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Brook K, Agarwala AV, Tewfik GL. Reframing the Morbidity and Mortality Conference: The Impact of a Just Culture. J Patient Saf 2024; 20:280-287. [PMID: 38470962 DOI: 10.1097/pts.0000000000001224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
ABSTRACT Morbidity and mortality (M&M) conferences are prevalent in all fields of medicine. Historically, they arose out a desire to improve medical care. Nevertheless, the goals of M&M conferences are often poorly defined, at odds with one another, and do not support a just culture. We differentiate among the various possible goals of an M&M and review the literature for strategies that have been shown to achieve these goals. Based on the literature, we outline an ideal M&M structure within the context of just culture: The process starts with robust adverse event and near miss reporting, followed by careful case selection, excluding cases solely attributable to individual error. Prior to the M&M, the case should be openly discussed with involved members and should be reviewed using a selected framework. The goal of the M&M should be selected and clearly defined, and the presentation format and rules of conduct should all conform to the selected presentation goal. The audience should ideally be multidisciplinary and multispecialty. The M&M should conclude with concrete tasks and assigned follow-up. The entire process should be conducted in a peer review protected format within an environment promoting psychological safety. We conclude with future directions for M&Ms.
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Affiliation(s)
| | - Aalok V Agarwala
- Department of Anaesthesia, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - George L Tewfik
- Department of Anesthesiology, Rutgers-New Jersey Medical School, Newark, New Jersey
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2
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Zvonar I, Jauregui J, Welsh LA. Posttraumatic growth for long-term success: Organizational strategies for supporting residents after medical error. AEM EDUCATION AND TRAINING 2024; 8:e10991. [PMID: 38765710 PMCID: PMC11099761 DOI: 10.1002/aet2.10991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/22/2024]
Affiliation(s)
- Ivan Zvonar
- Emergency MedicineUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Joshua Jauregui
- Emergency MedicineUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Laura A. Welsh
- Emergency Medicine at the Chobanian & Avedisian School of MedicineBoston UniversityBostonMassachusettsUSA
- Boston Medical Center Emergency Medicine Residency ProgramBostonMassachusettsUSA
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Carsky K, Rindskopf D, Patel VM, Ansari P, Dechario SP, Giangola G, Coppa GF, Antonacci AC. Using Concurrent Complication Reporting to Evaluate Resident Critical Thinking and Enhance Adult Learning. JOURNAL OF SURGICAL EDUCATION 2024; 81:702-712. [PMID: 38556440 DOI: 10.1016/j.jsurg.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 12/26/2023] [Accepted: 02/02/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE Critical thinking and accurate case analysis is difficult to quantify even within the context of routine morbidity and mortality reporting. We designed and implemented a HIPAA-compliant adverse outcome reporting system that collects weekly resident assessments of clinical care across multiple domains (case summary, complications, error analysis, Clavien-Dindo Harm, cognitive bias, standard of care, and ACGME core competencies). We hypothesized that incorporation of this system into the residency program's core curriculum would allow for identification of areas of cognitive weakness or strength and provide a longitudinal evaluation of critical thinking development. DESIGN A validated, password-protected electronic platform linked to our electronic medical record was used to collect cases weekly in which surgical adverse events occurred. General surgery residents critiqued 1932 cases over a 4-year period from 3 major medical centers within our system. These data were reviewed by teaching faculty, corrected for accuracy and graded utilizing the software's critique algorithm. Grades were emailed to the residents at the time of the review, collected prospectively, stratified, and analyzed by post-graduate year (PGY). Evaluation of the resident scores for each domain and the resultant composite scores allowed for comparison of critical thinking skills across post-graduate year (PGY) over time. SETTING Data was collected from 3 independently ACGME-accredited surgery residency programs over 3 tertiary hospitals within our health system. PARTICIPANTS General surgery residents in clinical PGY 1-5. RESULTS Residents scored highest in properly identifying ACGME core competencies and determining Clavien-Dindo scores (p < 0.006) with no improvement in providing accurate and concise clinical summaries. However, residents improved in recording data sufficient to identify error (p < 0.00001). A positive linear trend in median scores for all remaining domains except for cognitive bias was demonstrated (p < 0.001). Senior residents scored significantly higher than junior residents in all domains. Scores > 90% were never achieved. CONCLUSIONS The use of an electronic standardized critique algorithm in the evaluation and assessment of adverse surgical case outcomes enabled the measure of residents' critical thinking skills. Feedback in the form of teaching faculty-facilitated discussion and emailed grades enhanced adult learning with a steady improvement in performance over PGY. Although residents improved with PGY, the data suggest that further improvement in all categories is possible. Implementing this standardized critique algorithm across PGY allows for evaluation of areas of individual resident weakness vs. strength, progression over time, and comparisons to peers. These data suggest that routine complication reporting may be enhanced as a critical thinking assessment tool and that improvement in critical thinking can be quantified. Incorporation of this platform into M&M conference has the potential to augment executive function and professional identity development.
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Affiliation(s)
- Katie Carsky
- Lenox Hill Hospital, Northwell Health, New York, New York.
| | - David Rindskopf
- City University of New York, Graduate School And University Center, New York, New York
| | - Vihas M Patel
- Northwell North Shore University Hospital/Long Island Jewish Medical Center Department of Surgery, Manhasset, New York; Zucker School of Medicine at Hofstra/Northwell Department of Surgery, Hempstead, New York
| | - Parswa Ansari
- Lenox Hill Hospital, Northwell Health, New York, New York
| | | | - Gary Giangola
- Lenox Hill Hospital, Northwell Health, New York, New York
| | - Gene F Coppa
- Lenox Hill Hospital, Northwell Health, New York, New York
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Kim YJ, Chung KC. Failure: A Close Relative. Plast Reconstr Surg 2024; 153:985-988. [PMID: 38657006 DOI: 10.1097/prs.0000000000011216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Affiliation(s)
| | - Kevin C Chung
- the Section of Plastic Surgery, University of Michigan Medical School
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Yaow CYL, Ng QX, Chong RIH, Ong C, Chong NZY, Yap NLX, Hong ASY, Tan BKT, Loh AHP, Wong ASY, Tan HK. Intraoperative adverse events among surgeons in Singapore: a multicentre cross-sectional study on impact and support. BMC Health Serv Res 2024; 24:512. [PMID: 38659030 PMCID: PMC11040834 DOI: 10.1186/s12913-024-10998-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/16/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND It is known that many surgeons encounter intraoperative adverse events which can result in Second Victim Syndrome (SVS), with significant detriment to their emotional and physical health. There is, however, a paucity of Asian studies in this space. The present study thus aimed to explore the degree to which the experience of an adverse event is common among surgeons in Singapore, as well as its impact, and factors affecting their responses and perceived support systems. METHODS A self-administered survey was sent to surgeons at four large tertiary hospitals. The 42-item questionnaire used a systematic closed and open approach, to assess: Personal experience with intraoperative adverse events, emotional, psychological and physical impact of these events and perceived support systems. RESULTS The response rate was 57.5% (n = 196). Most respondents were male (54.8%), between 35 and 44 years old, and holding the senior consultant position. In the past 12 months alone, 68.9% recalled an adverse event. The emotional impact was significant, including sadness (63.1%), guilt (53.1%) and anxiety (45.4%). Speaking to colleagues was the most helpful support source (66.7%) and almost all surgeons did not receive counselling (93.3%), with the majority deeming it unnecessary (72.2%). Notably, 68.1% of the surgeons had positive takeaways, gaining new insight and improving vigilance towards errors. Both gender and surgeon experience did not affect the likelihood of errors and emotional impact, but more experienced surgeons were less likely to have positive takeaways (p = 0.035). Individuals may become advocates for patient safety, while simultaneously championing the cause of psychological support for others. CONCLUSIONS Intraoperative adverse events are prevalent and its emotional impact is significant, regardless of the surgeon's experience or gender. While colleagues and peer discussions are a pillar of support, healthcare institutions should do more to address the impact and ensuing consequences.
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Affiliation(s)
- Clyve Yu Leon Yaow
- NUS Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Qin Xiang Ng
- Health Services Research Unit, Singapore General Hospital, Singapore, Singapore.
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.
| | - Ryan Ian Houe Chong
- NUS Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Clarence Ong
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Nicolette Zy-Yin Chong
- NUS Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nicole Li Xian Yap
- NUS Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ashley Shuen Ying Hong
- NUS Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Benita Kiat Tee Tan
- Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Amos Hong Pheng Loh
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | | | - Hiang Khoon Tan
- Division of Surgery and Surgical Oncology, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore
- Singhealth Duke-NUS Global Health Institute, Singapore, Singapore
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States
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Ganguly AP, Oren H, Jack HE, Abe R. Equity M&M - Adaptation of the Morbidity and Mortality Conference to Analyze and Confront Structural Inequity in Internal Medicine. J Gen Intern Med 2024; 39:867-872. [PMID: 37904072 PMCID: PMC11043282 DOI: 10.1007/s11606-023-08487-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 10/13/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND At morbidity and mortality (M&M) conferences, medical teams review cases for medical education and system improvement. Adverse outcomes are often driven by social inequity, but processes to analyze such outcomes are lacking. AIM Adapt quality improvement and patient safety (QIPS) tools in the M&M format to systematically analyze adverse patient outcomes rooted in social and structural determinants of health (SSDH). SETTING One-hour conferences conducted in health systems in Seattle, WA, and Dallas, TX. PARTICIPANTS Equity M&M conferences were held 11 times, each with approximately 45 participants comprised of internal medicine trainees, faculty, and non-medical staff. PROGRAM DESCRIPTION Conferences included a case narrative and counternarrative highlighting SSDH, an equity-framed root cause analysis, and potential interventions. PROGRAM EVALUATION Conferences were received well across both institutions. Following conferences, most respondents reported increased identification of opportunities for action towards equity (88.5%) and confidence in discussing equity issues with colleagues (92.3%). DISCUSSION Equity M&M conferences are a structured tool for deconstructing and confronting structural inequity that leads to adverse patient outcomes. Evaluations demonstrate educational impact on participants. Anecdotal examples suggest institutional impact. Other health systems could adopt this model for similar advocacy and system improvement.
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Affiliation(s)
- Anisha P Ganguly
- Center of Innovation and Value at Parkland, Parkland Health, Dallas, TX, USA.
- Division of General Internal Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Hannah Oren
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Helen E Jack
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ryan Abe
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
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Tresselt E, Darnell Bowens C, Dhar A. An Innovative and Integrative Approach to Breaking Down Barriers to Traditional Morbidity and Mortality Conference. Clin Pediatr (Phila) 2024; 63:325-333. [PMID: 37148262 PMCID: PMC10893767 DOI: 10.1177/00099228231172486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Children are vulnerable to medical errors. Adverse events are leveraged as educational tools in Morbidity and Mortality (M&M) Conference. Traditionally, M&M has brought angst when discussing adverse events. Our goal was to transition M&M to an educational environment highlighting system failures. A survey was created to capture data on satisfaction, education, and system process improvement. Feedback from the surveys led to several changes, including fostering a multidisciplinary forum, prioritizing educational topics, and emphasizing process improvement. In 5 years, satisfaction with M&M Conference has increased by 29%, with an increase by 50% when asked if process improvement issues were addressed adequately, and 100% of faculty incorporate what they learn from M&M into their practice. By developing a hands-on approach to M&M, we have improved satisfaction and focused on education and system process improvement. This design could be used throughout the medical community to improve discussion of adverse events which should improve patient safety.
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Batthish M, Kuper A, Fine C, Laxer RM, Baker GR. Organizational Learning in the Morbidity and Mortality Conference. J Healthc Qual 2024; 46:100-108. [PMID: 38421908 DOI: 10.1097/jhq.0000000000000416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
INTRODUCTION The focus of morbidity and mortality conferences (M&MCs) has shifted to emphasize quality improvement and systems-level care. However, quality improvement initiatives targeting systems-level errors are challenged by learning in M&MCs, which occurs at the individual attendee level and not at the organizational level. Here, we aimed to describe how organizational learning in M&MCs is optimized by particular organizational and team cultures. METHODS A prospective, multiple-case study design was used. Using purposive sampling, three cases covering different medical/surgical specialties in North America were chosen. Data collection included direct observations of the M&MC, semistructured interviews with key M&MC members, and documentary information. RESULTS The role of the M&MC in all cases integrated two key concepts: recognition of system-wide trends and learning from error, at an organizational and team level. All cases provided evidence of double-loop learning and used organizational memory strategies to ensure knowledge was retained within the organization. A patient safety culture was linked to the promotion of open communication, fostering learning from adverse events. CONCLUSION This study describes three cases of systems-oriented M&MCs that reflected elements of organizational learning theory. The M&MC can therefore provide a context for organizational learning, allowing optimal learning from adverse events.
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Beaulieu-Jones BR, Wilson S, Howard DS, Rasic G, Rembetski B, Brotschi EA, Pernar LI. Defining a High-Quality and Effective Morbidity and Mortality Conference: A Systematic Review. JAMA Surg 2023; 158:1336-1343. [PMID: 37851458 DOI: 10.1001/jamasurg.2023.4672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
Importance Morbidity and mortality conferences (MMCs) are thought to advance trainee education, quality improvement (QI), and faculty development. However, there is considerable variability with regard to their completion. Objective To compile and analyze the literature describing the format, design, and other attributes of MMCs that appear to best advance their stated objectives related to QI and practitioner education. Evidence Review For this systematic review, a literature search with terms combining conference and QI or morbidity and mortality was performed in January 2022, using the PubMed, Embase, and ERIC (Education Resources Information Center) databases with no date restrictions. Included studies were published in English and described surgical or nonsurgical MMCs with explicit reference to quality or system improvement, education, professional development, or patient outcomes; these studies were classified by design as survey based, intervention based, or other methodologies. For survey-based studies, positively and negatively regarded attributes of conference design, format, and completion were extracted. For intervention-based studies, details of the intervention and their impact on stated MMC objectives were abstracted. Principal study findings were summarized for the other group. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI). Abstract screening, full-text review, and data extraction and analysis were completed between January 2022 and December 2022. Findings A total of 59 studies met appropriateness for study inclusion. The mean MERSQI score for the included studies was 6.7 (range, 5.0-9.5) of a maximum possible 18, which implied that the studies were of average quality. The evidence suggested that preparation and postconference follow-up regarding QI initiatives are equally as important as both (1) succinctly presenting case details, opportunities for improvement, and educational topics and (2) creating a constructive space for accountability, engagement, and multistakeholder discussion. Conclusions and Relevance These findings suggest that the published literature on MMCs provides substantial insight into the optimal format, design, and related attributes of an effective MMC. This systematic review provides a road map for surgical departments to improve MMCs in order to align their format and design with their principal objectives related to practitioner and trainee education, error prevention, and QI.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Spencer Wilson
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Daniel S Howard
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Gordana Rasic
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Ben Rembetski
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Erica A Brotschi
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Luise I Pernar
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Section of Minimally Invasive Surgery, Boston Medical Center, Boston University, Boston, Massachusetts
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Nakayama DK. Traditions of Professional Accountability and Social Responsibility of the Morbidity and Mortality Conference. Am Surg 2023; 89:5098-5101. [PMID: 36796419 DOI: 10.1177/00031348231158032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
- Don K Nakayama
- Mercer University School of Medicine, Chapel Hill, NC, USA
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Bralow L, McCaffery E, Leuchten S. Good Saves: How Emergency Medicine Residents are Learning From Success. Cureus 2023; 15:e49508. [PMID: 38152785 PMCID: PMC10752616 DOI: 10.7759/cureus.49508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 11/20/2023] [Indexed: 12/29/2023] Open
Abstract
INTRODUCTION The practice of learning from medical errors is well-established and well-researched in the literature on morbidity and mortality conferences. However, durable learning from case-based education occurs not only through the analysis of medical errors but also through the evaluation of how critical decisions were made to result in a positive clinical outcome, what we will call a "good save." The aim of the current study is to provide an overview of how US-based emergency medicine residencies are teaching using "good saves." METHODS A national survey of emergency medicine (EM) residency leadership was distributed through the Council of Residency Directors (CORD) and the Society of Academic Emergency Medicine (SAEM) listservs. A descriptive analysis of the results was undertaken. RESULTS Residency leadership representing 67 different US EM training programs participated in our survey. Of these, only 19 programs use formal learning objectives and dedicated education time to teach from "good saves." Thirty-six programs provide informal recognition, often in the form of a "shout-out." Residency leadership is motivated to provide this recognition and learning through efforts to promote wellness and resiliency among EM residents. Notably, the use of prizes and awards is not necessary. DISCUSSION Some EM residencies in the United States are making targeted efforts to promote the recognition of successful clinical care. This recognition and education are being used as tools both to promote wellness and to teach resiliency. However, there is wide heterogeneity in approaches. Our survey provides examples of the many ways that "good saves" can be incorporated into any EM residency curriculum with the potential for significant impact.
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Affiliation(s)
- Leah Bralow
- Emergency Medicine, St. Barnabas Hospital Health System, New York, USA
| | - Eleni McCaffery
- Emergency Medicine, Sophie Davis School of Medicine, City University of New York, New York, USA
| | - Scott Leuchten
- Emergency Medicine, St. Barnabas Hospital Health System, New York, USA
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Verhagen MJ, de Vos MS, van Schaik J, van der Vorst JR, Schepers A, Marang-van de Mheen PJ, Hamming JF. Surgical team dynamics in a reflective team meeting to improve quality of care: qualitative analysis of a shared mental model. Br J Surg 2023; 110:1271-1275. [PMID: 37190915 PMCID: PMC10480032 DOI: 10.1093/bjs/znad111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/27/2023] [Accepted: 04/04/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Merel J Verhagen
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Marit S de Vos
- Directorate of Quality and Patient Safety, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jan van Schaik
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Joost R van der Vorst
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Abbey Schepers
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Jaap F Hamming
- Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands
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Belkacemi Y, Debbi K, Besnard C, Grellier N, Fonteneau G, Colson-Durand L, Lerouge D, Durdux C, Campana F, Pons P, Flandin I, Pasquier D, de Crevoisier R, Wachter T, Thureau S, Noël G, Conzague-Casabianca L, Petit A, Supiot S, Azria D. [The morbidity and mortality review meetings in radiotherapy departments: Procedure, implementation and prospects of the "Proust" French national project]. Cancer Radiother 2023; 27:474-479. [PMID: 37507286 DOI: 10.1016/j.canrad.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 06/22/2023] [Indexed: 07/30/2023]
Abstract
Radiation-induced acute and late toxicity depends on several parameters. The type, severity and duration of morbidity are mainly related to irradiated volume, total dose and its fractionation and the intrinsic radiosensitivity of the patients. The follow-up of these toxicities is essential. However, unlike many specialties, morbidity and mortality reviews procedures are not developed as part of quality governance programs in radiation therapy departments for the monitoring of toxicity which sometimes hinder the patients' quality of life. One French survey published within the framework of the project entitled Prospective Registration of Morbidity and Mortality, Individual Radiosensitivity and Radiation Technique (Proust), conclude that there was a lack of knowledge of morbidity and mortality reviews and considerable confusion between these reviews and other quality processes without perspective for the local morbidity and mortality reviews development in a large number of the participated centers. In this article, we will discuss the procedure of the "ideal morbidity and mortality reviews" and its implementation through a monocentric experience started in 2015. Thus, the Proust project is a unique opportunity to implement and standardize a national morbidity and mortality reviews implementation in radiation therapy departments by involving the French regions.
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Affiliation(s)
- Y Belkacemi
- Service d'oncologie-radiothérapie, hôpital Henri-Mondor, AP-HP, université Paris-Est Créteil, Créteil, France; Équipe i-Biot, unité 955, Inserm, IMRB, université Paris-Est Créteil, Créteil, France.
| | - K Debbi
- Service d'oncologie-radiothérapie, hôpital Henri-Mondor, AP-HP, université Paris-Est Créteil, Créteil, France; Équipe i-Biot, unité 955, Inserm, IMRB, université Paris-Est Créteil, Créteil, France
| | - C Besnard
- Service d'oncologie-radiothérapie, hôpital Henri-Mondor, AP-HP, université Paris-Est Créteil, Créteil, France
| | - N Grellier
- Service d'oncologie-radiothérapie, hôpital Henri-Mondor, AP-HP, université Paris-Est Créteil, Créteil, France
| | - G Fonteneau
- Service d'oncologie-radiothérapie, hôpital Henri-Mondor, AP-HP, université Paris-Est Créteil, Créteil, France
| | - L Colson-Durand
- Service d'oncologie-radiothérapie, hôpital Henri-Mondor, AP-HP, université Paris-Est Créteil, Créteil, France; Service d'oncologie-radiothérapie, Institut oncologique Paris-Nord, Sarcelles, France
| | - D Lerouge
- Service d'oncologie-radiothérapie, centre François-Baclesse, Caen, France
| | - C Durdux
- Service d'oncologie-radiothérapie, hôpital européen Georges-Pompidou, AP-HP, université Paris-Cité, Paris, France
| | - F Campana
- Service d'oncologie-radiothérapie, institut Hartmann, Levallois-Perret, France
| | - P Pons
- Service d'oncologie-radiothérapie, institut Hartmann, Levallois-Perret, France
| | - I Flandin
- Service d'oncologie-radiothérapie, centre hospitalier universitaire de Grenoble, Grenoble, France
| | - D Pasquier
- Département universitaire d'oncologie-radiothérapie, centre Oscar-Lambret, UMR 9189, université de Lille, Centre de recherche en informatique, signal et automatique de Lille (Cristal), Lille, France
| | - R de Crevoisier
- Service d'oncologie-radiothérapie, centre Eugène-Marquis, Rennes, France
| | - T Wachter
- Service d'oncologie-radiothérapie, centre hospitalier général d'Orléans, Orléans, France
| | - S Thureau
- Service d'oncologie-radiothérapie, centre Henri-Becquerel, QuantIF Litis unit EA 4108, université de Rouen, Rouen, France
| | - G Noël
- Service d'oncologie-radiothérapie, institut de cancérologie Strasbourg Europe (ICANS), université de Strasbourg, Strasbourg, France
| | | | - A Petit
- Service d'oncologie-radiothérapie, institut Bergonié, Bordeaux, France
| | - S Supiot
- Service d'oncologie-radiothérapie, institut de cancérologie de l'Ouest, centre René-Gauducheau, université de Nantes, Nantes, France
| | - D Azria
- Service d'oncologie-radiothérapie, Institut du cancer de Montpellier (ICM), université de Montpellier, Institut de recherche sur le cancer de Montpellier (IRCM), unit 1194, Inserm, Montpellier, France
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Alexander-Savino CV, Morrell DS, Mervak JE, Bowers EV. Characteristics of Dermatology Residency Program Morbidity and Mortality Conferences: A Survey of Program Directors. JMIR DERMATOLOGY 2023; 6:e45194. [PMID: 37632923 PMCID: PMC10425815 DOI: 10.2196/45194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 06/08/2023] [Accepted: 07/14/2023] [Indexed: 08/28/2023] Open
Affiliation(s)
- Carolina V Alexander-Savino
- State University of New York Upstate Medical University, Syracuse, NY, United States
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Dean S Morrell
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Julie E Mervak
- Department of Dermatology, University of Michigan, Ann Arbor, MI, United States
| | - Edith V Bowers
- Department of Dermatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Miller KA, Nagler J, Wolff M, Schumacher DJ, Pusic MV. It Takes a Village: Optimal Graduate Medical Education Requires a Deliberately Developmental Organization. PERSPECTIVES ON MEDICAL EDUCATION 2023; 12:282-293. [PMID: 37520509 PMCID: PMC10377742 DOI: 10.5334/pme.936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 07/06/2023] [Indexed: 08/01/2023]
Abstract
Coaching is proposed as a means of improving the learning culture of medicine. By fostering trusting teacher-learner relationships, learners are encouraged to embrace feedback and make the most of failure. This paper posits that a cultural shift is necessary to fully harness the potential of coaching in graduate medical education. We introduce the deliberately developmental organization framework, a conceptual model focusing on three core dimensions: developmental communities, developmental aspirations, and developmental practices. These dimensions broaden the scope of coaching interactions. Implementing this organizational change within graduate medical education might be challenging, yet we argue that embracing deliberately developmental principles can embed coaching into everyday interactions and foster a culture in which discussing failure to maximize learning becomes acceptable. By applying the dimensions of developmental communities, aspirations, and practices, we present a six-principle roadmap towards transforming graduate medical education training programs into deliberately developmental organizations.
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Affiliation(s)
- Kelsey A. Miller
- Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - Joshua Nagler
- Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - Margaret Wolff
- Emergency Medicine and Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniel J. Schumacher
- Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Martin V. Pusic
- Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, USA
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Hachen M, Musy SN, Fröhlich A, Jeitziner MM, Kindler A, Perrodin S, Zante B, Zúñiga F, Simon M. Developing a reflection and analysis tool (We-ReAlyse) for readmissions to the intensive care unit: A quality improvement project. Intensive Crit Care Nurs 2023; 77:103441. [PMID: 37178615 DOI: 10.1016/j.iccn.2023.103441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/29/2023] [Accepted: 04/14/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Readmissions to the intensive care unit are associated with poorer patient outcomes and health prognoses, alongside increased lengths of stay and mortality risk. To improve quality of care and patients' safety, it is essential to understand influencing factors relevant to specific patient populations and settings. A standardized tool for systematic retrospective analysis of readmissions would help healthcare professionals understand risks and reasons affecting readmissions; however, no such tool exists. PURPOSE This study's purpose was to develop a tool (We-ReAlyse) to analyze readmissions to the intensive care unit from general units by reflecting on affected patients' pathways from intensive care discharge to readmission. The results will highlight case-specific causes of readmission and potential areas for departmental- and institutional-level improvements. METHOD A root cause analysis approach guided this quality improvement project. The tool's iterative development process included a literature search, a clinical expert panel, and a testing in January and February 2021. RESULTS The We-ReAlyse tool guides healthcare professionals to identify areas for quality improvement by reflecting the patient's pathway from the initial intensive care stay to readmission. Ten readmissions were analyzed by using the We-ReAlyse tool, resulting in key insights about possible root causes like the handover process, patient's care needs, the resources on the general unit and the use of different electronic healthcare record systems. CONCLUSIONS The We-ReAlyse tool provides a visualization/objectification of issues related to intensive care readmissions, gathering data upon which to base quality improvement interventions. Based on the information on how multi-level risk profiles and knowledge deficits contribute to readmission rates, nurses can target specific quality improvements to reduce those rates. IMPLICATIONS FOR CLINICAL PRACTICE AND RESEARCH With the We-ReAlyse tool, we have the opportunity to collect detailed information about ICU readmissions for an in-depth analysis. This will allow health professionals in all involved departments to discuss and either correct or cope with the identified issues. In the long term, this will allow continuous, concerted efforts to reduce and prevent ICU readmissions. To obtain more data for analysis and to further refine and simplify the tool, it may be applied to larger samples of ICU readmissions. Furthermore, to test its generalizability, the tool should be applied to patients from other departments and other hospitals. Adapting it to an electronic version would facilitate the timely and comprehensive collection of necessary information. Finally, the tool's emphasis comprises reflecting on and analyzing ICU readmissions, allowing clinicians to develop interventions targeting the identified problems. Therefore, future research in this area will require the development and evaluation of potential interventions.
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Affiliation(s)
- Martina Hachen
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Sarah N Musy
- Institute of Nursing Science, University of Basel, Basel, Switzerland.
| | - Annina Fröhlich
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Marie-Madlen Jeitziner
- Institute of Nursing Science, University of Basel, Basel, Switzerland; Department of Intensive Care Medicine, Inselspital, University Hospital Bern, Bern, Switzerland.
| | - Angela Kindler
- Department of Physiotherapy, Inselspital, University Hospital Bern, Bern, Switzerland.
| | - Stéphanie Perrodin
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Bjoern Zante
- Department of Intensive Care Medicine, Inselspital, University Hospital Bern, Bern, Switzerland.
| | - Franziska Zúñiga
- Institute of Nursing Science, University of Basel, Basel, Switzerland.
| | - Michael Simon
- Institute of Nursing Science, University of Basel, Basel, Switzerland.
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de Vos MS, Verhagen MJ, Hamming JF. The Morbidity and Mortality Conference: A Century-Old Practice with Ongoing Potential for Future Improvement. Eur J Pediatr Surg 2023; 33:114-119. [PMID: 36720246 PMCID: PMC10023258 DOI: 10.1055/s-0043-1760836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To discuss practical strategies to consider for morbidity and mortality conferences (M&M). MATERIALS AND METHODS This article reflects on (i) insights that can be drawn from the M&M literature, (ii) practical aspects to consider when organizing M&M, and (iii) possible future directions for development for this long-standing practice for routine reflection. RESULTS M&M offers the opportunity to learn from past cases in order to improve the care delivered to future patients, thereby serving both educational and quality improvement purposes. For departments seeking to implement or improve local M&M practice, it is difficult that a golden standard or best practice for M&M is nonexistent. This is partly because comparative research on different formats is hampered by the lack of objective outcome measures to evaluate the effectiveness of M&M. Common practical suggestions include the use of (i) a skillful and active moderator; (ii) structured formats for case presentation and discussion; and (iii) a dedicated committee to guide improvement plans that ensue from the meeting. M&M practice is affected by various sociological factors, for which qualitative research methods seem most suitable, but in the M&M literature these are sparsely used. Moreover, aspects influencing an open and blame-free atmosphere underline how local teams should tailor the format to best fit the local context and culture. CONCLUSION This article presents practice guidance on how to organize and carry out M&M This practice for routine reflection needs to be tailored to the local setting, with attention for various sociological factors that are at play.
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Affiliation(s)
- Marit S. de Vos
- Directorate of Quality and Patient Safety, Leiden University Medical Center, Rotterdam, the Netherlands
- Address for correspondence Marit S. de Vos, MD, PhD Directorate of Quality and Patient Safety, Leiden University Medical CenterAlbinusdreef 2, 2333 ZA Leidenthe Netherlands
| | - Merel J. Verhagen
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jaap F. Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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18
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Lefèvre B, Legoff A, Boutrou M, Goehringer F, Ngueyon-Sime W, Chirouze C, Revest M, Vernet Garnier V, Duval X, Delahaye F, Le Moing V, Selton-Suty C, Filippetti L, Hoen B, Agrinier N. Staphylococcus aureus endocarditis: Identifying prognostic factors using a method derived from morbidity and mortality conferences. Front Med (Lausanne) 2022; 9:1053278. [PMID: 36561723 PMCID: PMC9763316 DOI: 10.3389/fmed.2022.1053278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Objectives Lethality of Staphylococcus aureus (Sa) infective endocarditis (IE) is high and might be due to yet unidentified prognostic factors. The aim of this study was to search for new potential prognostic factors and assess their prognostic value in SaIE. Materials and methods We used a two-step exploratory approach. First, using a qualitative approach derived from mortality and morbidity conferences, we conducted a review of the medical records of 30 patients with SaIE (15 deceased and 15 survivors), randomly extracted from an IE cohort database (NCT03295045), to detect new factors of possible prognostic interest. Second, we collected quantitative data for these factors in the entire set of SaIE patients and used multivariate Cox models to estimate their prognostic value. Results A total of 134 patients with modified Duke definite SaIE were included, 64 of whom died during follow-up. Of the 56 candidate prognostic factors identified at the first step, 3 had a significant prognostic value in multivariate analysis: the prior use of non-steroidal anti-inflammatory drugs [aHR 3.60, 95% CI (1.59-8.15), p = 0.002]; the non-performance of valve surgery when indicated [aHR 1.85, 95% CI (1.01-3.39), p = 0.046]; and the decrease of vegetation size on antibiotic treatment [aHR 0.34, 95% CI (0.12-0.97), p = 0.044]. Conclusion We identified three potential SaIE prognostic factors. These results, if externally validated, might eventually help improve the management of patients with SaIE.
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Affiliation(s)
- Benjamin Lefèvre
- Université de Lorraine, CHRU-Nancy, Service des Maladies Infectieuses et Tropicales, Nancy, France,Université de Lorraine, APEMAC, Nancy, France,*Correspondence: Benjamin Lefèvre,
| | - Antoine Legoff
- Université de Lorraine, CHRU-Nancy, Service des Maladies Infectieuses et Tropicales, Nancy, France
| | - Mathilde Boutrou
- CH Andrée Rosemon, Unité de Maladies Infectieuses et Tropicales, Cayenne, France
| | | | - Willy Ngueyon-Sime
- CHRU-Nancy, Institut National de la Sante et de la Recherche Medicale (INSERM), Université de Lorraine, CIC, Epidémiologie Clinique, Nancy, France
| | - Catherine Chirouze
- UMR 6249 CNRS-UFC Chrono-environnement, Service de Maladies Infectieuses, CHRU Besançon, Besançon, France
| | - Matthieu Revest
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France,CIC-Institut National de la Sante et de la Recherche Medicale (INSERM) 1414, Pontchaillou University Hospital, Rennes, France,University of Rennes, Institut National de la Sante et de la Recherche Medicale (INSERM), Bacterial Regulatory RNAs and Medicine, UMR 1230, Rennes, France
| | | | - Xavier Duval
- Institut National de la Sante et de la Recherche Medicale (INSERM) CIC 1425, Bichat–Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,Institut National de la Sante et de la Recherche Medicale (INSERM), UMR-1137, IAME, Paris University, Paris, France,Université de Paris, IAME, Institut National de la Sante et de la Recherche Medicale (INSERM), Paris, France,Centre for Clinical Investigation, Assistance Publique-Hôpitaux de Paris, Bichat-Claude Bernard University Hospital, Paris, France
| | | | - Vincent Le Moing
- Montpellier University Hospital, Department of Infectious and Tropical Diseases, Montpellier, France
| | | | | | - Bruno Hoen
- Université de Lorraine, CHRU-Nancy, Service des Maladies Infectieuses et Tropicales, Nancy, France,Université de Lorraine, APEMAC, Nancy, France
| | - Nelly Agrinier
- Université de Lorraine, APEMAC, Nancy, France,CHRU-Nancy, Institut National de la Sante et de la Recherche Medicale (INSERM), Université de Lorraine, CIC, Epidémiologie Clinique, Nancy, France
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Lahnaoui O, EL Bahaoui N, El Atiq S, Amrani L, Majbar MA, Benkabbou A, Mohsine R, Souadka A. Beware of lethal Wernicke's encephalopathy after cytoreductive surgery with HIPEC for peritoneal pseudomyxoma: Case report of morbidity and mortality review. Int J Surg Case Rep 2022; 98:107500. [PMID: 36029660 PMCID: PMC9424939 DOI: 10.1016/j.ijscr.2022.107500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/07/2022] [Accepted: 08/07/2022] [Indexed: 11/26/2022] Open
Abstract
Background Pseudomyxoma peritonei (PMP) arising from the appendix is a rare entity. Complete cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is the only established curative treatment, and is reputedly linked to high morbidity and mortality. We report, to our knowledge, the first case of delayed lethal Wernicke encephalopathy (WE) complicating CRS with HIPEC for an appendicular PMP. WE, caused by a thiamine deficiency, is characterized by ataxia, nystagmus and changes in consciousness. Methods A patient underwent complete CRS with HIPEC for a low grade mucinous appendicular tumor at the stage of PMP with a peritoneal index of 31, and was readmitted at POD 36 for persistent vomiting and vague neurological symptoms of mental confusion. The classic triad of WE appeared tardily. Although thiamine substitution was promptly applied, the patient died at POD53. Conclusion WE is an uncommon and severe neurological disorder with a mortality rate up to 20 % and only 16 % of treated patients can fully recover. This diagnosis should always be anticipated in patients undergoing major surgery such as CRS- HIPEC. Efficient treatment should be quickly introduced in order to avoid a lethal outcome. Pseudomyxoma peritonei is a rare entity, treatment consists of complete cytoreductive surgery and hyperthermic intra peritoneal chemotherapy with positive effects established in the literature. However, this combined treatment is a complex procedure and is associated with high morbidity and mortality. Wernicke’s encephalopathy is a rare complication of this procedure and has been reported once in the literature. Wernicke’s encephalopathy is a diagnosis to keep in mind and anticipate in patients undergoing cytoreductive surgery and hyperthermic intra peritoneal chemotherapy
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Tuma F. Maximizing the educational potential of Morbidity and Mortality Conferences. Can J Surg 2022; 65:E619-E621. [PMID: 36130804 PMCID: PMC9503565 DOI: 10.1503/cjs.011621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 11/03/2022] Open
Abstract
Morbidity and Mortality Conferences (MMCs) are considered to be one of the most powerful education tools for clinicians; however, their current structure in many health care facilities focuses predominantly on quality and outcome improvement, and their retrospective approach limits their educational component. This article discusses how MMCs can be modified to enhance the educational outcomes and provide a valuable training session that adds to the quality control value.
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Affiliation(s)
- Faiz Tuma
- From the Department of Surgery, Central Michigan University College of Medicine, Saginaw, Mich.
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21
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Lahnaoui O, Souadka A, El Ahmadi B, Ghannam A, Belkhadir Z, Amrani L, Benkabbou A, Mohsine R, Majbar MA. Evaluation of the implementation of a quality improvement program through morbidity and mortality reviews in a developing country. Ann Med Surg (Lond) 2022; 80:103987. [PMID: 35855883 PMCID: PMC9287764 DOI: 10.1016/j.amsu.2022.103987] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 11/25/2022] Open
Abstract
Background Morbidity and mortality reviews represent an opportunity to discuss adverse events and healthcare issues. Aim: Report the first experience of implementing a procedure of MMR, and assess its impact on quality improvement. Methods From July 2019 to December 2019, members of the surgical and ICU departments designed and implemented a regular procedure of MMR. Cases of severe postoperative complications after curative resection for digestive cancer were selected to be presented by a surgical resident and discussed in an interdisciplinary conference following a standardized presentation based on an analysis tool adapted from the ALARM framework. Process was assessed by the number of MMRs held, number and type of recommendations issued and implemented. Results Among 13 serious complications during the study period, 10 were discussed. The “Tasks” category was activated in 90% of the cases where lack or misuse of protocols was identified in 90% of the events discussed. Test results availability or accuracy were incarnated in 30% of cases. Poor communication was a contributing factor in 60% of the cases. Written medical records were defective in 40% of the cases. From 16 recommendations for improvement emitted, 87.5% (14/16) were translated into projects and successfully implemented. Conclusions a standardized and regular procedure of morbidity and mortality reviews in a tertiary care facility in a developing country allowed a significant improvement in patient care through quality initiatives implementation. MMRs might be a strong tool for the improvement of surgical care particularly for low-mid income countries. Morbidity and mortality reviews (MMR) are an opportunity to discuss adverse events and healthcare issues. Experience of implementing a procedure of MMR in a tertiary care facility in a developing country. A standardized and regular procedure allowed a significant improvement in patient care through quality initiatives. MMR might be a strong tool for the improvement of surgical care particularly for low-mid income countries.
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Thai T, Louden DKN, Adamson R, Dominitz JA, Doll JA. Peer evaluation and feedback for invasive medical procedures: a systematic review. BMC MEDICAL EDUCATION 2022; 22:581. [PMID: 35906652 PMCID: PMC9335975 DOI: 10.1186/s12909-022-03652-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 07/19/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND There is significant variability in the performance and outcomes of invasive medical procedures such as percutaneous coronary intervention, endoscopy, and bronchoscopy. Peer evaluation is a common mechanism for assessment of clinician performance and care quality, and may be ideally suited for the evaluation of medical procedures. We therefore sought to perform a systematic review to identify and characterize peer evaluation tools for practicing clinicians, assess evidence supporting the validity of peer evaluation, and describe best practices of peer evaluation programs across multiple invasive medical procedures. METHODS A systematic search of Medline and Embase (through September 7, 2021) was conducted to identify studies of peer evaluation and feedback relating to procedures in the field of internal medicine and related subspecialties. The methodological quality of the studies was assessed. Data were extracted on peer evaluation methods, feedback structures, and the validity and reproducibility of peer evaluations, including inter-observer agreement and associations with other quality measures when available. RESULTS Of 2,135 retrieved references, 32 studies met inclusion criteria. Of these, 21 were from the field of gastroenterology, 5 from cardiology, 3 from pulmonology, and 3 from interventional radiology. Overall, 22 studies described the development or testing of peer scoring systems and 18 reported inter-observer agreement, which was good or excellent in all but 2 studies. Only 4 studies, all from gastroenterology, tested the association of scoring systems with other quality measures, and no studies tested the impact of peer evaluation on patient outcomes. Best practices included standardized scoring systems, prospective criteria for case selection, and collaborative and non-judgmental review. CONCLUSIONS Peer evaluation of invasive medical procedures is feasible and generally demonstrates good or excellent inter-observer agreement when performed with structured tools. Our review identifies common elements of successful interventions across specialties. However, there is limited evidence that peer-evaluated performance is linked to other quality measures or that feedback to clinicians improves patient care or outcomes. Additional research is needed to develop and test peer evaluation and feedback interventions.
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Affiliation(s)
| | | | - Rosemary Adamson
- University of Washington, Seattle, WA, USA
- VA Puget Sound Health Care System, Seattle, WA, USA
| | - Jason A Dominitz
- University of Washington, Seattle, WA, USA
- VA Puget Sound Health Care System, Seattle, WA, USA
- National Gastroenterology and Hepatology Program, Veterans Affairs Administration, Washington, DC, USA
| | - Jacob A Doll
- University of Washington, Seattle, WA, USA.
- VA Puget Sound Health Care System, Seattle, WA, USA.
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The Disparity Morbidity and Mortality Conference: A Mechanism to Identify and Remedy Healthcare Inequity. Ann Surg 2022; 276:e205-e207. [PMID: 35837954 DOI: 10.1097/sla.0000000000005570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Verhagen MJ, de Vos MS, Smaggus A, Hamming JF. Measuring What Matters at Morbidity and Mortality Conferences: A Scoping Review of Effectiveness Measures. J Patient Saf 2022; 18:e760-e768. [PMID: 35617601 DOI: 10.1097/pts.0000000000000936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Efforts to study morbidity and mortality conferences (M&MC) are hampered by the lack of rigorous instruments to assess the effectiveness of the conferences for the purpose of quality improvement and medical education. This might limit further advancement of the practice. The aim of this scoping review was to determine commonly used effectiveness measures of M&MC in the literature. METHOD A scoping review was performed of quantitative, qualitative, and mixed methods studies of M&MC, using databases from PubMed, Emcare, Embase, Web of Science, and the Cochrane library. Studies were included if an outcome was described after a general evaluation or an intervention to M&MC. Study quality was assessed with the Quality Assessment Tool for Studies with Diverse Designs. RESULTS A total of 43 articles were included in the review. The majority used a quantitative (n = 23) or mixed (n = 17) design, with surveys as the most frequent method used for data collection (n = 29). The overall Quality Assessment Tool for Studies with Diverse Designs scores were modest (64%). Outcome measures used to evaluate the effectiveness of M&MC were clustered in the following categories: "participant experiences," "characteristics of the meeting," "medical knowledge," "actions for improvement," and "clinical outcomes." CONCLUSIONS This review found a wide variety of effectiveness measures for M&MC. Rather than using isolated measures, approaches that combine multiple effectiveness measures could offer a more comprehensive assessment of M&MC. Although there was a preference for quantitative metrics, this fails to seize the opportunity of qualitative methods to yield insights into sociological purposes of M&MC, such as building professional identities and safety culture.
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Affiliation(s)
| | - Marit S de Vos
- Directorate of Quality and Patient Safety, Leiden University Medical Center, Leiden, the Netherlands
| | - Andrew Smaggus
- Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
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Lützeler R, Werner A, Neuner V, Plank SS. Process-Oriented Risk Analysis (PORA) in Academic Surgical Departments in Germany. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03451-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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de Loizaga SR, Clarke-Myers K, R Khoury P, Hanke SP. Parent Participation in Morbidity and Mortality Review: Parent and Physician Perspectives. J Patient Exp 2022; 9:23743735221102674. [PMID: 35647267 PMCID: PMC9134398 DOI: 10.1177/23743735221102674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This study examined Morbidity and Mortality (M&M) review practices and perspectives of physicians and parents regarding parent participation in M&M review. Surveys were distributed to parents of children with a prior hospitalization for congenital heart disease (CHD) and physicians caring for pediatric CHD patients. Response distributions and Fisher’s exact tests were performed to compare parent and physician responses. Qualitative survey data were thematically analyzed. Ninety-two parent and 36 physician surveys were analyzed. Physicians reported parent input or participation was rarely sought in M&M review. Parents with direct experience of adverse events or death of their child reported providers discussed events with them in a timely manner and answered their questions; however, nearly half wished their healthcare team had done something differently during the disclosure. There was no statistical difference between groups regarding transparency ( P = .37, .79); however, there was a significant difference in perspectives regarding parental involvement in the M&M review ( P < .001). Common themes important to parents which emerged from the qualitative analysis were being adequately informed, feeling their perspectives were acknowledged and respected, having attentive and empathetic providers, and receiving consistent messaging. Although rarely included in current practice, parent participation in M&M could offer unique insight and increase accountability to proposed change elucidated by M&M review.
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Affiliation(s)
| | | | - Philip R Khoury
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Samuel P Hanke
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Michel N, Bui-Xuan B, Bapteste L, Rimmele T, Lilot M, Chollet F, Favre H, Duclos A, Michel P. Implementation of an in situ simulation-based training adapted from Morbidity and Mortality conference cases: effect on the occurrence of adverse events-study protocol of a cluster randomised controlled trial. Trials 2022; 23:106. [PMID: 35109900 PMCID: PMC8812171 DOI: 10.1186/s13063-022-06040-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 01/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Morbidity and Mortality conference provides the necessary improvement measures for patient safety. However, they are an underused resource mainly because the conclusions to be drawn from the discussion and their implications for practice are not always well integrated by inpatient care teams. We therefore propose in this study two interventions to optimise their effectiveness: a passive feedback with wide dissemination by e-mail and/or on paper of the results of the Morbidity and Mortality conference to inpatient care teams and an active feedback with in situ inter-professional simulation-training programme in which scenarios will be based on cases studied in Morbidity and Mortality conference. In the present study, we hypothesise that the greatest reduction the occurrence of adverse event will be in the active feedback arm. METHODS A cluster randomised controlled study will be performed at four study sites. The unit of randomisation is wards within the study sites. Fifteen wards will be randomly assigned to passive feedback, active feedback, or a standard MMC (control arm). Passive feedback and active feedback arms will be compared to standard arm in terms of occurrence of adverse events. The trigger tool methodology used to identify adverse events is a retrospective review of inpatient records using "triggers": an adverse event is defined as a patient's stay with at least one positive trigger. DISCUSSION The in situ simulation training based on cases processed in Morbidity and Mortality conference is built according to the main topics identified for the successful implementation of healthcare simulation in patient safety programmes: technical skills, nontechnical skills, assessment, effectiveness, and system probing. The in situ simulation-training programme conducted as part of the study has the potential to improve patient safety during hospitalisation. We therefore expect the greatest reduction in the occurrence of adverse events in patients hospitalised in the active feedback arm. This expected result would have a direct impact on patient safety and would place in situ simulation at the highest level of the Kirkpatrick model. TRIAL REGISTRATION Clinicaltrials.gov NCT02771613. Registered on May 12, 2016. All items from the WHO Trial Registration Data Set can be found within the protocol.
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Affiliation(s)
- Nicolas Michel
- Departments of Anesthesia and Intensive Care, Hospices Civils of Lyon, Lyon, France.
| | - Bernard Bui-Xuan
- Departments of Anesthesia and Intensive Care, Hospices Civils of Lyon, Lyon, France
| | - Lionel Bapteste
- Departments of Anesthesia and Intensive Care, Hospices Civils of Lyon, Lyon, France
| | - Thomas Rimmele
- Departments of Anesthesia and Intensive Care, Hospices Civils of Lyon, Lyon, France.,Centre Lyonnais d'Enseignement par Simulation en Santé (CLESS, high fidelity medical simulation center), SAMSEI, Lyon, France.,EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Pi3), Claude Bernard Lyon 1 University-Biomérieux-Hospices Civils of Lyon, Lyon, France
| | - Marc Lilot
- Departments of Anesthesia and Intensive Care, Hospices Civils of Lyon, Lyon, France.,Centre Lyonnais d'Enseignement par Simulation en Santé (CLESS, high fidelity medical simulation center), SAMSEI, Lyon, France.,Department of Quality, patient safety and patient partnership, Hospices civils de Lyon, France, Université Claude Bernard Lyon 1, Health Services and Performance Research Lab (EA 7425 HESPER), Villeurbanne, France
| | | | - Hélène Favre
- Department of Quality, patient safety and patient partnership, Hospices civils de Lyon, France, Université Claude Bernard Lyon 1, Health Services and Performance Research Lab (EA 7425 HESPER), Villeurbanne, France
| | - Antoine Duclos
- Department of Quality, patient safety and patient partnership, Hospices civils de Lyon, France, Université Claude Bernard Lyon 1, Health Services and Performance Research Lab (EA 7425 HESPER), Villeurbanne, France.,Health Data Department, Hospices Civils de Lyon, Lyon, France
| | - Philippe Michel
- Department of Quality, patient safety and patient partnership, Hospices civils de Lyon, France, Université Claude Bernard Lyon 1, Health Services and Performance Research Lab (EA 7425 HESPER), Villeurbanne, France.,Quality Safety and Customer Relationship Department, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Hesper EA 7425, F -, 69003, Lyon, France
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Characterization and evaluation of a pharmacy morbidity, mortality, and improvement case conference for drug safety optimization: An 8‐year experience. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Levy AE, Whittington MD, Anstett TJ, Simon ST, Wentworth A, Carter JE, Ho PM. A Systems-Based Morbidity and Mortality Conference Was Associated With a Transient Reduction in ECG Completion Times. Qual Manag Health Care 2022; 31:28-33. [PMID: 34724456 PMCID: PMC9050961 DOI: 10.1097/qmh.0000000000000319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES During its monthly morbidity and mortality conference (MMC), the University of Colorado Division of Cardiology reviewed a "near-miss" patient safety event involving the delayed completion of a Stat-priority (ie, statim, meaning high priority) electrocardiogram (ECG). Because critical and interprofessional stakeholders participated in the conference, we hypothesized that the MMC would be associated with reduced ECG completion times. METHODS Data were collected for in-hospital ECGs performed at the University of Colorado Hospital between January 1, 2017, and June 30, 2018. An interrupted time series analysis was used to estimate the immediate and ongoing impact of the MMC (held on February 28, 2018) on ECG completion times, stratified by order priority (Stat, Now, or Routine). The percentage of delayed Stat-priority ECGs was analyzed as a secondary outcome. RESULTS Before the MMC, ECG completion times were stable for all order priorities ( P > .2), but the proportion of delayed Stat-priority ECGs increased from 5% in January 2017 to 20% in February 2018 ( P < .01). The MMC was associated with an immediate reduction in average daily ECG completion times for Routine (-18.4 minutes, P = .03) and Now (-8 minutes, P = .024) priority ECGs. No reduction was seen for Stat ECGs ( P = .97), though the percentage of delayed Stat ECGs stopped increasing ( P = .63). In the post-MMC period, completion times for Routine-priority ECGs increased and approached pre-MMC levels. CONCLUSIONS The MMC was associated with an immediate, but temporary, improvement in ECG completion times. Although the observed clinical benefit of the MMC is novel, these data support the need for more durable reforms to sustain initial improvements.
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Affiliation(s)
- Andrew E. Levy
- University of Colorado School of Medicine, Aurora, CO, USA
- Denver Health and Hospital Authority, Denver, CO, USA
| | | | | | | | | | | | - P. Michael Ho
- University of Colorado School of Medicine, Aurora, CO, USA
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Health Equity Morbidity and Mortality Conferences in Obstetrics and Gynecology. Obstet Gynecol 2021; 138:918-923. [PMID: 34735374 DOI: 10.1097/aog.0000000000004575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/19/2021] [Indexed: 11/26/2022]
Abstract
Maternal mortality and morbidity continue to occur at unacceptably high levels in the United States, with communities of color experiencing significantly higher rates than their White counterparts, even after adjustment for confounding factors such as socioeconomic status. Many obstetrics and gynecology departments across the country have begun to incorporate routine discussion and analysis of health equity into peer review and educational processes, including grand rounds and morbidity and mortality conferences. Despite the desire and drive, there is little published guidance on best practices for incorporation of an equity component into these conferences. This document outlines the current processes at four academic institutions to highlight the variety of ways in which health equity and social justice can be incorporated when analyzing patient experiences and health outcomes. This commentary also provides a list of specific recommendations based on the combined experiences at these institutions so that others across the country can incorporate principles of health equity into their peer-review processes.
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Andrews RT, DiGeronimo R, Virk HS, Goldman RE, Pillai R, Rao S, King E, Shah A, Vu CT. A SURVEY OF INTERVENTIONAL RADIOLOGISTS REGARDING THE USE OF MORBIDITY AND MORTALITY CONFERENCING IN DEPARTMENTAL QUALITY IMPROVEMENT PROGAMS. J Vasc Interv Radiol 2021; 33:150-158.e1. [PMID: 34774929 DOI: 10.1016/j.jvir.2021.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/24/2021] [Accepted: 10/26/2021] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Investigate the degree to which Morbidity and Mortality (M&M) conferencing is utilized in Interventional Radiology (IR), identify impediments to its adoption, and assess the experience of those using this tool. MATERIALS AND METHODS Members of the Society of Interventional Radiology (SIR) were offered a 10-question survey of practices and experiences regarding M&M conferencing within their Quality Assessment (QA) programs. RESULTS Among 604 respondents, 37.8% were university-based practitioners and 60% from outside of university practices. 43% of respondents reported practicing 100% IR, with 28.5% practicing 75-99% and 11% practicing IR less than 50% of the time. The use of M&M conferencing was significantly greater in university practices (90.7%) than in non-university practices (37.1%) and among practitioners performing at least 75% IR (71.2%) than among those practicing less than 75% (28.8%). Conferences were held monthly (66.6%) or more often and the majority (56%) of the events identified were scored using the SIR severity score. Roughly 20% of M&M conferences were multidisciplinary, shared most commonly with vascular surgery. The reasons cited for not using M&M included lack of time and the logistical challenges of the process. However, among those who participate in M&M conferences, the QA goals of the conference were met at very high rates. CONCLUSIONS M&M conferencing is well established in university IR programs and among full-time practitioners, but much less so elsewhere. For those sites that do not utilize M&M conferencing, there may be considerable benefit to addressing the obstacles that are limiting their implementation of this tool.
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Affiliation(s)
- R Torrance Andrews
- Department of Vascular and Interventional Radiology, University of California, Davis Medical Center, 4860 Y St, Suite 3100, Sacramento, CA 95817.
| | - Ryan DiGeronimo
- Department of Vascular and Interventional Radiology, University of California, Davis Medical Center, 4860 Y St, Suite 3100, Sacramento, CA 95817
| | - Harjot Singh Virk
- Department of Vascular and Interventional Radiology, University of California, Davis Medical Center, 4860 Y St, Suite 3100, Sacramento, CA 95817
| | - Roger E Goldman
- Department of Vascular and Interventional Radiology, University of California, Davis Medical Center, 4860 Y St, Suite 3100, Sacramento, CA 95817
| | - Rex Pillai
- Department of Vascular and Interventional Radiology, University of California, Davis Medical Center, 4860 Y St, Suite 3100, Sacramento, CA 95817
| | - Sishir Rao
- Department of Vascular and Interventional Radiology, University of California, Davis Medical Center, 4860 Y St, Suite 3100, Sacramento, CA 95817
| | - Eric King
- Department of Vascular and Interventional Radiology, University of California, Davis Medical Center, 4860 Y St, Suite 3100, Sacramento, CA 95817
| | - Amol Shah
- Department of Vascular and Interventional Radiology, University of California, Davis Medical Center, 4860 Y St, Suite 3100, Sacramento, CA 95817
| | - Catherine Tram Vu
- Department of Vascular and Interventional Radiology, University of California, Davis Medical Center, 4860 Y St, Suite 3100, Sacramento, CA 95817
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Gabrysz-Forget F, Zahabi S, Young M, Nepomnayshy D, Nguyen LH. "It's a Big Part of Being Good Surgeons": Surgical Trainees' Perceptions of Error Recovery in the Operating Room. JOURNAL OF SURGICAL EDUCATION 2021; 78:2020-2029. [PMID: 33888440 DOI: 10.1016/j.jsurg.2021.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 03/13/2021] [Accepted: 03/21/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND The burden of surgical error is high - errors threaten patient safety, lead to increased economic costs to society, and contribute to physician and resident burnout. To date, the majority of work has focused on strategies for reducing the incidence of surgical error, however, total error eradication remains unrealistic. Errors are, to some extent, unavoidable. Adequate preparation for practice should include optimal ways to manage and recover from errors; yet, these skills are rarely taught or assessed. OBJECTIVES This study aims to explore residents' perceptions and experiences of surgical error recovery. More specifically, we documented participant definitions of error recovery, and explored factors that were perceived to influence error recovery experiences and training in the operating room. METHOD Guided by a qualitative descriptive approach, we conducted semi-structured interviews with residents and fellows in surgical specialties in Canada and the United States. Purposive and snowball sampling were used to recruit residents and fellows in postgraduate year 1 to 5. Interviews were transcribed, analyzed and inductively coded. RESULTS A total of 15 residents and fellows participated. When exploring the importance of error recovery for the trainees, competency and safety emerged as main themes, with error recovery being considered an indicator of overall surgical competency. Data concerning factors perceived to influence error recovery training were grouped under 4 major themes: (1) supervision (supervisor-related factors such as attending behaviors and reactions to errors), (2) self (factors such as self-assessed competency), (3) surgical context (factors related to the specific surgery or patient), and (4) situation safeness. Situational safeness was identified as a transversal theme describing factors to be considered when balancing between patient safety and the learning benefits of error recovery training. CONCLUSION Error recovery was considered to be an important skill for safe surgical practice and was considered an important educational target for learners during surgical training. Trainees' opportunities to learn to recover from technical errors in the OR are perceived to be influenced by several factors, leading to variable experiences and inconsistent opportunities to practice error recovery skills. Focusing on factors related to "supervision," "self," "surgery," and "situational safeness" may be an initial framework on which to build initial educational interventions to support the development of error recovery skills to better support safe surgical practice.
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Affiliation(s)
- Fanny Gabrysz-Forget
- Department of Experimental Surgery, McGill University, Montreal, Quebec, Canada; Centre Hospitalier de l'Université de Montréal (CHUM), Department of Medicine, Montreal, Quebec, Canada
| | - Sarah Zahabi
- Department of Otolaryngology-Head and Neck Surgery, Schulich School of Medicine and Dentistry Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Meredith Young
- Institute for Health Sciences Education, McGill University, Montreal, Quebec, Canada
| | - Dmitry Nepomnayshy
- Center for Professional Development and Simulation, Lahey Health, Beth Israel Lahey Health, Burlington, Massachusetts
| | - Lily Hp Nguyen
- Institute for Health Sciences Education, McGill University, Montreal, Quebec, Canada; Department of Otolaryngology - Head and Neck Surgery, McGill University, Montreal, Quebec, Canada.
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Whitehead A. A Resident Morbidity and Mortality Conference Curriculum to Teach Identification of Cognitive Biases, Errors, and Debiasing Strategies. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2021; 17:11190. [PMID: 34765723 PMCID: PMC8551265 DOI: 10.15766/mep_2374-8265.11190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 08/01/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION The morbidity and mortality (M&M) conference has long been a part of the education of residents of all specialties in the United States, yet its structure is variable across training programs. Recent literature has described the use of M&M as a forum for education in quality improvement methodology; however, a structure focusing on education in cognitive biases and errors has not been previously described in MedEdPORTAL. METHODS This structured M&M conference series called upon resident presenters and peers in the audience to examine cognitive biases and errors involved in specific patient cases. Associated materials included preparatory guidelines provided to faculty advisors and resident presenters, a presentation template used during the introductory session, and a handout used during the discussion portions of presentations. RESULTS During the 2019-2020 academic year, a total of 24 PGY 2 pediatrics residents presented M&M cases. They identified a mean of 3.7 (SD = 1.9) cognitive biases and/or errors per case and a mean of 1.7 (SD = 0.7) debiasing strategies per case. Peers in the audience were also successful in identifying potential biases and errors at play during presentations. DISCUSSION We found that through this M&M conference structure, residents were able to demonstrate the ability to identify cognitive errors and biases both within themselves and in peers. This provided an effective forum for the identification and discussion of debiasing strategies, even when the series was forced to transition to a virtual format due to the COVID-19 pandemic.
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Affiliation(s)
- Anne Whitehead
- Assistant Professor of Emergency Medicine and Pediatrics, Department of Emergency Medicine, Indiana University School of Medicine
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Raja S, Litle VR. The critical role of learning from investigating and debriefing adverse events. J Thorac Dis 2021; 13:S3-S7. [PMID: 34447586 PMCID: PMC8371545 DOI: 10.21037/jtd-2020-epts-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/10/2020] [Indexed: 12/04/2022]
Abstract
Debriefing after and learning from adverse surgical events is becoming an integral component of our clinical practices and hospital systems. Morbidity and mortality conferences have been the foundation for this process; however, the approach has evolved to be more constructive with root cause analyses and identification of action items to prevent future adverse events. Additional quality improvement resources include the voluntary National Surgical Quality Improvement Program (NSQIP) and the Society of Thoracic Surgeons (STS) databases, which provide seeds for a systematic process of improving patient care. With large databases come not only a route for studying outcome expectedness but also an objective numeric source for development of risk scores to stratify patients and assist with shared decision making. There is also recognition of the collateral damage of adverse events, which, includes the second victims defined as the individuals other than the patient. After an adverse event the second victim can either thrive, just survive or drop-out, and institutional systems should be in place to care for this victim and prevent their travel down the road to burnout. As a contemporaneous topic, burnout impacts not only surgeon wellness but also negatively affects the clinical workforce, which includes nurses in addition to physicians. “To err is human” but to care is ethereal.
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Affiliation(s)
- Siva Raja
- Center for Esophageal Diseases, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Virginia R Litle
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
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Stocker M, Szavay P, Wernz B, Neuhaus TJ, Lehnick D, Zundel S. What are the participants' perspective and the system-based impact of a standardized, inter-professional morbidity/mortality-conferences in a children's hospital? Transl Gastroenterol Hepatol 2021; 6:48. [PMID: 34423169 DOI: 10.21037/tgh-20-42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/20/2020] [Indexed: 11/06/2022] Open
Abstract
Background Morbidity and mortality conferences (MMC) are well established but little data exists on inter-professional aspects, system-based outcomes and characteristics in pediatric departments. Our study aim was to analyze the system-based impact and to assess participant's perspectives on standardized, inter-professional MMCs in a children's hospital. Methods In a prospective observational analysis the inter-professional MMCs held at a tertiary teaching children's hospital in Switzerland were analyzed for (I) resulting clinical consequences and (II) participants perception on format, usefulness and no-blame atmosphere. Results Eighteen MMC, discussing 29 cases were analyzed. Twenty-seven clinical errors/problems were identified and 17 clinical recommendations were developed: ten new or changed clinical guidelines, two new therapeutic alternatives, three new teaching activities, and two guidelines on specific diagnostics. Altogether, the 466 participants evaluated the conferences favorably. Little differences were seen in the evaluations of physicians of different disciplines or seniority but non-physicians scored all questions lower than physicians. Overall, three quarters of the participants felt that there was a no-blame culture during the conferences but results varied depending on the cases discussed. Conclusions An inter-professional MMC can have relevant impact on clinical practice and affect system-based changes. Inter-professional conferences are profitable for all participants but evaluated differently according to profession. A standardized format and the presence of a moderator are helpful, but not a guarantee for a no-blame culture. Highly emotional cases are a risk factor to relapse to "blame and shame". A time gap between the event and the MMC may have a beneficial effect. Keywords Inter-professional communication; inter-professional health care; learning from failure; morbidity and mortality conference (MMC); patient safety; psychological safety.
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Affiliation(s)
- Martin Stocker
- Pediatric and Neonatal Intensive Care Unit, Children's Hospital Lucerne, Luzern, Switzerland.,Department of Pediatrics, Children's Hospital Lucerne, Luzern, Switzerland
| | - Philipp Szavay
- Department of Pediatric Surgery, Children's Hospital Lucerne, Luzern, Switzerland
| | - Birgit Wernz
- Department of Nursing, Children's Hospital Lucerne, Luzern, Switzerland
| | - Thomas J Neuhaus
- Department of Pediatrics, Children's Hospital Lucerne, Luzern, Switzerland
| | - Dirk Lehnick
- Biostatistics and Methodology, University of Lucerne, Luzern, Switzerland
| | - Sabine Zundel
- Department of Pediatric Surgery, Children's Hospital Lucerne, Luzern, Switzerland
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Scott L, Lim R, Foxcroft L, Lum PA. How can surgical programs use peer support programs in times of crisis? Can Urol Assoc J 2021; 15:S36-S39. [PMID: 34406930 DOI: 10.5489/cuaj.7302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Leslie Scott
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Rodrick Lim
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Laura Foxcroft
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - P Andrea Lum
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Benndorf M, Bamberg F. [Morbidity and mortality conference as an instrument for quality improvement in clinical radiology]. Radiologe 2021; 61:846-848. [PMID: 34383137 DOI: 10.1007/s00117-021-00899-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Matthias Benndorf
- Faculty of Medicine, Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland.
| | - Fabian Bamberg
- Faculty of Medicine, Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Deutschland
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Chun JY, Bharadwaz A, Kyaw Tun J, Bilhim T, Gonzalez-Junyent C, Kawa B. CIRSE Standards of Practice on Conducting Meetings on Morbidity and Mortality. Cardiovasc Intervent Radiol 2021; 44:1157-1164. [PMID: 34018022 DOI: 10.1007/s00270-021-02860-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/26/2021] [Indexed: 11/27/2022]
Abstract
This CIRSE Standards of Practice document is developed by an expert writing group under the guidance of the CIRSE Standards of Practice Committee. It aims to assist Interventional Radiologists in their daily practice by providing best practices for conducting meetings on morbidity and mortality.
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Affiliation(s)
- Joo-Young Chun
- Department of Radiology, St George's Hospital, London, UK.
| | - Arindam Bharadwaz
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jimmy Kyaw Tun
- Department of Interventional Radiology, Barts Health NHS Trust, London, UK
| | - Tiago Bilhim
- Interventional Radiology Unit, Centro Hospitalar Universitário de Lisboa Central, Saint Louis and CUF Hospital, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | | | - Bhavin Kawa
- Department of Radiology, St George's Hospital, London, UK
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de Vos MS, Hamming JF, Marang-van de Mheen PJ. Learning From Morbidity and Mortality Conferences: Focus and Sustainability of Lessons for Patient Care. J Patient Saf 2021; 17:231-238. [PMID: 29087979 DOI: 10.1097/pts.0000000000000440] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE It remains unclear to what extent the morbidity and mortality conference (M&M) meets the objective of improving quality and safety of patient care. It has been suggested that M&M may be too focused on individual performance, hampering system-level improvement. The aim of this study was to assess focus and sustainability of lessons for patient care that were derived from M&M. METHODS This is an observational study of routinely collected data on evaluated complications and identified lessons at surgical M&M for 8 years, assessing type and recurrence of lessons and cases from which these were drawn. Semistructured interviews with clinicians were qualitatively analyzed to explore factors contributing to lesson focus and recurrence. RESULTS Three hundred eighteen lessons were drawn from 10,883 evaluated complications, primarily for those that were more severe, related to surgical or other treatment, and occurring in nonemergent, lower risk cases (all P < 0.001). Most lessons targeted intraoperative (43%) rather than preoperative or postoperative care as well as specifically technical (87%) and individual-level issues (74%). There were 43 recurring lessons (14%), mostly about postoperative care (47%) and medication management (50%). Interviewed clinicians attributed the intraoperative, technical focus primarily to greater appeal and control but identified an array of factors contributing to lesson recurrence, such as typical staff turnover in teaching hospitals. CONCLUSIONS This study provided empirical evidence that learning at M&M has a tendency to focus on intraoperative, technical performance, with challenges to sustain lessons for more system-level issues. Morbidity and mortality conference formats need to anticipate these tendencies to ensure a wide focus for learning with lasting and wide impact.
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Tuca AC, Münch J, Schwappach DLB, Borenich A, Banfi C, Mautner S, Hoffmann M, Schwarz C, Kamolz LP, Brunner G, Sendlhofer G. Implementation status of morbidity and mortality conferences in Austrian hospitals-A cross-sectional national survey study. PLoS One 2021; 16:e0248692. [PMID: 33730067 PMCID: PMC7968694 DOI: 10.1371/journal.pone.0248692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/04/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Morbidity and mortality conferences (M&MCs) are an instrument for learning from past complications, unexpected follow-ups and deaths in hospitals and are important for improving patient safety. However, there are currently no quantitative data on the implementation of M&MCs in Austria. The aim of the study was to determine the status quo of the M&MCs in Austria. MATERIALS AND METHODS A national cross-sectional study was conducted by means of a survey of 982 chief physicians of surgical disciplines, internal medicine, anesthesiology, intensive care, gynecology/obstetrics and pediatrics. The questionnaire focused on overall goals, structure and procedures of hospital M&MCs. RESULTS Of the 982 contacted chief physicians, 314 (32.0%) completed the survey. Almost two thirds of the respondents, i.e. 203 (64.7%), had already implemented M&MCs. Of the 111 chief physicians who had not yet introduced M&MCs, 62 (55.9%) were interested in introducing such conferences in the future. Of the 203 respondents that had implemented M&MCs, 100 stated that their M&MC could be improved. They reported issues with "shame and blame" culture, hierarchical structures, too little knowledge about the capability of M&MC and, in particular, time constraints. Overall, the participating chief physicians showed that they are striving to improve their existing M&MCs. DISCUSSION/CONCLUSION While we found a relatively high number of already implemented M&MCs we also identified a large heterogeneity in the format of the M&MCs. A highly structured M&MC including guidelines, checklists or templates does not only considerably improve its outcome but can also alleviate the main limiting factor which is the lack of time.
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Affiliation(s)
- Alexandru-Cristian Tuca
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Johanna Münch
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - David L. B. Schwappach
- Swiss Patient Safety Foundation Zurich, Zürich, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Andrea Borenich
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Chiara Banfi
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Selma Mautner
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Magdalena Hoffmann
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Christine Schwarz
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Lars-Peter Kamolz
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Gernot Brunner
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Gerald Sendlhofer
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Executive Department for Quality and Risk Management, University Hospital Graz, Graz, Austria
- Austrian Society for Quality and Safety in Healthcare (ASQS), Graz, Austria
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Esclassan R, Valera MC, Bergia JM, Canceill T, Mendes LC, Bailleul-Forestier I, Gardette V, Vaysse F, Gurgel-Georgelin M, Noirrit E. Morbidity and Mortality Review in a University Dental Hospital: A Necessary Tool to Improve Quality of Care. Eur J Dent 2021; 15:307-311. [PMID: 33412606 PMCID: PMC8184302 DOI: 10.1055/s-0040-1719233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The study aimed to describe and to analyze the first morbidity and mortality review (MMRs) set up within a Dental University Hospital using detailed case reports to highlight the benefits of MMRs for patients, practitioners, teachers and to implement appropriate protocols to prevent recurrence. MATERIALS AND METHODS The MMRs were performed within the dentistry departments of the hospital over the 1-year study period. Each case was reviewed according to a protocol based on a tool defined by the Clinical Risk Unit and the Association of Litigation and Risk Management (ALARM). RESULTS Four cases were selected based on an oral report by a doctor from the dental service, a downstream service, or by the attending physician. The first case report related to a patient who suffered a breathing shock. The second concerned a tooth inhalation by a young disabled boy. The third was a therapeutic failure instigated by a student during a tooth preparation, and the fourth case involved an unexpected face-to-face meeting between a prisoner accompanied by police guards and an ancient victim at the dental hospital. DISCUSSION Clinical incidents were investigated with the ALARM protocol. This process is also less focused on the individual who makes the error and more on contributing systemic factors. The systematic analysis of cases associated with bibliographic reviews improves learning and performance outcomes. Clear answers were given in response to the problems raised during these MMRs. CONCLUSION In dental hospitals, the culture of MMRs needs to be integrated into resident training like in medical hospitals.
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Affiliation(s)
- Rémi Esclassan
- Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France.,CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France.,Laboratoire AMIS, CNRS, Toulouse, France
| | - Marie-Cécile Valera
- Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France.,CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France.,I2MC, CHU de Toulouse and Université de Toulouse, Toulouse, France
| | | | - Thibault Canceill
- Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France.,CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France.,CIRIMAT, University of Toulouse, CNRS, INPT, Université Paul Sabatier, Faculté de Pharmacie, Toulouse, France
| | - Leonor Costa Mendes
- Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France.,CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France
| | - Isabelle Bailleul-Forestier
- Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France.,CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France
| | - Virginie Gardette
- CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France.,UMR INSERM, Université Paul Sabatier, CHU de Toulouse, Hôtel-Dieu, Toulouse, France
| | - Frédéric Vaysse
- Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France.,CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France.,Laboratoire AMIS, CNRS, Toulouse, France
| | - Marie Gurgel-Georgelin
- Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France.,CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France
| | - Emmanuelle Noirrit
- Faculté de Chirurgie Dentaire de Toulouse, 03 chemin des Maraîchers, Toulouse, France.,CHU Rangueil, 03 chemin des Maraîchers, Toulouse, France.,I2MC, CHU de Toulouse and Université de Toulouse, Toulouse, France
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Bruny J, Inge T, Rannie M, Acker S, Levitt G, Cumbler E, Brumbaugh D. Transforming surgical morbidity and mortality into a systematic case review. J Pediatr Surg 2021; 56:80-84. [PMID: 33139023 DOI: 10.1016/j.jpedsurg.2020.09.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE The surgical morbidity and mortality (M&M) conferences at a regional children's hospital achieved the goals of case by case peer review and education for trainees but provided limited data for trending and analysis. In 2019, an institution-wide effort was initiated to create an electronic case review system with the goals of improving event capture and real-time practice performance feedback. Surgical M&M was migrated to this structured case review format to provide a platform for surgical performance improvement. METHODS An online secure database was created with a 3-step classification system based on Clavien-Dindo severity score, peer review, and causality fishbone analysis. The data entered were available in an interactive dashboard. Retrospective tabulation of the 2018 M&M data was performed using the archived paper system used prior to 2019. RESULTS For the calendar year of 2019, the division of pediatric surgery captured and categorized 193 complications in the case review system. The capture rate was 50 per 1000 surgical procedures. For a similar time frame in 2018, the capture rate was 35 per 1000 surgical procedures. The dashboard provided run charts of the incidence and types of complications by procedure and by surgeon. Similar trend data were not available in 2018. The dashboard output has made possible the creation of (non- risk adjusted) individual surgeon performance reports. The output has been used to direct process improvement projects and educational content. CONCLUSION Creation of an online database with interactive dashboard has allowed surgical M&M to evolve into a systematic case review that greatly facilitates quality improvement efforts. This system increased the event capture rate and provided novel practice performance feedback, resulting in process improvement projects and educational objectives predicated on the trending data. These electronic reporting tools are now available to all surgical divisions and represent a transformative approach to surgical case review. TYPE OF STUDY Retrospective Historical control; Quality improvement. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jennifer Bruny
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO.
| | - Thomas Inge
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO
| | | | - Shannon Acker
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO
| | | | | | - David Brumbaugh
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO
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Churchill KP, Murphy J, Smith N. Quality Improvement Focused Morbidity and Mortality Rounds: An Integrative Review. Cureus 2020; 12:e12146. [PMID: 33489558 PMCID: PMC7813522 DOI: 10.7759/cureus.12146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Morbidity and mortality conference (MMC) is a century-old tradition in medicine that was initially primarily focused on the review of surgical outcomes and errors. In recent years, the value of MMC in quality improvement (QI) and patient safety initiatives has been realized and incorporated into the MMCs of some disciplines and institutions. Despite this, there is a need for a standardized structure of MMC that emphasizes both QI and patient safety. The purpose of this integrative review is to synthesize the literature on MMC structure that is reflective of QI and patient safety. An integrative literature search was carried out using PubMed and MEDLINE. Abstracts were reviewed and non-relevant articles were excluded. Exclusion criteria were no mention of MMC, analysis of specific case, no focus on QI or patient safety, and non-English language. A total of 21 articles were identified for review. Articles were reviewed in their entirety for content regarding structuring of the MMC to reflect and further develop QI and patient safety. The follwing three themes emerged that were consistently identified as being important for restructuring MMCs: (1) the importance of careful case selection, (2) the format of discussion during the conferences, and (3) the action plans reflecting QI initiatives derived from the conferences. The review suggests that one standardized method of MMC implementation that encompasses the three pivotal themes should be developed. Further research needs to focus on instituting measures of effectiveness for the new MMC model.
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Affiliation(s)
- Kayla P Churchill
- Obstetrics and Gynecology, Faculty of Medicine, Eastern Health Memorial University, St. John's, CAN
| | - Justin Murphy
- Orthopedic Surgery, Memorial University of Newfoundland, St. John's, CAN
| | - Nick Smith
- Orthopedic Surgery, Faculty of Medicine, Eastern Health Memorial University, St. John's, CAN
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Chathampally Y, Cooper B, Wood DB, Tudor G, Gottlieb M. Evolving from Morbidity and Mortality to a Case-based Error Reduction Conference: Evidence-based Best Practices from the Council of Emergency Medicine Residency Directors. West J Emerg Med 2020; 21:231-241. [PMID: 33207171 PMCID: PMC7673891 DOI: 10.5811/westjem.2020.7.47583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 07/23/2020] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Yashwant Chathampally
- The University of Texas Health Sciences Center at Houston, Department of Emergency Medicine, Houston, Texas
| | - Benjamin Cooper
- The University of Texas Health Sciences Center at Houston, Department of Emergency Medicine, Houston, Texas
| | - David B Wood
- Yale University Medical Center, Department of Emergency Medicine, New Haven, Connecticut
| | - Gregory Tudor
- University of Illinois College of Medicine at Peoria/OSF Healthcare, Department of Emergency Medicine, Peoria, Illinois
| | - Michael Gottlieb
- Rush University, Medical Center, Department of Emergency Medicine, Chicago, Illinois
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Taking Morbidity and Mortality Conferences to a Next Level: The Resilience Engineering Concept. Ann Surg 2020; 272:678-683. [PMID: 32889871 DOI: 10.1097/sla.0000000000004447] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To explore possibilities to improve morbidity and mortality conferences using advancing insights in safety science. SUMMARY BACKGROUND DATA Mortality and Morbidity conferences (M&M) are the golden practice for case-based learning. While learning from complications is useful, M&M does not meet expectations for system-wide improvement. Resilience engineering principles may be used to improve M&M. METHODS After a review of the shortcomings of traditional M&M, resilience engineering principles are explored as a new way to evaluate performance. This led to the development of a new M&M format that also reviews successful outcomes, rather than only complications. This "quality assessment meeting" (QAM) is presented and the first experiences are evaluated using local observations and a survey. RESULTS During the QAM teams evaluate all discharged patients, addressing team resilience in terms of surgeons' ability to respond to irregularities and to monitor and learn from experiences. The meeting was feasible to implement and well received by the surgical team. Observations reveal that reflection on both complicated and uncomplicated cases strengthened team morale but also triggered reflection on the entire clinical course. The QAM serves as a tool to identify how adapting behavior led to success despite challenging conditions, so that this resilient performance can be supported. CONCLUSIONS The resilience engineering concept can be used to adjust M&M, in which learning is focused not only on complications but also on how successful outcomes were achieved despite ever-present challenges. This reveals the actual ratio between successful and unsuccessful outcomes, allowing to learn from both to reinforce safety-enhancing behavior.
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Teklewold B, Deresse T, Kinfe G, Teshome H. Participants' Opinion about Conduct of Morbidity and Mortality Conferences in Surgical Practice in a Tertiary Hospital, Ethiopia. Ethiop J Health Sci 2020; 30:355-362. [PMID: 32874078 PMCID: PMC7445942 DOI: 10.4314/ejhs.v30i3.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Morbidity and mortality conference has both educational and quality improvement purposes. However clear evidences for the effectiveness of the morbidity and mortality conferences in improving patient safety is lacking. Methods A facility based cross sectional study was conducted at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia, to assess participants' opinion on benefits and functioning of morbidity and mortality conferences. Univariate analysis was used to determine the influence of professional type on participants' opinion about the morbidity and mortality conferences. Result A total of 98 participants completed the survey. The majority of the participants agreed that there was a structured system of case identification (67.3%), meeting format (72.4%), the conferences were conducted every month (79.6%), it is blame free (71.4%) and system of care was focus of discussion (70%). Most (88.8%) participants agreed that the conferences were important for improvement of patient safety and quality of care, whereas 67.3% of the participants believed that there is no written term of reference and prior dissemination of agendas. Only 40% agreed that there is multidisciplinary team involvement. Fifty one percent of them disagreed that there is a follow up on the implementation of the forwarded recommendations. Conclusion Even though the majority of the participants were satisfied with the mortality and morbidity conferences, most disagreed on the presence of written term of reference, earlier dissemination of agendas, multidisciplinary team involvement and follow up on the implementation of the forwarded recommendations.
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Affiliation(s)
| | - Tilahun Deresse
- St. Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia
| | - Goytom Kinfe
- St. Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia
| | - Henok Teshome
- St. Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia
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Morbidity and mortality for the dermatologist: Resident-led pilot project. J Am Acad Dermatol 2020; 83:972-973. [DOI: 10.1016/j.jaad.2020.04.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 11/16/2022]
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Jansson PS, Schuur JD, Baker O, Hagan SC, Nadel ES, Aaronson EL. Anonymity Decreases the Punitive Nature of a Departmental Morbidity and Mortality Conference. J Patient Saf 2020; 15:e86-e89. [PMID: 30444742 DOI: 10.1097/pts.0000000000000555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We sought to analyze the effect of an anonymous morbidity and mortality (M&M) conference on participants' attitudes toward the educational and punitive nature of the conference. We theorized that an anonymous conference might be more educational, less punitive, and would shift analysis of cases toward systems-based analysis and away from individual cognitive errors. METHODS We implemented an anonymous M&M conference at an academic emergency medicine program. Using a pre-post design, we assessed attitudes toward the educational and punitive nature of the conference as well as the perceived focus on systems versus individual errors analyzed during the conference. Means and standard deviations were compared using a paired t test. RESULTS Fifteen conferences were held during the study period and 53 cases were presented. Sixty percent of eligible participants (n = 38) completed both the pretest and posttest assessments. There was no difference in the perceived educational value of the conference (4.42 versus 4.37, P = 0.661), but the conference was perceived to be less punitive (2.08 versus 1.76, P = 0.017). There was no difference between the perceived focus of the conference on systems (2.76 versus 2.76, P = 1.00) versus individual (4.21 versus 4.16, P = 0.644) errors. Most participants (59.5%) preferred that the conference remain anonymous. CONCLUSIONS We assessed the effect of anonymity in our departmental M&M conference for a 7-month period and found no difference in the perceived effect of M&M on the educational nature of the conference but found a small improvement in the punitive nature of the conference.
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Affiliation(s)
- Paul S Jansson
- From the Department of Emergency Medicine, Massachusetts General Hospital.,Department of Emergency Medicine, Brigham and Women's Hospital.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Olesya Baker
- Department of Emergency Medicine, Brigham and Women's Hospital
| | - Sean C Hagan
- Department of Emergency Medicine, Brigham and Women's Hospital
| | - Eric S Nadel
- From the Department of Emergency Medicine, Massachusetts General Hospital.,Department of Emergency Medicine, Brigham and Women's Hospital.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Emily L Aaronson
- From the Department of Emergency Medicine, Massachusetts General Hospital.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
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Castañeda-Motta C, Vega-Peña NV. Reuniones de morbilidad y mortalidad, ¿una estrategia de aprendizaje? IATREIA 2020. [DOI: 10.17533/udea.iatreia.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Las reuniones o conferencias de morbilidad y mortalidad (M&M), una práctica común en todo el mundo, buscan evaluar los eventos adversos y las complicaciones relacionadas con la atención médica, desde una perspectiva académica y considerando un mejoramiento en la calidad de la atención hospitalaria. Sin embargo, en nuestro país, su ejecución es un desafío metodológico debido a la dificultad para su conceptualización, implementación, evaluación de su efectividad y utilidad como herramienta educativa; al estar carente de una estructura formalizada que considere estos temas.
El objetivo de este trabajo es evaluar su papel desde una perspectiva académica individual e institucional, considerando diferentes teorías y modelos que podrían apoyar el M&M (teoría del aprendizaje experimental, teoría de la actividad en el aprendizaje sociocultural, cultura justa, teoría de la seguridad del modelo y teoría de la segunda víctima), con el fin de responder la pregunta: ¿son las reuniones de M&M una estrategia de aprendizaje?
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Offidani C, Lodise M, Gatto V, Frati P, D'Errico S, Atti MLCD, Raponi M. Improve Healthcare Quality Through Mortality Committee: Retrospective Analysis of Bambino Gesù Children Hospital's Ten Years' Experience 2008-2017. Curr Pharm Biotechnol 2020; 20:635-642. [PMID: 30747063 DOI: 10.2174/1389201020666190211124436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/19/2018] [Accepted: 02/04/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Healthcare quality improvements are one of the most important goals to reach a better and safer healthcare system. Reviewing in-hospital mortality data is useful to identify areas for improvement, and to monitor the impact of actions taken to avoid preventable cases, such as those related to healthcare associated infections (HAI). METHODS In this paper, we present the experience of the Mortality Committee of Bambino Gesù Children Hospital (OPBG). OPBG has instituted a process of systematic revision of all in-hospital deaths conducted by a multidisciplinary team. The goal is to identify system-wide issues that could be improved to reduce in-hospital preventable deaths. In this way, the mortality review goes alongside all the other risk management activities for the continuous quality improvement and patient safety. RESULTS In years 2008-2017, we performed a systematic analysis of 1148 inpatient deaths. In this time period, the overall mortality rate was 0.4%. Forty-seven deaths were caused due to infections, 10 of which involved patients with HAI transferred to OPBG from other facilities or patients with community- acquired infections. Six deaths related to HAI were followed by claims compensations. All these cases were not followed by compensation because the onset of HAI was considered an inevitable consequence of the underlying disease. CONCLUSION Introduction of the mortality review committee has proved to be a valid instrument to improve the quality of the care provided in a hospital, allowing early identification of care gaps that could lead to an increase in mortality rates. Article Highlights Box: Reduction of preventable deaths is one of the most important goals to be achieved for any health-care system and to improve the quality of care. • Several studies have shown that analysis of morbidity and mortality rate helps to detect any factors that can lead to an increase in in-hospital mortality rates. • The review of in-hospital deaths allows to learn how to improve the quality and safety of care through identification of critical issues that lead to an increase in mortality ratio. • In some medical areas, such as intensive care units or surgery, the implementation of the conference on mortality and morbidity is more useful for assessing procedures at high risk of errors. • The implementation of existing databases with data deriving from the systematic review of medical records and in-hospital deaths appears to be desirable. • Mortality Review Committees can represent a very useful tool for all the health facilities for the reduction of preventable deaths, such as those related to HAI.
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Affiliation(s)
- Caterina Offidani
- Unit of Legal Medicine, Bambino Gesu Children's Hospital, IRCCS, P.za Sant'Onofrio 4, Rome, 00165, Italy
| | - Maria Lodise
- Unit of Legal Medicine, Bambino Gesu Children's Hospital, IRCCS, P.za Sant'Onofrio 4, Rome, 00165, Italy
| | - Vittorio Gatto
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00185 Rome, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00185 Rome, Italy
| | - Stefano D'Errico
- Department of Legal Medicine Azienda USL Toscana Nordovest, Lucca, Italy
| | - Marta L C D Atti
- Unit of Clinical Epidemiology, Bambino Gesù Children's Hospital, Piazza di Sant'Onofrio 4, 00165, Rome, Italy
| | - Massimiliano Raponi
- Medical Direction, Bambino Gesu Children's Hospital, Piazza di Sant'Onofrio 4, 00165, Rome, Italy
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