Humanizing the Morbidity and Mortality Conference

Pang, Sharon; Warraich, Haider J.

doi:10.1097/acm.0000000000003901

Cited by 9 publications

(12 citation statements)

References 11 publications

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“…This study did not attempt to evaluate additional, unquantifiable effects of M&MCs such as promoting a culture of patient safety or serving as a forum for self-reflection and humanization. 26 Our study corroborated the notion that at least a subset of preventable errors attributable to clinical decision making are amenable to systems-based interventions and that when feasible, changes to written protocols are most likely to reduce risk of recurrence of a similar future error. This decade has seen an increasing focus on patient safety and care quality in neurology at the national level.…”

Section: Discussionsupporting

confidence: 79%

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Two-Year Profile of Preventable Errors in Hospital-Based Neurology

et al. 2022

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Background and Objectives:Medical errors are estimated to cause 7,000 deaths and cost 17-29 billion USD per year, but there is a lack of published real-world data on preventable errors, in particular in hospital-based neurology. We sought to characterize the profile of errors that occur on the inpatient neurology services at our institution in order to inform strategies on future error prevention.Methods:We reviewed all cases of preventable errors occurring on the inpatient neurology services from July 1, 2018 to June 30, 2020, logged in institutional error reporting systems and reviewed at departmental morbidity and mortality conferences (M&MC). Each case was characterized by primary category of error, level of harm as determined by the Agency for Healthcare Research & Quality (AHRQ) Common Format Harm Scale version 1.2, primary intervention, and recurrence within one year, with a final censoring date of June 30, 2021.Results:Of 72 cases, 43 (60%) were attributed to errors in clinical decision-making and 20 (28%) to systems or electronic health record-related errors. The majority of cases resulted in in-conference education on systems-based errors (29%) at departmental M&MCs followed by in-conference education on clinical neurology (25%). Among errors classified primarily as clinical, 28% were addressed via systems-based interventions including in-conference education on systems issues and changes in written protocol. In 23 cases (32%), a similar error recurred within one year of the presentation. In total, 7 cases (10%) resulted in a change in written protocol, none with recurrences.Discussion:Systems-based interventions may reduce both clinical and systems-based errors, and protocol changes are effective when feasible. Given the important goal of optimizing care for every patient, quality leaders should conduct continuous audits of preventable errors and quality improvement systems in their clinical areas.

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Section: Discussionsupporting

confidence: 79%

Section: Discussionmentioning

confidence: 99%

Two-Year Profile of Preventable Errors in Hospital-Based Neurology

et al. 2022

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“…Providing answers to parents can help alleviate parent self-blame and ensure accountability for system change ( 29 ). Additionally, parents identified wanting to incorporate positive feedback into the review process as well, highlighting excellence in care received, a concept not dissimilar from the suggestion of incorporating successes into the M&M process and humanizing the process ( 16 , 25 , 26 , 29 , 33 , 34 ).…”

Section: Discussionmentioning

confidence: 99%

“…While not completely universal, M&M review is an established proceeding in most US hospitals and has become a requirement of the Accreditation Council for Graduate Medical Education (ACGME) as part of resident education (13)(14)(15). Given the ACGME mandate, there has been widespread adoption of the M&M conference across US hospitals (16). Given its prevalence, the M&M review has the potential to significantly influence patient care and quality improvement (17)(18)(19)(20).…”

Section: Introductionmentioning

confidence: 99%

Parent Participation in Morbidity and Mortality Review: Parent and Physician Perspectives

Loizaga

Clarke‐Myers

Khoury

et al. 2022

Journal of Patient Experience

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This study examined Morbidity and Mortality (M&M) review practices and perspectives of physicians and parents regarding parent participation in M&M review. Surveys were distributed to parents of children with a prior hospitalization for congenital heart disease (CHD) and physicians caring for pediatric CHD patients. Response distributions and Fisher’s exact tests were performed to compare parent and physician responses. Qualitative survey data were thematically analyzed. Ninety-two parent and 36 physician surveys were analyzed. Physicians reported parent input or participation was rarely sought in M&M review. Parents with direct experience of adverse events or death of their child reported providers discussed events with them in a timely manner and answered their questions; however, nearly half wished their healthcare team had done something differently during the disclosure. There was no statistical difference between groups regarding transparency ( P = .37, .79); however, there was a significant difference in perspectives regarding parental involvement in the M&M review ( P < .001). Common themes important to parents which emerged from the qualitative analysis were being adequately informed, feeling their perspectives were acknowledged and respected, having attentive and empathetic providers, and receiving consistent messaging. Although rarely included in current practice, parent participation in M&M could offer unique insight and increase accountability to proposed change elucidated by M&M review.

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“…Healthcare organizations should schedule regular, open, and honest Morbidity & Mortality safety conferences to provide a secure setting for disclosing and discussing errors. 10 In the long-term, this may foster a safety culture, rather than one of blame and fear. 11 Healthcare organizations may intervene at other segments of the recovery trajectory to enhance outcomes.…”

mentioning

confidence: 99%

Health Care Professional Mental Health and Supporting the Second Victim – Can Organizations Across the World Do Better?

Kuris

Kleuver

Alsoof

et al. 2022

The American Journal of Medicine

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This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Humanizing the Morbidity and Mortality Conference

Cited by 9 publications

References 11 publications

Two-Year Profile of Preventable Errors in Hospital-Based Neurology

Two-Year Profile of Preventable Errors in Hospital-Based Neurology

Parent Participation in Morbidity and Mortality Review: Parent and Physician Perspectives

Health Care Professional Mental Health and Supporting the Second Victim – Can Organizations Across the World Do Better?

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