1
|
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.
Collapse
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
| |
Collapse
|
2
|
Blackburn KW, Brubaker LS, Van Buren Ii G, Feng E, Mohamed S, Ramamurthy U, Ramanathan V, Wood AL, Navarro Cagigas ME, Fisher WE. Real-Time Reporting of Complications in Hospitalized Surgical Patients by Surgical Team Members Using a Smartphone Application. Jt Comm J Qual Patient Saf 2024:S1553-7250(24)00056-4. [PMID: 38565473 DOI: 10.1016/j.jcjq.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The surgical morbidity and mortality (M&M) conference is a vital part of a resident's surgical education, but methods to collect and store M&M data are often rudimentary and unreliable. The authors propose a Health Insurance Portability and Accountability Act (HIPAA)-compliant, electronic health record (EHR)-connected application and database to report and store complication data. METHODS The app is linked to the patient's EHR, and as a result, basic data on each surgical case-including diagnosis, surgery type, and surgeon-are automatically uploaded to the app. In addition, all data are stored in a secure SQL database-with communications between the app and the database end-to-end encrypted for HIPAA compliance. The full surgical team has access to the app, democratizing complications reporting and allowing for reporting in both the inpatient and outpatient settings. This complication information can then be automatically pulled from the app with a premade presentation for the M&M conference. The data can also be accessed by a Power BI dashboard, allowing for easy quality improvement analyses. RESULTS When implemented, the app improved data collection for the M&M conference while providing a database for institutional quality improvement use. The authors also identified additional utility of the app, including ensuring appropriate revenue capture. The general appearance of the app and the dashboard can be found in the article. CONCLUSION The app developed in this project significantly improves on more common methods for M&M conference complication reporting-transforming M&M data into a valuable resource for resident education and quality improvement.
Collapse
|
3
|
Christopher D, Leininger WM, Beaty L, Nunziato JD, Kremer ME, Diaz Quinones JJ, Rutz S, Griffin TR, Klatt TE. Quality and Safety Practices Among Academic Obstetrics and Gynecology Departments. Am J Med Qual 2023; 38:165-173. [PMID: 37382305 DOI: 10.1097/jmq.0000000000000129] [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: 06/30/2023]
Abstract
The objective was to quantify resources devoted to quality and patient safety initiatives, to document the development and use of key performance indicator reports regarding patient outcomes and patient feedback, and to assess the culture of safety within academic obstetrics and gynecology departments. Chairs of academic obstetrics and gynecology departments were asked to complete a quality and safety assessment survey. Surveys were distributed to 138 departments, yielding 52 completed responses (37.7%). Five percent of departments reported including a patient representative on a quality committee. Most committee leaders (60.5%) and members (67.4%) received no compensation. Formal training was required in 28.8% of responding departments. Most departments monitored key performance metrics for inpatient outcomes (95.9%). Leaders scored their departments' culture of safety highly. Most departments provided no protected time to faculty devoted to quality efforts, generation of key performance indicators for inpatient activities was prevalent and integrating patient and community input remain unrealized opportunities.
Collapse
Affiliation(s)
| | - William M Leininger
- Department of Gynecologic Surgery and Obstetrics, Navy Medicine Research and Training Command, San Diego, CA
| | - Laurel Beaty
- University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jaclyn D Nunziato
- Department of Obstetrics and Gynecology, Carilion Clinic, Roanoke, VA
| | - Mallory E Kremer
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | | | - Sara Rutz
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Todd R Griffin
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Stony Brook Medicine, Stony Brook, NY
| | | |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Alexander-Leeder CA, Guess SC, Waiting DK, Davidow EB. Medical errors: Experiences, attitudes and perspectives of incoming and outgoing final-year veterinary students in the USA. Vet Rec 2022; 191:e1735. [PMID: 35607298 DOI: 10.1002/vetr.1735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/23/2022] [Accepted: 04/26/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Medical errors have an impact on veterinary patient safety. Studies in human medicine suggest that students can help prevent medical errors. However, there are no studies that address the role of veterinary students in patient safety. METHODS An electronic survey was distributed to incoming final-year (IFY) and outgoing final-year (OFY) students at the Washington State University College of Veterinary Medicine. Response data were compared between class year groups with a Fisher's exact test and Mann-Whitney U test. RESULTS The response rate was 26.8% (70/261). Most respondents (85.7%) reported being present during a medical error, and 60% reported causing a medical error. The OFY group indicated lower agreement with documenting an error in the patient record and whether all errors should be disclosed. The IFY group felt more distress surrounding potential errors and sequential career implications. Compared with the IFY group, the OFY group agreed more that errors occur frequently in veterinary medicine and disagreed more that hospital staffing is adequate to ensure patient safety. Open responses recognised a need for communication training and identified that the OFY group regarded errors more actionably, whereas the IFY group viewed errors more emotionally. CONCLUSION Most veterinary students will experience medical errors prior to graduation, but some lack clarity around appropriate disclosure and documentation. Additional training on medical errors and error disclosure should be provided to veterinary students.
Collapse
Affiliation(s)
| | - Sarah C Guess
- Washington State University College of Veterinary Medicine, Pullman, Washington, USA
| | - Denise K Waiting
- Washington State University College of Veterinary Medicine, Pullman, Washington, USA
| | - Elizabeth B Davidow
- Washington State University College of Veterinary Medicine, Pullman, Washington, USA
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Ryan SL, McKee KE, Londono-Sanchez L, Dougherty S, Singhal AB. Neurology Morbidity and Mortality Conferences and Quality Improvement: Single-Center Experience and National Survey. Neurohospitalist 2022; 12:231-240. [PMID: 35419121 PMCID: PMC8995624 DOI: 10.1177/19418744211067043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Morbidity and Mortality (M&M) conferences are widespread but vary in goals and methodology. Some focus on clinical enigmas while an increasing number utilize quality improvement (QI) tools to effect systems change. Little is known about the current state of US Neurology M&Ms. Methods We surveyed 56 US academic neurology departments regarding their M&Ms to understand the use of QI tools and assess variability. Additionally, we reviewed the evolution of M&Ms in our department. Results The survey was completed by 44 (80%) departments; 68% reported quarterly frequency with 61% discussing 1–2 safety events per conference. The number of written guidelines or protocols resulting from M&Ms in 2 years varied from 0 (14% of departments), 1–2 (45%), to >5 (5%). Institutional culture regarding quality and safety and conference timing were cited by 71% as important in improving participation. In our own department, the M&M format changed in 2014 based on a sentinel patient event combined with improving safety culture across the hospital: neurology M&Ms transformed into thematic quarterly conferences utilizing QI tools. Attendance increased 3-fold, and in 7 years, we have generated 26 guidelines or pathways with corresponding decision-support tools, among other improvement efforts, resulting in specific systems changes. Based on survey results and our experience, suggested M&M “best practices” include the use of just culture, peer review protection, safety event analysis with QI methodology, trainee involvement, and logistical optimization. Conclusion Structured M&Ms incorporating suggested QI-informed “best practices” can be highly effective in driving system change within neurology.
Collapse
Affiliation(s)
- Sophia L. Ryan
- Department of Neurology, Mount Sinai Health System, New York, NY, USA
| | - Kathleen E. McKee
- Neurosciences Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | | | - Sarah Dougherty
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Aneesh B. Singhal
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
8
|
Parente V, Feeney C, Page L, Johnson S, Porada K, Cheifetz I, Stephany A. Sustained Impact of a Pediatric Resident-Led Patient Safety Council. J Patient Saf 2021; 17:e1346-e1351. [PMID: 29781977 DOI: 10.1097/pts.0000000000000495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate the impact of a resident-led patient safety council. This study measured change in resident perceptions and knowledge of safety issues for 3 years, as well as behavioral choices to participate in patient safety activities during and after residency. METHODS Pediatric residents formed a resident-led safety council to engage their peers in patient safety activities. Surveys were distributed annually from 2013 to 2015 to measure residents' perception and knowledge surrounding patient safety. The number of patient safety reports submitted by residents was tracked for the same period. In addition, recent graduates were surveyed to assess the influence of the council on postresidency involvement in patient safety. RESULTS Resident perception of the institutional culture of safety improved and knowledge of basic patient safety concepts increased. The number of resident-submitted safety reports increased from 6.2 to 15.2 reports per month in the 2013 and 2015 academic years, respectively. Surveys of recent graduates suggest that involvement with the safety council during residency fostered future engagement in patient safety. CONCLUSIONS This resident-led council models successful involvement of trainees in system-based patient safety. Such involvement can help shape the safety culture within a training program and encourages continued participation in patient safety after residency completion.
Collapse
Affiliation(s)
| | | | | | - Shaina Johnson
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - Kelsey Porada
- Department of Pediatrics, Children's Hospital of Wisconsin, Wauwatosa, Wisconsin
| | | | - Alyssa Stephany
- Department of Pediatrics, Children's Hospital of Wisconsin, Wauwatosa, Wisconsin
| |
Collapse
|
9
|
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.
Collapse
Affiliation(s)
- Anne Whitehead
- Assistant Professor of Emergency Medicine and Pediatrics, Department of Emergency Medicine, Indiana University School of Medicine
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Odinet JS, Vest MH, Murphy K, Pappas AL, Stivers AP. Implementation of a pharmacy-focused morbidity, mortality, and improvement conference. Am J Health Syst Pharm 2021; 78:S52-S56. [PMID: 33057578 DOI: 10.1093/ajhp/zxaa313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Review lessons learned during the development and implementation of a pharmacy-focused Morbidity, Mortality, and Improvement conference at an academic medical center. SUMMARY Since the early 1900s, Morbidity and Mortality conferences have provided a forum for clinicians to discuss medical errors and adverse outcomes. Many institutions have now added "improvement" to the conference title to emphasize the goal of approaching these conferences in a systems-oriented manner. To date, a gap remains in the literature evaluating the impact of a pharmacy-focused Morbidity, Mortality, and Improvement (MM&I) conference. The primary goal in establishing this pharmacy-focused conference was to foster and strengthen the culture of medication safety within our department. In establishing our program, we identified an opportunity to leverage pharmacy residents similar to a medical resident-facilitated conference. After gaining leadership buy-in, a core planning team was formed to identify events and create conference materials. Primary metrics to gauge the success of implementation included event reporting trends and medication-safety strategic initiative tracking. The first year of MM&I conferences provided forward momentum for our department's safety culture. Safety event reporting by pharmacy staff increased by 150% over the fiscal year, and more frontline staff expressed a personal interest in becoming involved in safety projects and initiatives outside of their normal shift responsibilities. CONCLUSION We have learned several important lessons that may be helpful to others, the primary of which is that improving a culture of safety takes time.
Collapse
Affiliation(s)
- Johlee S Odinet
- Department of Pharmacy, Ochsner Medical Center, New Orleans, LA, USA
| | - Mary-Haston Vest
- Pharmacy Analytics, UNC Health Care System, Morrisville, NC, USA
| | - Kristin Murphy
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Ashley L Pappas
- Medication Management and Optimization, Pharmacy Analytics and Outcomes, Pharmacy Services, UNC Health Care System, Morrisville, NC, USA
| | - Andrew P Stivers
- Medication Use & Safety, Emory University Hospital Midtown, Pharmaceutical Services, Atlanta, GA, USA
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
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.
Collapse
|
14
|
Johnson CR, Noorzad A, Pujari A, Paiement G, Lin C. There is an App for That: Mobile Technology Improves Complication Reporting and Resident Perception of Their Role in Patient Safety. JB JS Open Access 2021; 6:JBJSOA-D-20-00077. [PMID: 33748638 PMCID: PMC7963495 DOI: 10.2106/jbjs.oa.20.00077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Morbidity and mortality (M&M) conferences are rooted within the culture of medicine. They serve a role in every training program and have been mandated by the Accreditation Council for Graduate Medical Education in surgical programs since 1983. Despite the patient safety improvements and educational benefits of these conferences, many adverse events are grossly under-reported. Methods We developed a web-based, Health Insurance Portability and Accountability Act-compliant, M&M reporting mobile application based on Research Electronic Data Capture. The list of possible complications was based on the American Board of Orthopaedic Surgery complications list for part II. The interface is accessible through all mobile platforms. All residents were encouraged to use the application for real-time reporting of complications. Using an unpaired T-test, we compared the reporting before and after the implementation of the mobile application. Residents were surveyed using the Agency for Healthcare Research and Quality Patient Safety Culture Survey before and after implementation to evaluate resident perception of the department's culture of safety. Results The application was launched in August 2017. All reported events were tallied from August 2016 through July 2019. Before the implementation of the application, there were 54 adverse events reported, with a mean of 4.0 per month. In the Post-App cohort, a total of 176 adverse events were reported in year 1, with a mean of 14.76 per month, and 236 adverse events were reported in year 2, with a mean of 19.66 per month. Residents were significantly more likely to feel that their input on patient safety was valued by attendings after the implementation of the app (p = 0.0243). Conclusions An anonymous mobile reporting method for M&M significantly increased the reporting of both major and minor complications and improved resident perception of their role in patient safety efforts. This suggests that traditional methods of M&M reporting may grossly underestimate the complication rates which can negatively affect patient safety and quality improvement efforts and that reducing barriers to the reporting of complication may improve resident engagement in patient safety.
Collapse
Affiliation(s)
- Christopher R Johnson
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Ali Noorzad
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Amit Pujari
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Guy Paiement
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| | - Carol Lin
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, California
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
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?
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
Lewis JJ, Hyder EC, Rosen C, Wolfe RE, Novack V, Grossman SA. Year-to-year trends in emergency medicine morbidity and mortality cases. Am J Emerg Med 2019; 38:1658-1661. [PMID: 31787443 DOI: 10.1016/j.ajem.2019.09.015] [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: 04/26/2019] [Revised: 09/02/2019] [Accepted: 09/23/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Morbidity and Mortality (M&M) rounds are peer review conferences during which cases with adverse outcomes and difficult management decisions are presented. Their primary objective is to learn from complications and errors, modify behavior and judgment based on previous experiences, and prevent repetition of errors leading to complications. The objective of this study was to determine if M&M conferences can reduce repetitive error making demonstrated by a shift of the incidence of cases presented at M&M by chief complaint (CC) and experience of attendings. METHODS All M&M cases from 1/1/2014-12/31/2017 derived from an urban, tertiary referral Emergency Department were reviewed and grouped into 12 different CC categories and by attending years of experience (1-4, 5-9 and 10+). Number and percent of M&M cases by CC and years of attending experience were calculated by year and a chi-squared analysis was performed. RESULTS 350 M&M cases were presented over the four-year study period. There was a significant difference between CC categories from year-to-year (p < 0.001). Attendings with 1-4 years of experience had the majority of cases (46.3%), while those with 5-9 years had the fewest total cases (15.1%, p < 0.001). CONCLUSIONS There was a persistent significant difference across CC categories of M&M cases from year-to-year, with down-trending and up-trending of specific CCs suggesting that M&M presentation may prevent repetitive errors. Newer attendings show increased rates of M&M cases relative to more experienced attendings. There may be a distinctive educational benefit of participation at M&M for attendings with fewer than five years of clinical experience.
Collapse
Affiliation(s)
- Jason J Lewis
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Road, Rosenberg 2, Boston, MA 02215, United States.
| | - Eric C Hyder
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Road, Rosenberg 2, Boston, MA 02215, United States
| | - Carlo Rosen
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Road, Rosenberg 2, Boston, MA 02215, United States
| | - Richard E Wolfe
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Road, Rosenberg 2, Boston, MA 02215, United States
| | - Victor Novack
- Beth Israel Deaconess Medical Center, Department of Anesthesia, One Deaconess Road, Boston, MA 02215, United States; Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, POB 151, 84101 Beer Sheba, Israel
| | - Shamai A Grossman
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Road, Rosenberg 2, Boston, MA 02215, United States
| |
Collapse
|
20
|
Berman L, Ottosen M, Renaud E, Hsi-Dickie B, Fecteau A, Skarda D, Goldin A, Rangel S, Tsao K. Preventing patient harm via adverse event review: An APSA survey regarding the role of morbidity and mortality (M&M) conference. J Pediatr Surg 2019; 54:1872-1877. [PMID: 30765152 DOI: 10.1016/j.jpedsurg.2018.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 11/01/2018] [Accepted: 12/08/2018] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Peer-review endeavors represent the continual learning environment critical for a culture of patient safety. Morbidity and mortality (M&M) conferences are designed to review adverse events to prevent future similar events. The extent to which pediatric surgeons participate in M&M, and believe M&M improves patient safety, is unknown. METHODS A cross-sectional survey of the American Pediatric Surgical Association membership was conducted to evaluate participation in and perception of M&M conferences. Closed and open-ended questions were provided to gauge participation and perceptions of M&M effectiveness. Standard frequency analyses and tests of associations between M&M program attributes and surgeons' perceptions of effectiveness were performed. RESULTS The response rate was 38% (353/928). Most surgeons (85%) reported that they always participate in M&M, but only 64% believe M&M is effective in changing practice or prevention of future adverse events. Effective M&Ms were more likely to emphasize loop closure, multidisciplinary participation, standardized assessment of events, and connection to quality improvement efforts. CONCLUSIONS Most pediatric surgeons participate in M&M, but many doubt its effectiveness. We identified attributes of M&M conferences that are perceived to be effective. Further investigation is needed to identify how to optimally utilize peer-review programs to prevent adverse events and improve patient safety. LEVEL OF EVIDENCE V.
Collapse
Affiliation(s)
- Loren Berman
- Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803, USA; Sidney Kimmel College at Thomas Jefferson University, 1025 Walnut St #100, Philadelphia, PA 19107, USA.
| | - Madelene Ottosen
- University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, 6410 Fannin St, Houston, TX 77030-3006, USA.
| | - Elizabeth Renaud
- Hasbro Children's Hospital, Brown University, 593 Eddy St, Providence, RI 02903, USA.
| | - Belinda Hsi-Dickie
- Boston Children's Hospital, 300 Longwood Ave and Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.
| | - Annie Fecteau
- Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8, Canada.
| | - David Skarda
- University of Utah, 201 Presidents Cir, Salt Lake City, UT 84112, USA.
| | - Adam Goldin
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA; University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Shawn Rangel
- Boston Children's Hospital, 300 Longwood Ave and Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.
| | - KuoJen Tsao
- University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety, 6410 Fannin St, Houston, TX 77030-3006, USA.
| | | |
Collapse
|
21
|
Eichbaum Q, Adkins B, Craig-Owens L, Ferguson D, Long D, Shaver A, Stratton C. Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error. ACTA ACUST UNITED AC 2019; 6:249-257. [PMID: 30511929 DOI: 10.1515/dx-2018-0089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 10/30/2018] [Indexed: 11/15/2022]
Abstract
Background Heuristics and cognitive biases are thought to play an important role in diagnostic medical error. How to systematically determine and capture these kinds of errors remains unclear. Morbidity and mortality rounds (MMRs) are generally focused on reducing medical error by identifying and correcting systems failures. However, they may also provide an educational platform for recognizing and raising awareness on cognitive errors. Methods A total of 49 MMR cases spanning the period 2008-2015 in our pathology department were examined for the presence of cognitive errors and/or systems failures by eight study participant raters who were trained on a subset of 16 of these MMR cases (excluded from the main study analysis) to identify such errors. The Delphi method was used to obtain group consensus on error classification on the remaining 33 study cases. Cases with <75% inter-rater agreement were subjected to subsequent rounds of Delphi analysis. Inter-rater agreement at each round was determined by Fleiss' kappa values. Results Thirty-six percent of the cases presented at our pathology MMRs over an 8-year period were found to contain errors likely due to cognitive bias. Conclusions These data suggest that the errors identified in our pathology MMRs represent not only systems failures but may also be composed of a significant proportion of cognitive errors. Teaching trainees and health professionals to correctly identify different types of cognitive errors may present an opportunity for quality improvement interventions in the interests of patient safety.
Collapse
Affiliation(s)
- Quentin Eichbaum
- Vanderbilt Pathology Education Research Group (VPERG), Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, TN, USA
| | - Brian Adkins
- Vanderbilt Pathology Education Research Group (VPERG), Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, TN, USA
| | - Laura Craig-Owens
- Vanderbilt Pathology Education Research Group (VPERG), Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, TN, USA
| | - Donna Ferguson
- Vanderbilt Pathology Education Research Group (VPERG), Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, TN, USA
| | | | - Aaron Shaver
- Vanderbilt Pathology Education Research Group (VPERG), Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, TN, USA
| | - Charles Stratton
- Vanderbilt Pathology Education Research Group (VPERG), Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center (VUMC), Nashville, TN, USA
| |
Collapse
|
22
|
Durstenfeld MS, Statman S, Dikman A, Fallahi A, Fang C, Volpicelli FM, Hochman KA. The Swiss Cheese Conference: Integrating and Aligning Quality Improvement Education With Hospital Patient Safety Initiatives. Am J Med Qual 2019; 34:590-595. [PMID: 30658537 DOI: 10.1177/1062860618817638] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Accreditation Council for Graduate Medical Education requires integration of quality improvement and patient safety education into graduate medical education (GME). The authors created a novel "Swiss Cheese Conference" to bridge the gap between GME and hospital patient safety initiatives. Residents investigate a specific patient safety event and lead a monthly multidisciplinary conference about the case. Resident presenters introduce the Swiss cheese model, present the case and their findings, and teach a patient safety topic. In groups, participants identify contributing factors and discuss how to prevent similar events. Presenters and stakeholders immediately huddle to identify next steps. The Swiss Cheese Conference has increased participants' comfort analyzing safety issues from a systems perspective, utilizing the electronic reporting system, and launching patient safety initiatives. The Swiss Cheese Conference is a successful multidisciplinary model that engages GME trainees by integrating resident-led, case-based quality improvement education with creation of patient safety initiatives.
Collapse
Affiliation(s)
| | - Scott Statman
- New York University, New York, NY.,NYU Langone Health, New York, NY
| | - Andrew Dikman
- New York University, New York, NY.,NYU Langone Health, New York, NY
| | - Anahita Fallahi
- New York University, New York, NY.,NYU Langone Health, New York, NY
| | - Cindy Fang
- New York University, New York, NY.,NYU Langone Health, New York, NY
| | | | | |
Collapse
|
23
|
Zindel J, Kaderli RM, Jakob MO, Dosch M, Tschan F, Candinas D, Beldi G. Electronic Voting to Improve Morbidity and Mortality Conferences. World J Surg 2018; 42:3474-3481. [PMID: 29770874 PMCID: PMC6182754 DOI: 10.1007/s00268-018-4670-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND It is of major importance in clinical surgery to identify potential patterns and specific causes of complications. Therefore, morbidity and mortality meetings (M&M) are widely used to discuss and evaluate deviations from expected outcomes in order to improve surgical practice. Moreover, M&M represent an important tool for continuous medical education. In this study, we introduced an electronic voting system to assess whether anonymity during M&M could limit potential biases due to hierarchical structures or opinion leaders. METHODS This study was conducted in the surgical department of a European tertiary care center. During the study period, electronic voting was applied in 412 M&M cases and compared with a baseline of 330 conventional M&M entries. In this interrupted time series, the educational quality and participant satisfaction of the M&M were assessed using surveys before and after the introduction of electronic voting. The surveys were refined using principle component analysis. In addition, the classification of the cause of the complication was recorded. RESULTS The introduction of electronic voting led to a significant increase in perceived educational quality from 2.63 to 3.36 (p < 0.01), and the overall participant satisfaction increased from 2.6 ± 0.9 to 3.7 ± 1.2 (p < 0.01) on a five-point Likert scale. The frequency of voting shifted from "patient's disease" (before 42.9, after 27.6%, p = 0.04) to "misadventure" (before 1.1, after 16.0%, p < 0.01). The voting frequencies for the causes attributed to "management" and "technical" remained constant. CONCLUSIONS An electronic voting system in M&M meetings increases perceived educational quality and participant satisfaction.
Collapse
Affiliation(s)
- Joel Zindel
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Reto M Kaderli
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Manuel O Jakob
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Michel Dosch
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Franziska Tschan
- Institute for Work and Organizational Psychology, University of Neuchatel, Neuchâtel, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
| |
Collapse
|
24
|
Schwappach DLB, Häsler L, Pfeiffer Y. Chief physicians’ perceived need for improvement of morbidity and mortality conferences: the role of structural and procedural characteristics. BMJ LEADER 2018. [DOI: 10.1136/leader-2017-000052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundMortality and morbidity conferences (M&MCs) are used to retrospectively discuss adverse events. Recently, the focus of the M&MC shifted from a clinical learning tool to a forum for analysing events using systems-based approaches. The aim of this study was to explore the M&MC characteristics that are associated with perceived improvement needs reported by chief physicians.MethodsA cross-sectional survey among chief physicians assessed characteristics of currently implemented M&MCs in Switzerland (44 items). A summative score was developed covering information on procedural and structural characteristics commonly recommended for design of M&MCs.ResultsOf 223 participants, 145 (65%) indicated that their M&MC could be improved. Regression analysis revealed that the score (ie, the sum of structural and procedural features of the M&MC) was associated with self-perceived need for improvement of M&MCs (OR=0.73, CI 0.62 to 0.85, P<0.001). Chief physicians who explicitly select cases for M&MC discussion which involve problems in cooperation had twice the odds of reporting a need for improvement (OR=1.99, CI 1.05 to 3.74, P=0.034).ConclusionOur study provides important insights into the factors contributing to chief physicians’ evaluation of M&MCs. Offering support for addressing the procedural and structural features of the M&MCs may be a good lever to improve them.
Collapse
|
25
|
de Vos MS, Marang-van de Mheen PJ, Smith AD, Mou D, Whang EE, Hamming JF. Toward Best Practices for Surgical Morbidity and Mortality Conferences: A Mixed Methods Study. JOURNAL OF SURGICAL EDUCATION 2018; 75:33-42. [PMID: 28720425 DOI: 10.1016/j.jsurg.2017.07.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 06/28/2017] [Accepted: 07/02/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To assess formats for surgical morbidity and mortality conferences (M&M) for strengths and challenges. DESIGN A mixed methods approach with local observations to assess key domains of M&M practice (i.e., goals, structure, and process/content) and surveys to assess participants' expectations and experiences. SETTING Surgical departments of two teaching hospitals (Boston, USA and Leiden, Netherlands). PARTICIPANTS Participants of surgical M&M, including attending surgeons, residents, physician assistants, and medical students (total n = 135). RESULTS Surgical M&M practices at both hospitals had education as its overarching goal, but varied in structure and process/content. Expectations were similar at both sites with ≥80% of participants (n = 90; 67% response) expecting M&M to be focused on education as well as quality improvement (QI), blame-free, mandatory for both residents and attendings, and to lead to changes in clinical practice. However, compared to expectations, significantly fewer participants at both sites experienced: a QI focus (both p < 0.001); mandatory faculty attendance (p = 0.004; p < 0.001) and changes to practice (both p < 0.001). In comparison, at the site where an active moderator and QI committee are present, respondents seemed more positive about experiencing a QI focus (73% vs 30%) and changes to practice (44% vs 16%). CONCLUSION Despite variation in M&M practice, the same (unmet) expectations existed at both hospitals, indicating that certain challenges may be more universal. M&M was reported to be well-focused on education, and certain aspects (e.g., active moderator and QI committee) seemed beneficial, but expectations were not met for the conference's focus and function for QI. Greater exchange of "best practices" for M&M may enhance the conference's value for improving surgical care.
Collapse
Affiliation(s)
- Marit S de Vos
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands; Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands; Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | | | - Ann D Smith
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Danny Mou
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edward E Whang
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
26
|
de Vos MS, Hamming JF, Marang-van de Mheen PJ. Barriers and facilitators to learn and improve through morbidity and mortality conferences: a qualitative study. BMJ Open 2017; 7:e018833. [PMID: 29133335 PMCID: PMC5695320 DOI: 10.1136/bmjopen-2017-018833] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore barriers and facilitators to successful morbidity and mortality conferences (M&M), driving learning and improvement. DESIGN This is a qualitative study with semistructured interviews. Inductive, thematic content analysis was used to identify barriers and facilitators, which were structured across a pre-existing framework for change in healthcare. SETTING Dutch academic surgical department with a long tradition of M&M. PARTICIPANTS An interview sample of surgeons, residents and physician assistants (n=12). RESULTS A total of 57 barriers and facilitators to successful M&M, covering 18 themes, varying from 'case type' to 'leadership', were perceived by surgical staff. While some factors related to M&M organisation, others concerned individual or social aspects. Eight factors, of which four were at the social level, had simultaneous positive and negative effects (eg, 'hierarchy' and 'team spirit'). Mediating pathways for M&M success were found to relate to available information, staff motivation and realisation processes. CONCLUSIONS This study provides leads for improvement of M&M practice, as well as for further research on key elements of successful M&M. Various factors were perceived to affect M&M success, of which many were individual and social rather than organisational factors, affecting information and realisation processes but also staff motivation. Based on these findings, practical recommendations were formulated to guide efforts towards best practices for M&M.
Collapse
Affiliation(s)
- Marit S de Vos
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | | |
Collapse
|
27
|
Smaggus A, Mrkobrada M, Marson A, Appleton A. Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and educational goals: a systematic review. BMJ Qual Saf 2017; 27:74-84. [DOI: 10.1136/bmjqs-2017-006632] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 08/23/2017] [Accepted: 09/03/2017] [Indexed: 12/13/2022]
Abstract
BackgroundThe quality and safety movement has reinvigorated interest in optimising morbidity and mortality (M&M) rounds. We performed a systematic review to identify effective means of updating M&M rounds to (1) identify and address quality and safety issues, and (2) address contemporary educational goals.MethodsRelevant databases (Medline, Embase, PubMed, Education Resource Information Centre, Cumulative Index to Nursing and Allied Health Literature, Healthstar, and Global Health) were searched to identify primary sources. Studies were included if they (1) investigated an intervention applied to M&M rounds, (2) reported outcomes relevant to the identification of quality and safety issues, or educational outcomes relevant to quality improvement (QI), patient safety or general medical education and (3) included a control group. Study quality was assessed using the Medical Education Research Study Quality Instrument and Newcastle-Ottawa Scale-Education instruments. Given the heterogeneity of interventions and outcome measures, results were analysed thematically.ResultsThe final analysis included 19 studies. We identified multiple effective strategies (updating objectives, standardising elements of rounds and attaching rounds to a formal quality committee) to optimise M&M rounds for a QI/safety purpose. These efforts were associated with successful integration of quality and safety content into rounds, and increased implementation of QI interventions. Consistent effects on educational outcomes were difficult to identify, likely due to the use of methodologies ill-fitted for educational research.ConclusionsThese results are encouraging for those seeking to optimise the quality and safety mission of M&M rounds. However, the inability to identify consistent educational effects suggests the investigation of M&M rounds could benefit from additional methodologies (qualitative, mixed methods) in order to understand the complex mechanisms driving learning at M&M rounds.
Collapse
|
28
|
George J. Medical morbidity and mortality conferences: past, present and future. Postgrad Med J 2016; 93:148-152. [DOI: 10.1136/postgradmedj-2016-134103] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 09/04/2016] [Accepted: 10/18/2016] [Indexed: 12/15/2022]
|
29
|
Envisioning the Future Morbidity and Mortality Conference: A Vehicle for Systems Change. Pediatr Qual Saf 2016; 1:e003. [PMID: 30229144 PMCID: PMC6132584 DOI: 10.1097/pq9.0000000000000003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 09/21/2016] [Indexed: 11/27/2022] Open
|
30
|
Chaneliere M, Jacquet F, Occelli P, Touzet S, Siranyan V, Colin C. Assessment of patient safety culture: what tools for medical students? BMC MEDICAL EDUCATION 2016; 16:255. [PMID: 27687526 PMCID: PMC5043596 DOI: 10.1186/s12909-016-0778-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 09/23/2016] [Indexed: 06/01/2023]
Abstract
BACKGROUND The assessment of patient safety culture refers mainly to surveys exploring the perceptions of health professionals in hospitals. These surveys have less relevance when considering the assessment of the patient safety culture of medical students, especially at university or medical school. They are indeed not fully integrated in care units and constitute a heterogeneous population. This work aimed to find appropriate assessment tools of the patient safety culture of medical students. METHODS Systematic review of the literature. Surveys related to a care unit were excluded. A typology of the patient safety culture of medical students was built from the included surveys. RESULTS Eighteen surveys were included. In our typology of patient safety culture of medical students (15 dimensions), the number of dimensions explored by survey (n) ranged from 1 to 12, with 6 "specialized" tools (n ≤ 4) and 12 "global" tools (N ≥ 5). These surveys have explored: knowledge about patient safety, acknowledgment of the inevitability of human error, the lack of skills as the main source of errors, the errors reporting systems, disclosure of medical errors to others health professionals or patients, teamwork and patient involvement to improve safety in care. CONCLUSIONS We recommend using Wetzel's survey for making an overall assessment of the patient safety culture of medical students at university. In a specific purpose-e.g. to assess an educational program on medical error disclosure-the authors recommend to determine which dimensions of patient safety will be taught, to select the best assessment tool. Learning on patient safety should however be considered beyond the university. International translations of tools are required to create databases allowing comparative studies.
Collapse
Affiliation(s)
- M. Chaneliere
- Health Services and Performance Research (HESPER), 162 Avenue Lacassagne Bât A—F69424, Lyon, cedex 03 France
- Claude Bernard University Lyon 1 (UCBL), 8 avenue Rockefeller, F 69373, Lyon, Cedex 08 France
- Hospices Civils de Lyon, Pôle IMER, 162 Avenue Lacassagne Bât A—F69424, Lyon, cedex 03 France
- Department of Family Practice—UCB Lyon, 1 - 8 av Rockefeller 69373, Lyon, cedex 08 France
| | - F. Jacquet
- Claude Bernard University Lyon 1 (UCBL), 8 avenue Rockefeller, F 69373, Lyon, Cedex 08 France
| | - P. Occelli
- Claude Bernard University Lyon 1 (UCBL), 8 avenue Rockefeller, F 69373, Lyon, Cedex 08 France
- Hospices Civils de Lyon, Pôle IMER, 162 Avenue Lacassagne Bât A—F69424, Lyon, cedex 03 France
| | - S. Touzet
- Claude Bernard University Lyon 1 (UCBL), 8 avenue Rockefeller, F 69373, Lyon, Cedex 08 France
- Hospices Civils de Lyon, Pôle IMER, 162 Avenue Lacassagne Bât A—F69424, Lyon, cedex 03 France
| | - V. Siranyan
- Health Services and Performance Research (HESPER), 162 Avenue Lacassagne Bât A—F69424, Lyon, cedex 03 France
- Claude Bernard University Lyon 1 (UCBL), 8 avenue Rockefeller, F 69373, Lyon, Cedex 08 France
| | - C. Colin
- Health Services and Performance Research (HESPER), 162 Avenue Lacassagne Bât A—F69424, Lyon, cedex 03 France
- Claude Bernard University Lyon 1 (UCBL), 8 avenue Rockefeller, F 69373, Lyon, Cedex 08 France
- Hospices Civils de Lyon, Pôle IMER, 162 Avenue Lacassagne Bât A—F69424, Lyon, cedex 03 France
| |
Collapse
|
31
|
Walker M, Rubio D, Horstman M, Trautner B, Stewart D. Stop the Blame Game: Restructuring Morbidity and Mortality Conferences to Teach Patient Safety and Quality Improvement to Residents. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2016; 12:10475. [PMID: 31008253 PMCID: PMC6464420 DOI: 10.15766/mep_2374-8265.10475] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 09/02/2016] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Adverse events leading to patient harm are rarely the result of an individual error but are instead due to a series of errors resulting from system breakdowns. Thus, the Accreditation Council for Graduate Medical Education requires all residents to participate in quality improvement and patient safety programs. However, a major reported obstacle to sustainable quality improvement and patient safety curricula, as well as meaningful practice improvement, is the small number of faculty with expertise or training in these topics. METHODS This workshop provides a simple framework for redesigning traditional morbidity and mortality conferences for faculty who have minimal quality improvement training. The materials associated with this publication include a standardized presentation template, sample teaching points, and a faculty facilitator's guide. RESULTS Between August 2014 and February 2015, 135 trainees from one of our tertiary training sites attended seven of these redesigned conferences. The largest gains were made in teaching residents how to use a systems-based approach to analyze medical error and how to identify corresponding error-reduction strategies. Residents also perceived themselves as more likely to put their knowledge into action through filing an incident report after attending the conference. The one item that did not change was the residents' perception of safety culture at their institution, suggesting that attendance at a monthly conference is not sufficient to change culture. DISCUSSION Similarly formatted M&Mconferences may help institutions address several aspectof the ACGME CLER program that provides programswith periodic feedback regarding trainee education onpatient safety and quality improvement as well.
Collapse
Affiliation(s)
- Megan Walker
- Chief Resident in Quality and Patient Safety, Baylor College of Medicine
| | - David Rubio
- Assistant Professor and Hospitalist, University of Texas MD Anderson Cancer Center
| | - Molly Horstman
- Health Services Research Fellow, Baylor College of Medicine
| | - Barbara Trautner
- Associate Professor, Department of Internal Medicine, Baylor College of Medicine
| | - Diana Stewart
- Assistant Professor and Hospitalist, Departments of Pediatrics and Internal Medicine, Baylor College of Medicine
| |
Collapse
|
32
|
Lecoanet A, Vidal-Trecan G, Prate F, Quaranta JF, Sellier E, Guyomard A, Seigneurin A, François P. Assessment of the contribution of morbidity and mortality conferences to quality and safety improvement: a survey of participants' perceptions. BMC Health Serv Res 2016; 16:176. [PMID: 27169924 PMCID: PMC4865106 DOI: 10.1186/s12913-016-1431-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 02/05/2016] [Indexed: 11/24/2022] Open
Abstract
Background Evidence for the effectiveness of the morbidity and mortality conferences in improving patient safety is lacking. The aim of this survey was to assess the opinion of participants concerning the benefits and the functioning of morbidity and mortality conferences, according to their organizational characteristics. Methods We conducted a survey of professionals involved in a morbidity and mortality conference using a self-administered questionnaire in three French teaching hospitals in 2012. The questionnaire focused on the functioning of morbidity and mortality conferences, the perceived benefits, the motivations of participants, and how morbidity and mortality conferences could be improved. The perception of participants was analysed according to the characteristics of morbidity and mortality conferences. Results A total of 698 participants in 54 morbidity and mortality conferences completed the questionnaire. Most of them (91 %) were satisfied with how the morbidity and mortality conference they attended was conducted. The improvements in healthcare quality and patient safety were the main benefits perceived by participants. Effectiveness in improving safety was mainly perceived when cases were thoroughly analysed (adjusted odds ratio [a0R] =2.31 [1.14–4.66]). The existence of a written charter (p = 0.05), the use of a standardized case presentation (p = 0.049), and prior dissemination of the meeting agenda (p = 0.02) were also associated with the perception of morbidity and mortality conference effectiveness. The development and achievement of improvement initiatives were associated with morbidity and mortality conferences perceived as being more effective (p < 0.01). Participants suggested improving the attendance of medical and paramedical professionals to enhance the effectiveness of morbidity and mortality conferences. Conclusions Morbidity and mortality conferences were positively perceived. These results suggest that a structured framework and thoroughly analyzing cases improve their effectiveness.
Collapse
Affiliation(s)
- André Lecoanet
- Public Health Department, University Hospital, Grenoble, F-38043, France
| | - Gwenaëlle Vidal-Trecan
- Public health unit: Risk Management and Quality of Care, Paris Centre University Hospital Group, AP-HP, Paris, F-75014, France.,Research Unit: METHODS team, INSERM U1153 (Centre de Recherche Epidémiologie Biostatistique, Sorbonne Paris Cité), Paris, F-75005, France.,Medical School, Paris Descartes University, Paris, F-75006, France
| | - Frédéric Prate
- Public Health Department, University Hospital, Nice, F-06003, France
| | | | - Elodie Sellier
- Public Health Department, University Hospital, Grenoble, F-38043, France.,Research Unit TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38041, France
| | - Alizé Guyomard
- Public Health Department, University Hospital, Grenoble, F-38043, France
| | - Arnaud Seigneurin
- Public Health Department, University Hospital, Grenoble, F-38043, France.,Research Unit TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38041, France
| | - Patrice François
- Public Health Department, University Hospital, Grenoble, F-38043, France. .,Research Unit TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38041, France.
| |
Collapse
|
33
|
Mondoux SE, Frank JR, Kwok ESH, Cwinn AA, Lee AC, Calder LA. Teaching M&M rounds skills: enhancing and assessing patient safety competencies using the Ottawa M&M model. Postgrad Med J 2016; 92:631-635. [DOI: 10.1136/postgradmedj-2015-133265] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/01/2016] [Accepted: 03/07/2016] [Indexed: 11/04/2022]
|
34
|
Şalvız EA, Edipoğlu Sİ, Sungur MO, Altun D, Büget Mİ, Seyhan TÖ. Critical Incident Reporting System in Teaching Hospitals in Turkey: A Survey Study. Turk J Anaesthesiol Reanim 2016; 44:59-70. [PMID: 27366560 DOI: 10.5152/tjar.2016.75133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 12/30/2015] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE Critical incident reporting systems (CIRS) and morbidity-mortality meetings (MMMs) offer the advantages of identifying potential risks in patients. They are key tools in improving patient safety in healthcare systems by modifying the attitudes of clinicians, nurses and staff (human error) and also the system (human and/or technical error) according to the analysis and the results of incidents. METHODS One anaesthetist assigned to an administrative and/or teaching position from all university hospitals (UHs) and training and research hospitals (TRHs) of Turkey (n=114) was contacted. In this survey study, we analysed the facilities of anaesthetists in Turkish UHs and TRHs with respect to CIRS and MMMs and also the anaesthetists' knowledge, experience and attitudes regarding CIs. RESULTS Anaesthetists from 81 of 114 teaching hospitals replied to our survey. Although 96.3% of anaesthetists indicated CI reporting as a necessity, only 37% of departments/hospitals were reported to have CIRS. True definition of CI as "an unexpected /accidental event" was achieved by 23.3% of anaesthetists with CIRS. MMMs were reported in 60.5% of hospitals. Nevertheless, 96% of anaesthetists believe that CIRS and MMMs decrease the incidence of CI occurring. CI occurrence was attributed to human error as 4 [1-5]/10 and 3 [1-5]/10 in UHs and TRHs, respectively (p=0.005). In both hospital types, technical errors were evaluated as 3 [1-5]/10 (p=0.498). CONCLUSION This first study regarding CIRS in the Turkish anaesthesia departments/hospitals highlights the lack of CI knowledge and CIRS awareness and use in anaesthesia departments/teaching hospitals in Turkey despite a safety reporting system set up by the Turkish Ministry of Health.
Collapse
Affiliation(s)
- Emine Aysu Şalvız
- Department of Anaesthesiology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Saadet İpek Edipoğlu
- Clinic of Anaesthesiology, Süleymaniye Training and Research Hospital, İstanbul, Turkey
| | - Mukadder Orhan Sungur
- Department of Anaesthesiology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Demet Altun
- Department of Anaesthesiology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Mehmet İlke Büget
- Department of Anaesthesiology, İstanbul University School of Medicine, İstanbul, Turkey
| | - Tülay Özkan Seyhan
- Department of Anaesthesiology, İstanbul University School of Medicine, İstanbul, Turkey
| |
Collapse
|
35
|
Bernstein J. Not the Last Word: Morbidity and Mortality Conference: Theater of Education. Clin Orthop Relat Res 2016; 474:882-6. [PMID: 26886690 PMCID: PMC4773326 DOI: 10.1007/s11999-016-4750-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 02/10/2016] [Indexed: 01/31/2023]
Affiliation(s)
- Joseph Bernstein
- Department of Orthopaedic Surgery, University of Pennsylvania, 424 Stemmler Hall, Philadelphia, PA 19104 USA
| |
Collapse
|
36
|
Kobewka DM, van Walraven C, Turnbull J, Worthington J, Calder L, Forster A. Quality gaps identified through mortality review. BMJ Qual Saf 2016; 26:141-149. [PMID: 26856617 PMCID: PMC5284344 DOI: 10.1136/bmjqs-2015-004735] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 11/20/2015] [Accepted: 01/17/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Hospital mortality rate is a common measure of healthcare quality. Morbidity and mortality meetings are common but there are few reports of hospital-wide mortality-review processes to provide understanding of quality-of-care problems associated with patient deaths. OBJECTIVE To describe the implementation and results from an institution-wide mortality-review process. DESIGN A nurse and a physician independently reviewed every death that occurred at our multisite teaching institution over a 3-month period. Deaths judged by either reviewer to be unanticipated or to have any opportunity for improvement were reviewed by a multidisciplinary committee. We report characteristics of patients with unanticipated death or opportunity for improved care and summarise the opportunities for improved care. RESULTS Over a 3-month period, we reviewed all 427 deaths in our hospital in detail; 33 deaths (7.7%) were deemed unanticipated and 100 (23.4%) were deemed to be associated with an opportunity for improvement. We identified 97 opportunities to improve care. The most common gap in care was: 'goals of care not discussed or the discussion was inadequate' (n=25 (25.8%)) and 'delay or failure to achieve a timely diagnosis' (n=8 (8.3%)). Patients who had opportunities for improvement had longer length of stay and a lower baseline predicted risk of death in hospital. Nurse and physician reviewers spent approximately 142 h reviewing cases outside of committee meetings. CONCLUSIONS Our institution-wide mortality review found many quality gaps among decedents, in particular inadequate discussion of goals of care.
Collapse
Affiliation(s)
- Daniel M Kobewka
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Epidemiology and Community Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Carl van Walraven
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | | | | | - Lisa Calder
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alan Forster
- Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Department of Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
37
|
François P, Prate F, Vidal-Trecan G, Quaranta JF, Labarere J, Sellier E. Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study. BMC Health Serv Res 2016; 16:35. [PMID: 26831501 PMCID: PMC4734851 DOI: 10.1186/s12913-016-1279-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 01/22/2016] [Indexed: 11/11/2022] Open
Abstract
Background The aim of this study was to identify the characteristics of morbidity and mortality conferences (MMCs) associated with the implementation of patient health-care quality and safety improvement initiatives. Methods We conducted an observational study of MMCs and followed up improvement initiatives for 1 year. Data on MMC baseline characteristics were abstracted using document analysis and observation of a meeting in three university hospitals in France (Grenoble, Nice, and Cochin [Paris] hospitals). Fifty-nine MMCs were included in medical (n = 24), surgical (n = 21), and anesthesiology and/or intensive care (n = 14) departments. An effectiveness index was computed by summing a composite score for each initiative pertaining to the MMC. Results Overall, 282 initiatives were identified in 42 MMCs. During the follow-up period, 215 initiatives (76 %) were totally or partially implemented and the impact was evaluated for 73 (26 %). An effectiveness index higher than the median (i.e., ≥10) was associated with a standardized presentation of cases (81 % versus 29 %, p <0.001), recording of improvement initiatives (94 versus 57, p = 0.001), the existence of an annual activity report (94 % versus 68 %, p = 0.01), the prior dissemination of a meeting agenda (71 % versus 36 %, p = 0.007), longer meeting duration (109 versus 80 min, p = 0.005), anesthesiology and/or intensive care specialty (39 % versus 7 %, p = 0.02), a theme-focused MMC (29 % versus 4 %, p = 0.01), and a thorough analysis of failures (58 % versus 25 %, p = 0.01). Conclusions This study suggests that the implementation of improvement initiatives relates to MCC characteristics. Recommendations for developing more effective patient safety-oriented MMCs can be proposed. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1279-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Patrice François
- Quality of Care Unit, University Hospital, and Research Unit, TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38043, France.
| | - Frédéric Prate
- Public Health Department, University Hospital, Nice, F-06003, France
| | - Gwenaëlle Vidal-Trecan
- Public Health Unit: Risk Management and Quality of Care, Paris Centre University Hospital Group, AP-HP, and Research Unit, (INSERM U738), Paris Descartes University, Sorbonne Paris cite, Paris, F- 75014, France
| | | | - José Labarere
- Quality of Care Unit, University Hospital, and Research Unit, TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38043, France
| | - Elodie Sellier
- Quality of Care Unit, University Hospital, and Research Unit, TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38043, France
| |
Collapse
|
38
|
Abstract
OBJECTIVE Determine the effectiveness of a structured systems-oriented morbidity and mortality conference in improving the process of reviewing and responding to adverse events in a PICU. DESIGN Prospective time series analysis before and after implementation of a systems-oriented morbidity and mortality conference. SETTING Single tertiary referral PICU in Baltimore, MD. PATIENTS Thirty-three patients discussed before and 31 patients after implementation of a systems-oriented morbidity and mortality conference over a total of 20 morbidity and mortality conferences, from April 2013 to March 2014. INTERVENTIONS Systems-oriented morbidity and mortality conference incorporating elements of medical incident analysis. MEASUREMENTS AND MAIN RESULTS There was a significant increase in meeting attendance (mean, 12 vs 31 attendees per morbidity and mortality conference; p < 0.001) after the systems-oriented morbidity and mortality conference was instituted. There was no significant difference in the mean number of cases suggested (4.2 vs 4.6) or discussed (3.3 vs 3.1) per morbidity and mortality conference. There was also no significant difference in the mean number of adverse events identified per morbidity and mortality conference (3.4 vs 4.3). However, there was an increase in the proportion of cases discussed using a standard case review tool, but this did not reach statistical significance (27% vs 45%; p = 0.231). Nevertheless, we observed a significant increase in the mean number of quality improvement interventions suggested (2.4 vs 5.6; p < 0.001) and implemented (1.7 vs 4.4; p < 0.001) per morbidity and mortality conference. All adverse event categories identified had corresponding interventions suggested after the systems-oriented morbidity and mortality conference was instituted compared with before (80% vs 100%). Intervention-to-adverse event ratios per category were also higher (mean, 0.6 vs 1.5). CONCLUSIONS A structured systems-oriented PICU morbidity and mortality conference incorporating elements of medical incident analysis improves the process of reviewing and responding to adverse events by significantly increasing quality improvement interventions suggested and implemented. Future work would involve testing locally adapted versions of the systems-oriented morbidity and mortality conference in multiple inpatient settings.
Collapse
|
39
|
At the Crossroad with Morbidity and Mortality Conferences: Lessons Learned through a Narrative Systematic Review. Can J Gastroenterol Hepatol 2016; 2016:7679196. [PMID: 27446868 PMCID: PMC4904689 DOI: 10.1155/2016/7679196] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 09/19/2015] [Indexed: 02/07/2023] Open
Abstract
Objective. To determine the process and structure of Morbidity and Mortality Conference (MMC) and to provide guidelines for conducting MMC. Methods. Using a narrative systematic review methodology, literature search was performed from January 1, 1950, to October 2, 2012. Original articles in adult population were included. MMC process and structure, as well as baseline study demographics, main results, and conclusions, were collected. Results. 38 articles were included. 10/38 (26%) pertained to medical subspecialties and 25/38 (66%) to surgical subspecialties. 15/38 (40%) were prospective, 14/38 (37%) retrospective, 7/38 (18%) interventional, and 2/38 (5%) cross-sectional. The goals were quality improvement and education. Of the 10 medical articles, MMC were conducted monthly 60% of the time. Cases discussed included complications (60%), deaths (30%), educational values (30%), and system issues (40%). Recommendations for improvements were made frequently (90%). Of the 25 articles in surgery, MMCs were weekly (60% of the time). Cases covered mainly complications (72%) and death (52%), with fewer cases dedicated to education (12%). System issues and recommendations were less commonly reported. Conclusion. Fundamental differences existed in medical versus surgical departments in conducting MMC, although the goals remained similar. We provide a schematic guideline for MMC through a summary of existing literature.
Collapse
|
40
|
Khine M, Leung E, McGregor JR. A survey of morbidity and mortality review meetings in the general surgical units of the West of Scotland. Scott Med J 2015. [PMID: 26209613 DOI: 10.1177/0036933015597179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS There is little consensus as to the conduct of surgical morbidity and mortality review meetings. The aim of this survey was to determine how surgical morbidity and mortality meetings in the surgical units in the West of Scotland are carried out and to explore possible areas for improvement. METHODS AND RESULTS Forty six surgical trainees distributed between the 15 general surgery units of the West of Scotland were asked to provide details of their surgical morbidity and mortality meetings for the training year 2012-2013. Twenty-five of 46 (54%) specialty trainees responded with all units being represented. All had designated time for surgical morbidity and mortality review. Meeting frequency varied as follows: weekly (3 units), fortnightly (1 unit), monthly (10 units), three monthly (1 unit). Fewer than half the units (6) included Foundation Trainees, and only one meeting was attended by nursing staff. Five units had clear criteria for morbidity, but only three included morbidity collected from outpatient follow-up. A standardised proforma was used to present the cases in only 2 units. CONCLUSIONS All 15 surgical units in the West of Scotland have a regular surgical morbidity and mortality meeting but significant variations were observed as to frequency and participating personnel. A more robust system for reporting morbidities should be considered.
Collapse
Affiliation(s)
- Myo Khine
- Specialty Doctor in General Surgery, Department of Surgery, Crosshouse Hospital, UK
| | - Edward Leung
- Consultant General and Colorectal Surgeon, Department of Surgery, Crosshouse Hospital, UK
| | - John R McGregor
- Consultant General and Colorectal Surgeon, Department of Surgery, Crosshouse Hospital, UK
| |
Collapse
|
41
|
Kirkman MA, Sevdalis N, Arora S, Baker P, Vincent C, Ahmed M. The outcomes of recent patient safety education interventions for trainee physicians and medical students: a systematic review. BMJ Open 2015; 5:e007705. [PMID: 25995240 PMCID: PMC4442206 DOI: 10.1136/bmjopen-2015-007705] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 04/14/2015] [Accepted: 04/16/2015] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To systematically review the latest evidence for patient safety education for physicians in training and medical students, updating, extending and improving on a previous systematic review on this topic. DESIGN A systematic review. DATA SOURCES Embase, Ovid Medline and PsycINFO databases. STUDY SELECTION Studies including an evaluation of patient safety training interventions delivered to trainees/residents and medical students published between January 2009 and May 2014. DATA EXTRACTION The review was performed using a structured data capture tool. Thematic analysis also identified factors influencing successful implementation of interventions. RESULTS We identified 26 studies reporting patient safety interventions: 11 involving students and 15 involving trainees/residents. Common educational content included a general overview of patient safety, root cause/systems-based analysis, communication and teamwork skills, and quality improvement principles and methodologies. The majority of courses were well received by learners, and improved patient safety knowledge, skills and attitudes. Moreover, some interventions were shown to result in positive behaviours, notably subsequent engagement in quality improvement projects. No studies demonstrated patient benefit. Availability of expert faculty, competing curricular/service demands and institutional culture were important factors affecting implementation. CONCLUSIONS There is an increasing trend for developing educational interventions in patient safety delivered to trainees/residents and medical students. However, significant methodological shortcomings remain and additional evidence of impact on patient outcomes is needed. While there is some evidence of enhanced efforts to promote sustainability of such interventions, further work is needed to encourage their wider adoption and spread.
Collapse
Affiliation(s)
- Matthew A Kirkman
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, London, UK
| | - Nick Sevdalis
- Health Service and Population Research Department, Centre for Implementation Science, King's College London, London, UK
| | - Sonal Arora
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Paul Baker
- Health Education North West, Manchester, UK
| | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Maria Ahmed
- Centre for Primary Care, NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| |
Collapse
|
42
|
Bhalla VK, Boone L, Lewis F, Gucwa AL, Kruse EJ. The Utility of the Matrix Format for Surgical Morbidity and Mortality Conference. Am Surg 2015. [DOI: 10.1177/000313481508100533] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
With the limitations posed by increasing work hour restrictions, surgical residency programs are focusing more on maximizing the educational benefit of their conferences. The Morbidity and Mortality (M&M) conference serves as a forum to discuss adverse events and patient care improvement using evidence-based medicine. The matrix format (MF) is an enhancement to the traditional format (TF), focusing on the case selection process and a postconference newsletter reiterating the relevant literature review and discussion points. Our institution adopted the MF to evaluate both its short- and long-term educational values. Surveys were distributed to residents and faculty within the Department of General Surgery to assess their interest and satisfaction, perception of educational value, and efficiency with the MF compared with the TF. Responses were obtained from 22/22 (100%) residents for the TF and 11/23 (48%) for the MF. Faculty responses were 19/19 (100%) and 9/16 (56%), respectively. Reasons for an overall decreased response with the MF were not investigated further, as participation was strictly voluntary. Our results confirmed an overall approval of the MF by both residents and faculty. Faculty reported an improved efficiency of the conference ( P < 0.039), encompassing improved content and presentation quality. Residents reported an improved overall interest and satisfaction with the MF ( P < 0.001) as well as an improvement in the educational value ( P < 0.007). Residents spent less time preparing presentations and reported learning greater educational benefit to the conference when preparing their own presentations ( P < 0.001). In conclusion, the MF resulted in a greater overall satisfaction for residents and attending surgeons with an increased investment by the audience and overall improvement in perceived educational benefit.
Collapse
Affiliation(s)
- Varun K. Bhalla
- Department of General Surgery, Georgia Regents University, Augusta, Georgia
| | - Luke Boone
- Department of General Surgery, University Missouri Kansas City, and the
| | - Frank Lewis
- Section of Surgical Oncology, Department of General Surgery, Georgia Regents University, Augusta, Georgia
| | - Angela L. Gucwa
- Department of General Surgery, Georgia Regents University, Augusta, Georgia
| | - E. James Kruse
- Section of Surgical Oncology, Department of General Surgery, Georgia Regents University, Augusta, Georgia
| |
Collapse
|
43
|
Stover DG, Zerillo JA. Morbidity and mortality revisited: applying a new quality improvement paradigm in oncology. J Oncol Pract 2015; 11:e428-33. [PMID: 25901054 DOI: 10.1200/jop.2014.003566] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Using a quality improvement (QI) paradigm, the authors conducted 11 multidisciplinary conferences throughout 2013-2014 at two tertiary academic cancer centers and a satellite community-based oncology practice. They present their approach including key components and an example case.
Collapse
Affiliation(s)
- Daniel G Stover
- Dana-Farber Cancer Institute; and Beth Israel Deaconess Medical Center, Boston, MA
| | - Jessica A Zerillo
- Dana-Farber Cancer Institute; and Beth Israel Deaconess Medical Center, Boston, MA
| |
Collapse
|
44
|
Gonzalo JD, Bump GM, Huang GC, Herzig SJ. Implementation and evaluation of a multidisciplinary systems-focused internal medicine morbidity and mortality conference. J Grad Med Educ 2014; 6:139-46. [PMID: 24701325 PMCID: PMC3963772 DOI: 10.4300/jgme-d-13-00162.1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 09/17/2013] [Accepted: 10/02/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Morbidity and mortality (M&M) conferences provide a forum for discussing adverse events and systems-based practice (SBP) issues; however, few models for implementing multidisciplinary, systems-focused M&M conferences exist. OBJECTIVE To implement a new systems-focused M&M conference and evaluate success in focusing on adverse events and systems issues in a nonpunitive, multidisciplinary manner. METHODS We implemented a new M&M conference into our large university-based internal medicine residency program. Using content analysis, we qualitatively analyzed audio recordings of M&M conferences from the first year of implementation (2010-2011) to determine the frequency of adverse events (injury resulting from medical care), SBP discussion, and allocation of blame. Multidisciplinary attendance was evaluated by attendance logs. Surveys assessed change in interns' perceptions of M&M conferences before and after the conference series (measured by median Likert-scale response) and trainee/faculty attitudes regarding the goal of M&M conferences. RESULTS There were 226 attendees (66 faculty, 160 residents/fellows) at 9 M&M conferences. Average attendance per conference was 71, with representation from 16 disciplines. All M&M conferences (100%) included adverse events, SBP discussion, and lacked explicit individual blame. Interns' perceptions improved, including their belief that the M&M conference's purpose is systems improvement (4.35 versus 4.71, P = .02) and complications are discussed without blame (3.81 versus 4.34, P = .01). After experiencing M&M conferences, trainees/faculty reported favorable ratings, including beliefs that the M&M conference is important for education (97%) and the purpose is systems improvement (95%). CONCLUSIONS The implementation of a new systems-focused M&M conference resulted in a conference series focusing on adverse events and associated system issues in a nonpunitive, multidisciplinary context.
Collapse
|
45
|
de Feijter JM, de Grave WS, Koopmans RP, Scherpbier AJJA. Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning be enhanced? A narrative review. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2013; 18:787-805. [PMID: 22948951 DOI: 10.1007/s10459-012-9400-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 08/16/2012] [Indexed: 06/01/2023]
Abstract
Learning from error is not just an individual endeavour. Organisations also learn from error. Hospitals provide many learning opportunities, which can be formal or informal. Informal learning from error in hospitals has not been researched in much depth so this narrative review focuses on five learning opportunities: morbidity and mortality conferences, incident reporting systems, patient claims and complaints, chart review and prospective risk analysis. For each of them we describe: (1) what can be learnt, categorised according to the seven CanMEDS competencies; (2) how it is possible to learn from them, analysed against a model of informal and incidental learning; and (3) how this learning can be enhanced. All CanMEDS competencies could be enhanced, but there was a particular focus on the roles of medical expert and manager. Informal learning occurred mostly through reflection and action and was often linked to the learning of others. Most important to enhance informal learning from these learning opportunities was the realisation of a climate of collaboration and trust. Possible new directions for future research on informal learning from error in hospitals might focus on ways to measure informal learning and the balance between formal and informal learning. Finally, 12 recommendations about how hospitals could enhance informal learning within their organisation are given.
Collapse
Affiliation(s)
- Jeantine M de Feijter
- Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands,
| | | | | | | |
Collapse
|
46
|
Ahmed M, Arora S, Tiew S, Hayden J, Sevdalis N, Vincent C, Baker P. Building a safer foundation: the Lessons Learnt patient safety training programme. BMJ Qual Saf 2013; 23:78-86. [DOI: 10.1136/bmjqs-2012-001740] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
47
|
Abstract
Diagnostic errors are a major patient safety concern. Although the majority of diagnostic errors are partially attributable to cognitive mistakes, the most effective means of improving clinician cognition in order to achieve gains in diagnostic reliability are unclear. We propose a tripartite educational agenda for improving diagnostic performance among students, residents and practising physicians. This agenda includes strengthening the metacognitive abilities of clinicians, fostering intuitive reasoning and increasing awareness of the role of systems in the diagnostic process. The evidence supporting initiatives in each of these realms is reviewed and a course of future implementation and study is proposed. The barriers to designing and implementing this agenda are substantial and include limited evidence supporting these initiatives and the challenges of changing the practice patterns of practising physicians. Implementation will need to be accompanied by rigorous evaluation.
Collapse
|
48
|
|
49
|
Gonzalo JD, Yang JJ, Huang GC. Systems-based content in medical morbidity and mortality conferences: a decade of change. J Grad Med Educ 2012; 4:438-44. [PMID: 24294419 PMCID: PMC3546572 DOI: 10.4300/jgme-d-12-00016.1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 03/05/2012] [Accepted: 03/18/2012] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Following the Accreditation Council for Graduate Medical Education recommendations in 1999 to foster education in the systems-based practice (SBP) competency by examining adverse clinical events, institutions have modified the morbidity and mortality conference (MMC) to increase SBP-related discussion. We sought to examine the extent to which SBP-related content has increased in our department's MMCs compared with MMCs 10 years prior. METHOD We qualitatively analyzed audio recordings of our MMCs during 2 academic years, 1999-2000 (n = 30) and 2010-2011 (n = 30). We categorized comments and questions from moderators and faculty as SBP or non-SBP and characterized conferences by whether adverse events were presented and which systems issues were discussed. RESULTS Compared with MMCs in 1999-2000, present-day MMCs included a greater average percentage of SBP comments stated (69% versus 12%; P ≤ .001) and questions asked (13% versus 1%; P = .001) by the moderator, SBP comments stated (44% versus 4%; P ≤ .001) and questions asked (19% versus 1%; P ≤ .001) by faculty, and were more likely to present adverse events (87% versus 13%; P < .001). Interrater reliability for the distinction between SBP and non-SBP content was good (κ = 0.647). Most common categories of systems issues discussed in 2010-2011 were critical laboratory value processing and reporting, institutional policies, and hospital-based factors. CONCLUSIONS Over the past decade, our MMC has transformed to include more discussion of SBP-related content and adverse events. The MMC can be used to educate residents in SBP and can also serve as a cornerstone for departmental quality and safety initiatives.
Collapse
|
50
|
Marsal S, Heffner JE. Creating a web-based incident analysis and communication system. J Hosp Med 2012; 7:142-7. [PMID: 21998093 DOI: 10.1002/jhm.956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 04/29/2011] [Accepted: 06/11/2011] [Indexed: 11/07/2022]
Abstract
BACKGROUND Hospitals perform root cause analyses (RCA) and implement action plans for sentinel events (SE) to prevent similar adverse events. Dissemination of RCA action plans between hospitals has been limited by an absence of universal definitions of terms and classification frameworks, which have been recently proposed by the World Health Organization's International Classification for Patient Safety (ICPS). Tools do not exist, however, to assist hospitals in performing SE reviews aligned with the ICPS framework. METHODS We developed an intranet-based decision support tool that aligns SE reviews with the ICPS framework, and captures SEs and action plans into a searchable database for aggregate reporting. Its structural elements include: 1) encrypted database on a secure server; 2) decision support resources that align SE analyses with the ICPS classification; 3) drop-down lists and help tools to standardize input; 4) standardized individual and aggregate SE reports that vary depending on recipients; 5) real-time access to Web-based RCA resources; 6) fishbone diagramming; and 7) query functions for database searches. RESULTS Entry of 15 SE reports into the database framework identified gaps in our previous reviews. Safety personnel and health system leadership have expressed positive assessments of the database and approved funding for evaluation of system-wide implementation. DISCUSSION Expansion of our database to all safety incidents beyond SEs provides a resource for communicating safety opportunities between hospitals. We demonstrate how the ICPS classifications can be migrated into a decision support tool that has potential for standardizing root cause analyses, disseminating action plans, and improving patient safety.
Collapse
Affiliation(s)
- Scott Marsal
- Department of Medical Education, Providence Portland Medical Center, Portland, OR 97213, USA
| | | |
Collapse
|