Lessons Learned From the Surgical Morbidity and Mortality Conference

Ferreira, Kaio S.; Lynch, Kenneth; Ryder, Beth A.; Connolly, Michael D.; Miner, Thomas J.; Harrington, David

doi:10.1016/j.jsurg.2018.07.002

Cited by 9 publications

(11 citation statements)

References 11 publications

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“…77 Improvements resulting from effective action plans foster the willingness of frontline providers to report near misses and errors. 31 Increased reporting provides the MMC with critical information from which proactive improvements can occur. For example, the University of Pennsylvania Health System established an interdisciplinary Mortality Review Committee to identify and intervene on opportunities for improvement in the provision of patient care.…”

Section: Challenge 5: Mmcs Examine Problems and Provide Recommendatio...mentioning

confidence: 99%

The Morbidity and Mortality Conference: Opportunities for Enhancing Patient Safety

et al. 2020

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Since the 20th century, health care institutions have used morbidity and mortality conferences (MMCs) as a forum to discuss complicated cases and fatalities to capitalize on lessons learned. Medical technology, health care processes, and the teams who provide care have evolved over time, but the format of the MMC has remained relatively unchanged. The present article outlines 5 key areas for improvement within the MMC along with prescriptive and actionable recommendations for mitigating these challenges. This work incorporates the contributions of numerous researchers and practitioners from the educational, training, debrief, and health care fields. With the best practices and lessons learned from various domains in mind, we recommend optimizing the MMC by (1) encouraging a culture that leverages expertise from multiple sources, (2) allocating ample time for innovative thinking, (3) using a global approach that considers individual, team, and system-level factors, (4) leveraging learnings from errors as well as near misses, and (5) promoting communication, innovative thinking, and actionable planning. The 5 evidence-based recommendations herein serve to ensure that MMCs are structured learning events that promote, encourage, and support safe, reliable care. Furthermore, the outlined recommendations seek to capitalize upon the MMC's opportunity to engage early discovery as well as proactive risk assessment and action-oriented solutions.B ecause of the prevalence of adverse events, the health care sector has made efforts to improve patient safety and quality care. The morbidity and mortality conference (MMC) is a forum to improve patient care through the disclosure and review of error and near-miss events by analyzing errors to gain insights and extract knowledge to improve care processes and outcomes. 1,2 To elaborate further, MMCs are traditionally regularly scheduled meetings in which select patient case studies and provider-raised issues are reviewed to (1) determine the appropriateness and evidence-base of the clinical provision of care when weighed against accepted best practices, (2) learn from patient cases where errors and complications occurred, and (3) determine whether future errors can be prevented or mitigated by adjusting actions and judgments. [3][4][5][6] Morbidity and mortality conferences are similar to debriefs (i.e., a forum of reflection and planning to improve performance 7 ); that is, participants in debriefs as well as MMCs reflect on a previous experience or case to identify actions, construct meaning, and uncover lessons that can be applied to improve outcomes. 7 Similar to MMCs, properly executed debriefs can improve performance of individuals and teams but only if they achieve their desired objectives. 7 Morbidity and mortality conferences are designed to educate the disciplines based on the experiences of a select, unfortunate few. 8,9 This education, ideally, leads to positively changed clinical practice, 10 and some advocate for increasing the frequency of the MMC. 11 Across health...

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Section: Challenge 5: Mmcs Examine Problems and Provide Recommendatio...mentioning

confidence: 99%

The Morbidity and Mortality Conference: Opportunities for Enhancing Patient Safety

et al. 2020

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“…The German Medical Association has produced a methodological guideline for morbidity and mortality conferences, which provides good support for the efficient organization of such events. An interdisciplinary approach to the conferences is useful [28][29][30]. Depending on the particular structure of the hospital, the radiology department can arrange participation of the radiologist in an already established conference of other specialties or can issue an interdisciplinary invitation to a conference.…”

Section: Morbidity and Mortality Conferencesmentioning

confidence: 99%

Complication Management and Prevention in Vascular and non-vascular Interventions

Weiss

Wilms

Ivan

et al. 2022

Rofo

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Purpose This overview summarizes key points of complication management in vascular and non-vascular interventions, particularly focusing on complication prevention and practiced safety culture. Flowcharts for intervention planning and implementation are outlined, and recording systems and conferences are explained in the context of failure analysis. In addition, troubleshooting by interventionalists on patient cases is presented. Material and Methods The patient cases presented are derived from our institute. Literature was researched on PubMed. Results Checklists, structured intervention planning, standard operating procedures, and opportunities for error and complication discussion are important elements of complication management and essential for a practiced safety culture. Conclusion A systematic troubleshooting and a practiced safety culture contribute significantly to patient safety. Primarily, a rational and thorough error analysis is important for quality improvement. Key Points: Citation Format

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“…M&M meetings are deemed an important component of clinical governance that provide both the necessary administrative assurances that poor outcomes are being monitored and addressed and the environment in which learning from them may take place. [53][54][55][56] • An open forum for the collaborative review of adverse events without fear of retribution or blame. The primary goals should be improving patient care and maximising the educational benefits of a shared experience.…”

Section: Clinical Auditmentioning

confidence: 99%

Developing consensus for definitions of key veterinary‐specific quality improvement (QI) terms using an eDelphi‐study method

et al. 2021

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Background: Quality improvement (QI) methods are a continuous process of iterative tests to improve the quality of a service or product. Using common language has been linked to the successful implementation of QI in human healthcare. This study aimed to assimilate and achieve consensus on veterinary-specific definitions for terms associated with quality care and QI methods in UK veterinary practice. Methods: A four-round modified eDelphi process with a panel of 50 UK veterinary practice stakeholders was used to generate consensus. The panel selected or suggested the definition they best felt 'fitted' each term. Consensus was reached if there was >70% agreement, and terms were eliminated if there was <15% selection. Results: Thirty-one panellists completed all three rounds of eDelphi; eight participants completed an optional feedback round. From 14 terms, 10 reached consensus, leaving four unresolved definitions. Conclusions: A majority of terms reached consensus; 90% were new or amended definitions proposed by panel members. Utilising plain English refined by stakeholders will allow successful implementation of QI in veterinary healthcare. Not all terms achieved consensus, highlighting a need for further research to enable successful integration of QI principles as seen in human healthcare.

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Lessons Learned From the Surgical Morbidity and Mortality Conference

Cited by 9 publications

References 11 publications

The Morbidity and Mortality Conference: Opportunities for Enhancing Patient Safety

The Morbidity and Mortality Conference: Opportunities for Enhancing Patient Safety

Complication Management and Prevention in Vascular and non-vascular Interventions

Developing consensus for definitions of key veterinary‐specific quality improvement (QI) terms using an eDelphi‐study method

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