Processes for Identifying and Reviewing Adverse Events and Near Misses at an Academic Medical Center

Improving the quality of surgical morbidity and mortality conference using a standardized reporting and assessment tool: a validation study from a large academic medical center in the United States

BACKGROUND

The purpose of this study is two-fold: (1) Improve the quality of Morbidity and Mortality conferences by developing a standardized presentation template and assessment tool; (2) Assess the intervention impact by comparing pre- and post-intervention data.

METHODS

A pre-post study was conducted at a tertiary care academic medical center between January 2022- January 2023. A standardized presentation template was created and a short assessment tool was developed to evaluate the quality of presentations on eight domains. We hypothesized that development of this template would significantly improve the quality of M&M conferences. Pre- and post-intervention data were compared using the Kruskal-Wallis test to evaluate for significant differences. Effect sizes for each domain were assessed by Cohen's d.

RESULTS

A total of 127 pre-intervention responses and 61 post-intervention responses were received over a six-month period. Statistically significant increases in post-intervention scores were noted in nearly all presentation domains, including clarity of case selection rationale, nature of the safety event, circumstances leading to the safety event, contributing factors, understanding of the safety event, and anticipated benefits to patient outcomes (p < 0.05). The effect sizes ranged from medium for rationale for case selection to small for the identification of corrective actions.

CONCLUSIONS

The introduction of a standardized, guided template improved the quality of Morbidity and Mortality presentations, with medium effect sizes and statistically significant increases in nearly all surveyed domains. A ceiling effect in the overall assessment score was noted as presentations prior to the intervention were rated highly. Standardization of case selection and presentations can promote alignment of the Quality Improvement Morbidity and Mortality workflow with broader-scope initiatives, departmentally and institutionally.

Practice priorities for acute care nursing: A Delphi study

AIMS AND OBJECTIVES

To describe the risk and frequency of challenges in acute care nursing, and the practice priorities in Australian hospital wards based upon expert consensus.

BACKGROUND

Health care is facing increasing demands that are negatively impacting upon the safety and quality of nursing care.

DESIGN

Delphi Method.

METHOD

A three-round electronic Delphi method was used to collect and synthesise expert consensus opinion of 30 participants in Rounds One and Two of the survey, and 12 participants in Round Three. The study was carried out from July to December 2016. This study complied with the STROBE checklist.

RESULTS

High patient acuity or complexity, as well as inadequate bed space on wards, are "very high" risks that occur "often" and "very often," respectively. The pressure to admit patients, delayed medical review and patient boarding are all "high" risks that occur "often." Though only occurring "sometimes," inadequate numbers and skill mix of staff, suboptimal communication and early or inappropriate discharge all pose a "very high" risk to patient care.

CONCLUSION

The key practice priorities for nurse managers should include the design, implementation and evaluation of sustainable system-wide frameworks, processes and models of care that address patient boarding, communication and discharge processes, job satisfaction, staffing numbers and expertise.

RELEVANCE TO CLINICAL PRACTICE

This study provides a description of the challenges that face acute care nursing in the provision of safe and high-quality care.

Tracking medical errors and near misses in the new graduate registered nurse

This article provides a narrative that describes the current state of medical errors and near misses in the general health care setting and for new graduate registered nurses specifically. It then proposes a "wild idea" to create a national database for the reporting of errors that would act as a call to action to change our current reporting system to one of transparency and shared information for the purpose of creating needed education in both academic and practice settings.

Preventing patient harm via adverse event review: An APSA survey regarding the role of morbidity and mortality (M&M) conference

INTRODUCTION

Peer-review endeavors represent the continual learning environment critical for a culture of patient safety. Morbidity and mortality (M&M) conferences are designed to review adverse events to prevent future similar events. The extent to which pediatric surgeons participate in M&M, and believe M&M improves patient safety, is unknown.

METHODS

A cross-sectional survey of the American Pediatric Surgical Association membership was conducted to evaluate participation in and perception of M&M conferences. Closed and open-ended questions were provided to gauge participation and perceptions of M&M effectiveness. Standard frequency analyses and tests of associations between M&M program attributes and surgeons' perceptions of effectiveness were performed.

RESULTS

The response rate was 38% (353/928). Most surgeons (85%) reported that they always participate in M&M, but only 64% believe M&M is effective in changing practice or prevention of future adverse events. Effective M&Ms were more likely to emphasize loop closure, multidisciplinary participation, standardized assessment of events, and connection to quality improvement efforts.

CONCLUSIONS

Most pediatric surgeons participate in M&M, but many doubt its effectiveness. We identified attributes of M&M conferences that are perceived to be effective. Further investigation is needed to identify how to optimally utilize peer-review programs to prevent adverse events and improve patient safety.

LEVEL OF EVIDENCE

V.

Barriers and facilitators to learn and improve through morbidity and mortality conferences: a qualitative study

OBJECTIVES

To explore barriers and facilitators to successful morbidity and mortality conferences (M&M), driving learning and improvement.

DESIGN

This is a qualitative study with semistructured interviews. Inductive, thematic content analysis was used to identify barriers and facilitators, which were structured across a pre-existing framework for change in healthcare.

SETTING

Dutch academic surgical department with a long tradition of M&M.

PARTICIPANTS

An interview sample of surgeons, residents and physician assistants (n=12).

RESULTS

A total of 57 barriers and facilitators to successful M&M, covering 18 themes, varying from 'case type' to 'leadership', were perceived by surgical staff. While some factors related to M&M organisation, others concerned individual or social aspects. Eight factors, of which four were at the social level, had simultaneous positive and negative effects (eg, 'hierarchy' and 'team spirit'). Mediating pathways for M&M success were found to relate to available information, staff motivation and realisation processes.

CONCLUSIONS

This study provides leads for improvement of M&M practice, as well as for further research on key elements of successful M&M. Various factors were perceived to affect M&M success, of which many were individual and social rather than organisational factors, affecting information and realisation processes but also staff motivation. Based on these findings, practical recommendations were formulated to guide efforts towards best practices for M&M.