A Report Card System Using Error Profile Analysis and Concurrent Morbidity and Mortality Review: Surgical Outcome Analysis, Part II

Restructuring the Morbidity and Mortality Conference in a Department of Pediatrics to Serve as a Vehicle for System Changes

“…2 The format and methods by which cases are identified, presented, and discussed vary widely among training programs and disciplines across the United States and Canada 3,4 and even within our own institution. 5 Although much has been published about both traditional and innovative uses of the MMC in internal medicine, 1,3,6 emergency medicine, [7][8][9][10][11] surgery, [12][13][14][15][16][17][18][19][20][21][22][23][24][25] and other disciplines as a forum for highlighting the core competencies of ACGMEs and quality improvement, [12][13][14][26][27][28][29] there is a paucity of literature about the role of the MMC in pediatrics. 4,30 At the Johns Hopkins Children's Center, the MMC had become very similar to the weekly case management conference in which interesting and instructive cases were discussed by faculty members with, primarily, residents and medical students in attendance.…”

Practice-Based Learning and Improvement: A Two-Year Experience with the Reporting of Morbidity and Mortality Cases by General Surgery Residents

“…Our adverse event rate reported by general surgery residents at the University of Pittsburgh Medical Center (2.5%) was even lower than the existing adverse incident underreporting rate by residents in the largest study we could find in the published literature (4.3%). 8,9 Our institutional reporting rate falls far below the more objective adverse event rates for patients of 29% to 41%. [5][6][7] The causes behind this degree of underreporting are unclear.…”

“…Cases appearing in duplicate and "interesting cases" without adverse events were omitted from the analyses. Deidentified patient cases were described according to the 15 adverse event categories and modified subcategory listings described by Antonacci et al 8,9 Adverse events categorized as deaths by this method were subsequently categorized by a modified method as described by Nugent. 10 In the original method, (5) Pre-Existing Catastrophic Conditions.…”

“…Second, we want to determine the adverse event rate for patients reported across surgical services and compare this rate to the largest published resident-based reporting rate found in the literature of 4.3%. 8,9 Finally, we want to describe the nature of those adverse events to start to understand which complications general surgery residents deem important or relevant to report at surgical Morbidity and Mortality Conference. We hypothesize that the reporting patterns and incidence rates for patient adverse events will remain constant over time, and that our institutional adverse event rate will be comparable with the largest resident-based reporting adverse event rate of 4.3%.…”

Overview of surgical death investigations: could a dreaded experience be turned into an opportunity?

“…3 There is evidence that these audits reduce mortality, but is uncertain what proportions of recommendations are implemented and whether their impacts are subsequently evaluated. 4 Aggregate data provide a reliable and contemporary representation of the state of surgical care at a national level and of trends in mortality.…”