becomes a second victim. The mentors' proposals for improvement of this competency gap referred to training in communication skills and patient safety, safety culture, work climate, individual attitudes, a reference person for trainees, formal incorporation into the curricula of health care degrees and specialization pathways, specific systems and mechanisms to give trainees a voice, institutional risk management, regulations, guidelines and standards, supervision, and resources to support trainees. In terms of teaching methodology, the mentors recommended innovative strategies, many of them based on technological tools or solutions, including videos, seminars, lectures, workshops, simulation learning or role-playing with or without professional actors, case studies, videos with practical demonstrations or model situations, panel discussions, clinical sessions for joint analysis of patient safety incidents, and debriefings to set and discuss lessons learned.

CONCLUSIONS

This study sought to promote psychological safety competencies as a formal part of the training of future health care professionals, facilitating the translation of international guidelines into practice and clinical settings in the pan-European context.

Real-Time Reporting of Complications in Hospitalized Surgical Patients by Surgical Team Members Using a Smartphone Application

BACKGROUND

The surgical morbidity and mortality (M&M) conference is a vital part of a resident's surgical education, but methods to collect and store M&M data are often rudimentary and unreliable. The authors propose a Health Insurance Portability and Accountability Act (HIPAA)-compliant, electronic health record (EHR)-connected application and database to report and store complication data.

METHODS

The app is linked to the patient's EHR, and as a result, basic data on each surgical case-including diagnosis, surgery type, and surgeon-are automatically uploaded to the app. In addition, all data are stored in a secure SQL database-with communications between the app and the database end-to-end encrypted for HIPAA compliance. The full surgical team has access to the app, democratizing complications reporting and allowing for reporting in both the inpatient and outpatient settings. This complication information can then be automatically pulled from the app with a premade presentation for the M&M conference. The data can also be accessed by a Power BI dashboard, allowing for easy quality improvement analyses.

RESULTS

When implemented, the app improved data collection for the M&M conference while providing a database for institutional quality improvement use. The authors also identified additional utility of the app, including ensuring appropriate revenue capture. The general appearance of the app and the dashboard can be found in the article.

CONCLUSION

The app developed in this project significantly improves on more common methods for M&M conference complication reporting-transforming M&M data into a valuable resource for resident education and quality improvement.

A scoping review of patient safety research carried out in the Republic of Ireland

Maintaining the highest levels of patient safety is a priority of healthcare organisations. However, although considerable resources are invested in improving safety, patients still suffer avoidable harm. The aims of this study are: (1) to examine the extent, range, and nature of patient safety research activities carried out in the Republic of Ireland (RoI); (2) make recommendations for future research; and (3) consider how these recommendations align with the Health Service Executive's (HSE) patient safety strategy. A five-stage scoping review methodology was used to synthesise the published research literature on patient safety carried out in the RoI: (1) identify the research question; (2) identify relevant studies; (3) study selection; (4) chart the data; and (5) collate, summarise, and report the results. Electronic searches were conducted across five electronic databases. A total of 31 papers met the inclusion criteria. Of the 24 papers concerned with measuring and monitoring safety, 12 (50%) assessed past harm, 4 (16.7%) the reliability of safety systems, 4 (16.7%) sensitivity to operations, 9 (37.5%) anticipation and preparedness, and 2 (8.3%) integration and learning. Of the six intervention papers, three (50%) were concerned with education and training, two (33.3%) with simplification and standardisation, and one (16.7%) with checklists. One paper was concerned with identifying potential safety interventions. There is a modest, but growing, body of patient safety research conducted in the RoI. It is hoped that this review will provide direction to researchers, healthcare practitioners, and health service managers, in how to build upon existing research in order to improve patient safety.

NSQIP versus institutional morbidity and mortality conference: complementary complication reporting in pediatric spine fusion

PURPOSE

Other fields of medicine have demonstrated underreported surgical complication rates by institutional M&M compared to NSQIP. However, a study comparing surgical complication rates in the pediatric spine population, using an identical set of patients rather than nationally extrapolated, has not been performed.

METHODS

A single institution's ASC-NSQIP Pediatric spine fusion cases and its departmental team-reported M&M database for the same were reviewed for January 1, 2012 to December 31, 2018. Differences in surgical complication reporting between the two databases for the identical patient cohort were recorded.

RESULTS

NSQIP identified 50 pediatric spine fusion patients with complications out of 386 NSQIP-algorithm-sampled cases (13%). Of these complications, 23 were not reported in the M&M conference database (6% of NSQIP-sampled cases, 2.5% of all M&M cases). The most common under-reported complication categories include pneumonia (100% under-reported), clostridium difficile (100%), urinary tract infection (83%), and superficial wound disruption (67%). During the same 7 years, M&M covered 924 spine fusions and identified 162 complications. Of these 162 patients, 22 were included in the NSQIP sampling and were not reported as complications (6% of NSQIP sampled patients).

CONCLUSION

Recognizing complication rates is central to implement strategies for delivering better quality care. NSQIP data may serve as an important quality check for pediatric spine institutional M&M data, but both may not include all complications even within its sampled patients. In general, NSQIP's protocols identified more medical complications, while M&M has a surgical focus, benefits from the limitless follow-up, and involves timely departmental awareness of complications.

There is an App for That: Mobile Technology Improves Complication Reporting and Resident Perception of Their Role in Patient Safety

Morbidity and mortality (M&M) conferences are rooted within the culture of medicine. They serve a role in every training program and have been mandated by the Accreditation Council for Graduate Medical Education in surgical programs since 1983. Despite the patient safety improvements and educational benefits of these conferences, many adverse events are grossly under-reported.

METHODS

We developed a web-based, Health Insurance Portability and Accountability Act-compliant, M&M reporting mobile application based on Research Electronic Data Capture. The list of possible complications was based on the American Board of Orthopaedic Surgery complications list for part II. The interface is accessible through all mobile platforms. All residents were encouraged to use the application for real-time reporting of complications. Using an unpaired T-test, we compared the reporting before and after the implementation of the mobile application. Residents were surveyed using the Agency for Healthcare Research and Quality Patient Safety Culture Survey before and after implementation to evaluate resident perception of the department's culture of safety.

RESULTS

The application was launched in August 2017. All reported events were tallied from August 2016 through July 2019. Before the implementation of the application, there were 54 adverse events reported, with a mean of 4.0 per month. In the Post-App cohort, a total of 176 adverse events were reported in year 1, with a mean of 14.76 per month, and 236 adverse events were reported in year 2, with a mean of 19.66 per month. Residents were significantly more likely to feel that their input on patient safety was valued by attendings after the implementation of the app (p = 0.0243).

CONCLUSIONS

An anonymous mobile reporting method for M&M significantly increased the reporting of both major and minor complications and improved resident perception of their role in patient safety efforts. This suggests that traditional methods of M&M reporting may grossly underestimate the complication rates which can negatively affect patient safety and quality improvement efforts and that reducing barriers to the reporting of complication may improve resident engagement in patient safety.

Evolving from Morbidity and Mortality to a Case-based Error Reduction Conference: Evidence-based Best Practices from the Council of Emergency Medicine Residency Directors

Morbidity and mortality conferences are common among emergency medicine residency programs and are an important part of quality improvement initiatives. Here we review the key components of running an effective morbidity and mortality conference with a focus on goals and objectives, case identification and selection, session structure, and case presentation.

Adverse Events Associated With Laser Use in the Upper Airway

OBJECTIVE

Surgical lasers are used extensively in head and neck surgery. Laser use in the upper airway offers many advantages but also presents risks to patients and operators that are not reported comprehensively. This study aims to summarize device malfunctions, patient complications, and subsequent interventions related to laser use in the upper airway.

METHODS

The US Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for reports of surgical laser adverse events from January 2010 to March 2020. Data were extracted from reports pertaining to the upper airway.

RESULTS

Sixty-two reports involving upper airway laser use in an operating room were identified, from which 95 events were extracted. Of these, 40 (42.1%) were adverse events to patients, 2 (2.1%) adverse events to operators, and 53 (55.8%) device malfunctions. Dislodgement of laser fiber in the airway (23 [57.5%]), burn (8 [20%]), and scar (5 [12.5%]) were the most common adverse events to patients. Two incidents of eye exposure through unfiltered microscope lenses were the only adverse events to operators. Fiber break (26 [49.1%]) and flare (12 [22.6%]) were the most common device malfunctions.

DISCUSSION

Surgical lasers have demonstrated utility in head and neck surgery but are associated with risks. This study discusses adverse events and device malfunctions associated with airway laser surgery and emphasizes shortcomings in current reporting.

IMPLICATIONS FOR PRACTICE

Standardized reporting and multi-institutional research are needed to better understand adverse events related to surgical laser use and to allow accurate estimation of their prevalence.

Best Practices in Patient Safety and Communication

Emergency medicine is a high-risk area of medical practice, with a high rate of preventable adverse events. This is multifactorial, hinging on the myriad system and processes issues that complicate emergency care. Strong teamwork and communication have been identified as critical components for safe care in emergency medicine. Health care professionals and leaders within emergency medicine can implement solutions aimed at cultivating a strong safety culture, creating processes and system-based approaches to improve patient safety. This article provides an overview of the evidence-based approaches to improve patient safety and communication.

Application of the Clavien-Dindo classification to a pediatric surgical network

INTRODUCTION

A comprehensive validated system to evaluate surgical complications is required in our specialty to facilitate comparison and audit. The Clavien-Dindo (CD) classification of post-surgical complications was originally described in an adult general surgical setting in 1992 and has become widely used. We aimed to apply this to a pediatric surgical setting.

METHODS

Data were collected on emergency and elective surgical activity together with complications in a prospective audit over a recent 4-month period in three geographical conjoined regional pediatric surgical units (including two major trauma centres). Briefly the CD classification codes complications according to degree of harm and magnitude of intervention required [I - V (death) with III and IV sub-divided according to whether general anesthesia was needed]. Length of stay and mode of admission were recorded. Data are given as median (range). Non-parametric comparison was used, and a p value of <0.05 was regarded as significant.

RESULTS

During the period JULY - OCT 2018 (inclusive), there were 1822 admissions (elective, n = 1186: emergency, n = 636) and 1556 operations (elective, n = 1189, and of these 393 were urological). There were 69 patient complications: CDI (n = 7), CD-II (n = 19), CD-IIIa (n = 4), CD-IIIb (n = 28), CD-IV (n = 4), CD-V (n = 7). Deaths were principally in neonates and due to NEC (n = 6) at 2.5 (1-140) days post-operatively. There was a single post-traumatic death in an adolescent. LOS was 9 (0-217) days in CD I-IV. The incidence of any complication was 4.4%, of serious complication (defined as ≥CD III) 2.6% (A = 2.1%, B = 2.0%, and C = 3.2%: p = 0.16), and of death 0.45%. The most frequent complications were wound infection (n = 12) and post-appendicectomy collections/abscess (n = 10).

CONCLUSIONS

This appears to be the 1st report of the C-D classification in a general pediatric surgery network and can be considered a benchmark. The risk of death or serious harm is very low in such a practice.

TYPE OF STUDY

Prospective Cohort Study.

LEVEL OF EVIDENCE

IIb.

The Impact of Anonymity in Emergency Medicine Morbidity and Mortality Conferences: Findings from a National Survey of Resident Physicians

Introduction

Although the Accreditation Council for Graduate Medical Education mandates structured case review and discussion as a part of residency training, there remains little guidance on how best to structure these conferences to cultivate a culture of safety, promote learning, and ensure that system-based improvements can be made. We hypothesized that anonymous case discussion was associated with a more effective, and less punitive, morbidity and mortality (M&M) conference. Secondarily, we were interested in determining whether this core structural element was correlated with the culture of safety at an institution.

Methods

We conducted a national survey at 33 emergency medicine residency programs evaluating residents’ perceptions of M&M and the culture of safety at their institutions. Data was analyzed using descriptive statistics and bivariate analyses. We summarized Likert scores using mean and 95% confidence intervals. We also performed content analysis of the free-text comments and report on the themes identified.

Results

There were 1248 residents at the 33 programs surveyed. Of the 1002 who replied (80.3% response rate), 231 respondents reported anonymous case presentations and 744 reported non-anonymous case presentations. Residents at programs with anonymous case presentations were more likely to report that M&M was non-punitive. There were no other significant differences between anonymous and non-anonymous case presentations on any of the culture of safety domains measured. When these comments were systematically analyzed and coded, we found that the comments related to anonymity were both positive and negative. Among the themes identified were anonymity’s impact on punitive response to error, the ability to learn from cases, and professional responsibility.

Conclusion

Anonymous M&Ms are associated with a perception of a less-punitive M&M and with better ratings in several conference-specific outcomes; however, there appears to be no association between the other Agency for Healthcare Research and Quality culture of safety scores and anonymity in M&M.

Informing best practice for conducting morbidity and mortality reviews: a literature review

Objective Preventable hospital mortality is a critical public health issue, particularly when mortalities are associated with events that are preventable. Mortality and morbidity reviews (MMRs) provide a rigorous, systematic, open, collaborative and transparent review process for clinicians to examine areas of improvement. The aim of the present review was to explore the evidence for best practice when conducting MMRs. Methods Searches of published and grey literature from 2009 to February 2016 were conducted. This period was selected to update a previous review. Inclusion and exclusion criteria was established a priori and based on the Population-Intervention-Comparison-Outcome (PICO) framework. Specific search terms were generated and used to identify relevant articles, with reference lists and citing articles also screened for inclusions. Titles and abstracts were screened and duplicates removed. Study details regarding setting, study design, reported outcomes, tool type, clinicians present and the timing of MMRs were extracted and summarised. Results After screening, 31 documents were included in the present review: 20 peer-reviewed articles and 11 items from the grey literature. Specific outcomes reported included mortality rates, satisfaction, education, cost and quality of care. The most common features of MMRs included timing, leadership, attendees, case presentation format, terms of reference, agenda and governance. Conclusions MMRs decrease gross mortality rates and are effective in identifying and engaging clinicians in system improvements. MMRs should not focus on the actions of individuals, rather on education and/or quality improvement. MMRs should consist of a multidisciplinary team following a structured presentation format with an analysis of error process including actions to be followed-up. Further, it is possible for a single standardised MMR to be implemented hospital wide. What is known about the topic? MMRs are conducted in a variety of clinical settings to educate clinicians and improve patient care. What does this paper add? This review updates a previous review published in 2009 and summarises current evidence around morbidity and mortality reviews. This review also provides a framework for a standardised MMR to be implemented hospital wide. What are the implications for practitioners? This summary of the evidence can be used to guide the development, formation or conduct of MMRs in any healthcare setting.

ENT Quality Improvement Program as a tool to improve the collection of morbidity and mortality data: a multisite audit carried out over 6 months

Objective

This project aims to assess the role of a standardised process of data collection to improve morbidity and mortality data across the region.

Design

Six hospitals within the North West (UK) were recruited and adopted the ENT Quality Improvement Program (QIP) into their daily practice. Monthly anonymous data were sent back to the reviewer for trend analysis.

Outcome measures

Four outcome measures were defined: (1) number of cases recorded within the region each month; (2) assessment of the severity of cases and trends; (3) assessment of action plans reviewing any changes in practice made as a result of using this tool; (4) long-term use of the tool and qualitative feedback from units.

Results

162 patients over the 6 months were included with 180 case discussions. 170 of these were morbidities and 10 were mortalities. Mortality was more frequent in patients with a diagnosis of head and neck cancer. Of the 162 patients, 133 encountered postoperative complications. Post-tonsillectomy (62/133 47%) and post-thyroid surgery (19/133 14%) complications were the most frequently encountered. 66% of the complications were low grade with 18% requiring management under general anaesthetic. Actions plans included four policy reviews with the introduction of three new policies. All sites found the tool user-friendly and are continuing to use it beyond the data collection period.

Conclusions

The ENT QIP has been found to be a simple, user-friendly tool which has improved the quality of data over the six sites and resulted in improvements in practice. Implementation of the tool allows clinicians to critically appraise their practice and to reflect as well as to demonstrate how complications have resulted in change.

Pediatric Surgeon Perceptions of Participation in External Patient Safety Programs: impact on Patient Safety

Introduction:

Surgeons play a crucial role in preventing harm and contributing to the safety culture of their institutions. External safety data programs are designed to review adverse events and provide performance benchmarks to ameliorate future adverse events. The extent to which pediatric surgeons are aware of these programs, utilize data from these programs, and believe that they improve patient safety, is unknown.

Methods:

A cross-sectional survey of the American Pediatric Surgical Association membership was conducted to evaluate participation in and attitudes toward national safety benchmark programs (eg, National Surgical Quality Improvement Program). Surgeons’ perceptions of these activities, including barriers to participation and utilization of safety data, were measured. We performed standard frequency analyses and tests of associations between surgeon characteristics and the likelihood of utilizing safety data.

Results:

The response rate was 38% (353/928). Seventy-two percentage of respondents reported institutional participation in external safety benchmark programs. Of those, only 68% utilized data to improve or monitor patient safety. Surgeon-reported barriers to this process included lack of knowledge, time, and institutional resources.

Conclusions:

Many pediatric surgeons are aware of institutional participation in external safety data programs, but only a portion are involved in the utilization of these data. We have identified several barriers to participation and data utilization. These findings can help direct educational efforts to optimize our ability to learn from adverse event benchmarking and improve pediatric surgical care.

[Content of a weekly morbidity and mortality conference in visceral surgery]

BACKGROUND

Morbidity and mortality (M&M) conferences are essential instruments for quality improvement in surgical departments; however, publications concerning the detailed contents of M&M conferences are rare and have not been published in the German language.

OBJECTIVE

Detailed analysis of the content of a weekly M&M conference in a department of general and visceral surgery.

MATERIAL AND METHODS

Data from a weekly M&M conference were prospectively collected. Epidemiological data, diagnosis, type of surgery, morbidity, postoperative course and mortality were documented for each patient. Type (surgical vs. medicinal) and severity (I-V according to Clavien-Dindo classification) of complications were analyzed.

RESULTS

From 1 January 2010 to 31 December 2014 a total of 761 out of 11,470 patients with a mean age of 62.2 (15.9) years were discussed in the M&M conferences. Of the M&M patients 39.4% were female, 88.9% showed surgical complications while 28.9% were diagnosed with a medical complication and 91 patients (12.0%) died. Complications were classified as Clavien-Dindo I: 27.9%, II: 10.5%, III: 37.7%, IV: 12% and V: 12.0%. Most surgical complications were classified as Clavien-Dindo I (30.0%) and Clavien-Dindo III (40.9%), medical complications were most often classified as Clavien-Dindo IV (29.6%) and V (34.6%). Wound healing impairment (41%), pulmonary complications (16.6%), anastomotic leakage (15.6%), septic (8.9%) and cardiac (8.0%) complications were discussed most often. Cardiac, pulmonary and septic complications were the main cause of morbidity in deceased patients.

CONCLUSION

The M&M conferences display a morbidity profile of each surgical department. Depending on the speciality and focus of a surgical department, the content of the M&M conferences will vary. Detailed knowledge about the content of M&M conferences enable specific measures to be taken to improve quality and patient safety.

Electronic Voting to Improve Morbidity and Mortality Conferences

BACKGROUND

It is of major importance in clinical surgery to identify potential patterns and specific causes of complications. Therefore, morbidity and mortality meetings (M&M) are widely used to discuss and evaluate deviations from expected outcomes in order to improve surgical practice. Moreover, M&M represent an important tool for continuous medical education. In this study, we introduced an electronic voting system to assess whether anonymity during M&M could limit potential biases due to hierarchical structures or opinion leaders.

METHODS

This study was conducted in the surgical department of a European tertiary care center. During the study period, electronic voting was applied in 412 M&M cases and compared with a baseline of 330 conventional M&M entries. In this interrupted time series, the educational quality and participant satisfaction of the M&M were assessed using surveys before and after the introduction of electronic voting. The surveys were refined using principle component analysis. In addition, the classification of the cause of the complication was recorded.

RESULTS

The introduction of electronic voting led to a significant increase in perceived educational quality from 2.63 to 3.36 (p < 0.01), and the overall participant satisfaction increased from 2.6 ± 0.9 to 3.7 ± 1.2 (p < 0.01) on a five-point Likert scale. The frequency of voting shifted from "patient's disease" (before 42.9, after 27.6%, p = 0.04) to "misadventure" (before 1.1, after 16.0%, p < 0.01). The voting frequencies for the causes attributed to "management" and "technical" remained constant.

CONCLUSIONS

An electronic voting system in M&M meetings increases perceived educational quality and participant satisfaction.

Using Audience Response Systems for Real-Time Learning Assessments During Surgical Morbidity and Mortality Conference

OBJECTIVE

Morbidity and mortality (M&M) conference is a mainstay of surgical education. However, its effectiveness is poorly described. The purpose of this study was to demonstrate the feasibility of a real-time audience response system for learner assessment during M&M.

DESIGN

We integrated a web-based audience response system into weekly M&M conference. First, this platform collected qualitative responses about the role of M&M. Then, we used the platform to direct questions to attendees in real time. Questions focused on surgical risk estimation and classifying root causes. Responses were grouped by training and compared to a validated risk tool's prediction. Root cause assignment concordance was statistically compared using Cohen's kappa between the pluralities of faculty responses to that of trainees.

SETTING

General surgical residency program based at a tertiary academic medical center.

PARTICIPANTS

Affiliated categorical residents, preliminary residents, and clinical fellows.

RESULTS

We enrolled 110 participants (38 faculty, 31 senior trainees, and 41 trainees). The majority of respondents (75.9%) cited education as the purpose of M&M, and all of respondents stated education as their personal motivation. Audience response questions were integrated into 34 unique case presentations. Mean absolute differences between predicted complication rates and attendees' predictions were highest for faculty (-9.4%, p = 0.009) and lowest for junior residents (-1.8%, p = 0.385). When assigning root cause of each morbidity, concordance between faculty and trainees was low to moderate (K = 0.41).

CONCLUSIONS

Assessment of learning during M&M can be performed in real time with discrimination observed by learner experience level. These data support development of this response platform to trend learner performance over time and to monitor targeted educational interventions at future M&Ms.

How common are cognitive errors in cases presented at emergency medicine resident morbidity and mortality conferences?

Background

Cognitive errors are a major contributor to medical error. Traditionally, medical errors at teaching hospitals are analyzed in morbidity and mortality (M&M) conferences. We aimed to describe the frequency of cognitive errors in relation to the occurrence of diagnostic and other error types, in cases presented at an emergency medicine (EM) resident M&M conference.

Methods

We conducted a retrospective study of all cases presented at a suburban US EM residency monthly M&M conference from September 2011 to August 2016. Each case was reviewed using the electronic medical record (EMR) and notes from the M&M case by two EM physicians. Each case was categorized by type of primary medical error that occurred as described by Okafor et al. When a diagnostic error occurred, the case was reviewed for contributing cognitive and non-cognitive factors. Finally, when a cognitive error occurred, the case was classified into faulty knowledge, faulty data gathering or faulty synthesis, as described by Graber et al. Disagreements in error type were mediated by a third EM physician.

Results

A total of 87 M&M cases were reviewed; the two reviewers agreed on 73 cases, and 14 cases required mediation by a third reviewer. Forty-eight cases involved diagnostic errors, 47 of which were cognitive errors. Of these 47 cases, 38 involved faulty synthesis, 22 involved faulty data gathering and only 11 involved faulty knowledge. Twenty cases contained more than one type of cognitive error. Twenty-nine cases involved both a resident and an attending physician, while 17 cases involved only an attending physician. Twenty-one percent of the resident cases involved all three cognitive errors, while none of the attending cases involved all three. Forty-one percent of the resident cases and only 6% of the attending cases involved faulty knowledge. One hundred percent of the resident cases and 94% of the attending cases involved faulty synthesis.

Conclusions

Our review of 87 EM M&M cases revealed that cognitive errors are commonly involved in cases presented, and that these errors are less likely due to deficient knowledge and more likely due to faulty synthesis. M&M conferences may therefore provide an excellent forum to discuss cognitive errors and how to reduce their occurrence.

Clinical care review systems in healthcare: a systematic review

Background

Clinical care review is the process of retrospectively examining potential errors or gaps in medical care, aiming for future practice improvement. The objective of our systematic review is to identify the current state of care review reported in peer-reviewed publications and to identify domains that contribute to successful systems of care review.

Methods

A librarian designed and conducted a comprehensive literature search of eight electronic databases. We evaluated publications from January 1, 2000, through May 31, 2016, and identified common domains for care review. Sixteen domains were identified for further abstraction.

Results

We found that there were few publications that described a comprehensive care review system and more focus on individual pathways within the overall systems. There is inconsistent inclusion of the identified domains of care review.

Conclusion

While guidelines for some aspects of care review exist and have gained traction, there is no comprehensive standardized process for care review with widespread implementation.

Electronic supplementary material

The online version of this article (10.1186/s12245-018-0166-y) contains supplementary material, which is available to authorized users.

Emergency Medicine Morbidity and Mortality Conference and Culture of Safety: The Resident Perspective

OBJECTIVE

Morbidity and mortality conference (M&M) is common in emergency medicine (EM) and an Accreditation Council for Graduate Medical Education (ACGME) requirement. We aimed to characterize the prevalence of elements of EM M&M conferences that foster a strong culture of safety.

METHODS

Emergency medicine residents at 33 programs across the United States were surveyed using questions adapted from a previously tested survey of EM program directors and the Agency for Healthcare Research and Quality (AHRQ) Culture of Safety Survey.

RESULTS

The survey response rate was 80.3% (1,002/1,248). A total of 60.3% (601/997) of residents had not submitted a case of theirs to M&M in the past year. A total of 7.6% (73/954) reported that issues raised at M&M always led to change while 88.3% (842/954) reported that they sometimes did and 4.1% (39/954) reported that they never did. A total of 56.2% (536/954) responded that changes made due to M&M were reported back to the residents. Of residents who had cases presented at M&M, 24.2% (130/538) responded that there was regular debriefing, 65.2% (351/538) responded that there was not, and 10.6% (57/578) were unsure. A total of 10.2% (101/988) of respondents agreed that M&M was punitive, 17.4% were neutral (172/988), and 72.4% (715/988) disagreed. A total of 18.0% (178/987) of residents agreed that they felt pressure to order unnecessary tests because of M&M, 22.3% (220/987) were neutral, and 59.6% (589/987) disagreed. A total of 87.4% (862/986) felt that M&M was a valuable educational didactic session, and 78.3% (766/978) believed that M&M contributes to a culture of safety in their institution.

CONCLUSIONS

While most residents believe that M&M is a valuable didactic session and contributes to institutional culture of safety, there are opportunities to improve by communicating changes made in response to M&M, debriefing residents who have had cases presented, and taking steps to make M&M not feel punitive to some residents.

What Happened to the Complication? The Importance of ACS NSQIP Pediatric in Optimizing Quality Improvement Initiatives for Resident Education

OBJECTIVE

Morbidity and Mortality (M&M) conference is considered the golden hour of surgical education. Most training programs lack standardized methods to evaluate self-reported outcomes and contributions to resident education. The purpose of this study was to determine whether residents underreport pediatric postoperative complications thereby limiting a comprehensive educational opportunity and the ability to adequately perform quality improvement during M&M conference.

DESIGN

A retrospective analysis of resident reports submitted to the M&M committee at an academic medical center was conducted over 1 year. All complications were compared to the American College of Surgeons (ACS) Pediatric National Surgical Quality Improvement Program (NSQIP) data abstracted over the same period. A descriptive analysis of perioperative events was performed.

SETTING

This study was conducted at the Medical University of South Carolina Medical Center and MUSC Children's Hospital, an academic tertiary care center located in Charleston, South Carolina.

RESULTS

Overall, 81 complications were captured. Resident and NSQIP databases captured 27 (33%) and 68 (84%) complications, respectively. Residents were more likely to report major complications. More common sources of postoperative morbidity, including surgical site infection and transfusion, were underreported at 20% and 5%, respectively.

CONCLUSIONS

Resident reporting inadequately captures the full complement of pediatric perioperative complications. NSQIP-abstracted data serve as a useful adjunct to traditional M&M reporting in capturing complications underreported by trainees.

Identifying Adverse Events in Pediatric Surgery: Comparing Morbidity and Mortality Conference with the NSQIP-Pediatric System

BACKGROUND

Recent improvements to morbidity and mortality (M&M) conference have focused on the case review system. However, case selection occurs by physician reporting, which is limited by selection bias. We compared the effectiveness of our M&M conference with the NSQIP-Pediatric (NSQIP-P) system for identifying adverse events.

STUDY DESIGN

Complications from January 2010 to September 2015 were compared between M&M and NSQIP-P. Only M&M patients meeting NSQIP-P criteria were compared with patients from the NSQIP-P system; exclusions were studied separately. Complication rates in M&M conference before and after a 2012 format change designed to increase case reporting were also compared.

RESULTS

Detection of mortality in M&M conference and NSQIP-P was not different. Morbidity events identified by NSQIP-P were significantly higher than M&M conference during the entire study period (194 vs 100 occurrences/1,000 cases) (p < 0.0001). Morbidity occurrences in M&M conference increased with the 2012 improvements, however, they still remained less than that identified by NSQIP-P (226 vs 141 occurrences/1,000 cases) (p < 0.0001). Of 863 patients presented in M&M conference, 210 were excluded from direct comparison because they did not meet NSQIP-P criteria. These included 62 deaths and 287 occurrences of morbidity. Their analysis in M&M conference resulted in 32 action initiatives directed at system failures.

CONCLUSIONS

The NSQIP-P identified more complications than M&M. The M&M conference improvements increased reported cases, but they still remained lower than NSQIP-P. However, M&M conference identified events resulting in systems changes that would not have been identified by NSQIP-P. Although NSQIP-P captures occurrences to compare large patient cohorts, M&M analyzes singular failures and initiates direct interventions. Integration of these systems can optimize their usefulness in quality improvement.

Morbidity and Mortality Conferences: A Narrative Review of Strategies to Prioritize Quality Improvement

BACKGROUND

The morbidity and mortality conference (MMC) provides a valuable opportunity to review patient care processes and safety concerns, aligning with a growing quality improvement (QI) mandate. Yet the structure, processes, and aims of many MMCs are often ill-defined. This review summarizes strategies employed by medical, surgical, and critical care departments in the development of patient safety-centered MMCs.

METHODS

A structured narrative review of literature was conducted using combinations of the search terms "morbidity and mortality conference(s)," "morbidity and mortality meetings," or "morbidity and mortality round(s)." The titles and abstracts of 250 returned articles were screened; 76 articles were reviewed in full, with 32 meeting the full inclusion criteria.

RESULTS

The literature review elicited a number of methods used by medical, surgical, and critical care MMCs to emphasize QI and patient safety outcomes. A list of actionable changes made in each article was compiled. Five themes common to QI-centered MMCs were identified: (1) defining the role of the MMC, (2) involving stakeholders, (3) detecting and selecting appropriate cases for presentation, (4) structuring goal-directed discussion, and (5) forming recommendations and assigning follow-up. Innovative methods to pair adverse event screening with MMCs were superior to nonstructured voluntary reporting and case selection for overall morbidity detection. Structured case review, discussion, and follow-up were more likely to lead to implementing systems-based change, and interdisciplinary MMCs were associated with a greater likelihood of forming an action item.

CONCLUSION

The modern patient safety-centered MMC shares common themes of practices that can be adopted by institutions looking to create a venue for analysis of care processes, a platform to launch QI initiatives, and a culture of safety.

National Surgical Quality Improvement Program integration with Morbidity and Mortality conference is essential to success in the march to zero

BACKGROUND

Morbidity and Mortality conference (M&M) and the National Surgical Quality Improvement Program (NSQIP) are systems to improve surgical care. We evaluated the commonality of adverse events (AEs) and the change in AE rates after integration.

METHODS

A single institution's NSQIP and M&M registries were analyzed to determine commonality of AE reported. Causal determinant groups were then created to categorize and standardize AE. Incidence of AE and patient commonality identified by these systems was evaluated over 2 years.

RESULTS

The 68 common patients identified in 2012 represented 27% of NSQIP and 43% of M&M patients. Common AE reported by M&M and NSQIP decreased from 16.9% (2013) to 9.6% (2014). Causality code analysis demonstrated significant differences in proportion of issues addressed within each (P < .0001).

CONCLUSIONS

Despite standardized coding, M&M focus differed from NSQIP. Low commonality affirms NSQIP as a critical adjunct to voluntary reporting. Combining both may help eliminate preventable AEs.

Prospective assessment of complications on a daily basis is essential to determine morbidity and mortality in routine pediatric surgery

AIMS OF THE STUDY

We aimed to assess postoperative complications prospectively on a daily basis and hypothesized that this would lead to an increase in the number of detected complications.

METHODS

Surgical complications were assessed prospectively during a period of 8months. Systematic documentation was carried out daily during a team meeting (period S). Data were compared to those of a preceding period of 8-months of nonsystematic assessment (period N) in which complications had been documented in a self-reporting fashion. Complications were classified according to the Clavien-Dindo classification.

RESULTS

A total of 1291 patients (mean age: 6.6years) were included. During period S complications were determined in 16% of 790 operations compared to 4% of 741 procedures in period N (p<0.01). This difference was owing to an increased detection of minor complications (grade I-III), i.e. wound infection, dysuria after hypospadias repair or postoperative bleeding. In contrast, the incidence of severe complications (grade IV+V) was not significantly different between the time periods (1.3% in period S and 0.8% in period N). Most frequent major complications were cardiopulmonary arrest, enterocolitis, and death. Severe complications accounted for 8% of complications discussed during weekly morbidity and mortality conferences in period S versus 22% in period N (p<0.05).

CONCLUSION

Our results indicate that a systematic documentation of complications on a daily basis reveals a more realistic picture of the incidence of pediatric surgical complications and should be the method of choice.

Understanding Quality Issues in Your Surgical Department: Comparing the ACS NSQIP With Traditional Morbidity and Mortality Conferences in a Canadian Academic Hospital

INTRODUCTION

Review of surgical complications in traditional morbidity and mortality (M&M) rounds remains an important mechanism to identify and discuss quality-of-care issues. This process relies on case selection by providers; therefore, complications identified for review may differ from those captured in comprehensive quality programs such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Additionally, although the ACS NSQIP captures robust data on complications in surgical wards, without strategies to disseminate this information to staff and improve practice, minimal change may result. The objective of this study was to compare complications identified by the ACS NSQIP with those captured in M&M conferences at a large Canadian academic hospital.

METHODS

Retrospective medical record reviews of all patients admitted to the general surgery unit from March 2012 to March 2013 were reviewed. Number and types of complications were recorded for cases that were both submitted and reviewed in M&M rounds and those cases that were submitted but not reviewed. These complications were compared with those extracted from our local ACS NSQIP database.

RESULTS

A total of 1348 general surgical procedures were performed. The ACS NSQIP captured complications in 143 patients compared with 58 patients identified for review in M&M rounds. Both the methods identified similar proportions of major and minor complications (ACS NSQIP 52% major, 48% minor; M&M 58% major, 42% minor). More postoperative deaths were entered into the ACS NSQIP (12) than in M&M conferences (8 reviewed and 2 submitted). The ACS NSQIP identified higher proportions of surgical site infections and readmissions. However, M&M conferences captured additional complications in patients who did not undergo surgery and identified potential quality issues in patients who did not ultimately experience an adverse outcome.

CONCLUSIONS

M&M rounds and the ACS NSQIP provide important and potentially complementary data on surgical quality. Incorporating the ACS NSQIP outcomes data into traditional M&M conferences may help to optimize quality improvement efforts.

Morbidity and Mortality Conference in Emergency Medicine Residencies and the Culture of Safety

Introduction

Morbidity and mortality conferences (M+M) are a traditional part of residency training and mandated by the Accreditation Counsel of Graduate Medical Education. This study’s objective was to determine the goals, structure, and the prevalence of practices that foster strong safety cultures in the M+Ms of U.S. emergency medicine (EM) residency programs.

Methods

The authors conducted a national survey of U.S. EM residency program directors. The survey instrument evaluated five domains of M+M (Organization and Infrastructure; Case Finding; Case Selection; Presentation; and Follow up) based on the validated Agency for Healthcare Research & Quality Safety Culture survey.

Results

There was an 80% (151/188) response rate. The primary objectives of M+M were discussing adverse outcomes (53/151, 35%), identifying systems errors (47/151, 31%) and identifying cognitive errors (26/151, 17%). Fifty-six percent (84/151) of institutions have anonymous case submission, with 10% (15/151) maintaining complete anonymity during the presentation and 21% (31/151) maintaining partial anonymity. Forty-seven percent (71/151) of programs report a formal process to follow up on systems issues identified at M+M. Forty-four percent (67/151) of programs report regular debriefing with residents who have had their cases presented.

Conclusion

The structure and goals of M+Ms in EM residencies vary widely. Many programs lack features of M+M that promote a non-punitive response to error, such as anonymity. Other programs lack features that support strong safety cultures, such as following up on systems issues or reporting back to residents on improvements. Further research is warranted to determine if M+M structure is related to patient safety culture in residency programs.

The morbidity and mortality conference as an adverse event surveillance tool in a paediatric intensive care unit

OBJECTIVE

To determine if standardised chart review applied to records of patients discussed at a paediatric intensive care unit (PICU) morbidity and mortality conference (MMC) yields additional or different information regarding safety event occurrence and characteristics.

DESIGN

Retrospective record review.

SETTING

Single tertiary referral PICU in Baltimore, Maryland, USA.

PARTICIPANTS

96 patients discussed at the PICU MMC over 14 months (November 2011-December 2012).

MAIN OUTCOME MEASURES

Safety events and their characteristics (medical error category, severity and preventability).

RESULTS

A total of 275 safety events were identified through the MMC and/or chart review. The MMC identified 131 (48%) events, 53 (19%) of which were identified through the MMC alone. After chart review was performed, an additional 144 (52%) events were identified. 78 (28%) events were identified through both. High severity adverse events potentially contributing to permanent harm or death were more likely to be identified through both the MMC and chart review (47%) compared with either alone. The MMC alone identified more near-misses (21%) and preventable events (96%) compared with chart review alone or both MMC and chart review. Although chart review alone helped to identify many healthcare-associated infections, medication errors and sedation/pain control issues not elicited through the MMC, the MMC alone identified more communication errors and workflow problems. The MMC alone also identified 40% of all diagnostic errors, which would not have been discovered otherwise despite chart review by itself identifying 50% of such misdiagnoses.

CONCLUSIONS

Standardised chart review applied to records of patients discussed at a PICU MMC identified significantly more safety events not initially discovered through the MMC. However, the MMC was superior to chart review in identifying broader problems such as communication errors, workflow issues and certain diagnostic errors not captured by chart review, which can potentially affect many aspects of care.

Assessing the impact of an ageing population on complication rates and in-patient length of stay

BACKGROUND

Ireland has an ageing population; with the proportion of people aged over 80 years estimated to increase over the next 20 years from 1.1% to 2.1%.

AIMS

The aim of this study was to examine the demographics of the population served by the surgical department in a tertiary referral centre in the west of Ireland and to examine whether increasing age had an influence on morbidity, mortality and length of stay.

METHODS

Data pertaining to all surgical admissions over a 6-month period between was collected prospectively using an ACS-NSQIP based proforma. Data collected included patient age, gender, operative intervention, in-patient length of stay, mode of admission and complications related to their admission.

RESULTS

A total of 2209 patients were admitted under the care of the general, vascular and breast services in our centre over a 6-month period between August and January. Two thousand and nineteen patients had complete data collected. The average age was 50.37 years (± 23.62), with 24.12% (n = 533) older than 70 years. Only 12.31% of patients aged younger than 70 years experienced morbidity, compared to 25.10% of older patients. It was shown that there was a stepwise increase with complication rates and hospital in-patient stay across each decade of increasing age. Multivariate analysis showed those factors most predictive of a complication to include emergency admission, major or complex major surgical intervention, female gender and age. Length of stay was also found to have a positive correlation with increasing age (Spearman's Rho, p < 0.001).

CONCLUSION

Increasing age is associated with increased complication rates and increased hospital length of stay.