Morbidity and Mortality Rounds in Liver Transplantation

Abstract

sepsis or primary non-function. We provide a summary of recommendations for conducting MMCs based on conferences held in our department combined with the literature. Conclusion: We present our experience with MMCs held over the past 24 months in consideration of guidelines on MMCs provided in the literature. As there is little conformity to known models for analyzing medical incidents, models for best practice in conduction MMCs are urgently needed. © 2016 S. Karger GmbH, Freiburg IntroductionThe morbidity and mortality conference (MMC) is the most visible stage for the critical evaluation of adverse events and errors in academic medicine, and has therefore been referred to as the 'golden hour' of surgical education [1]. Over the last century, it has become the most critical aspect of quality assurance and education in surgery departments. First recommendations pertaining to MMCs were documented by Codman [2] as a study in hospital efficiency, recommending the documentation of patient history and outcome analysis, including a systematic review of adverse events and a categorization of causative errors. Through its guidelines published in 1983, the American Accreditation Council of Graduate Medical Education (ACGME) required departments with surgical training programs to institute weekly reviews of 'all current complications and deaths, including radiologic and pathologic correlation of surgical specimens and autopsies ' [3]. Ever since MMCs Keywords Morbidity and mortality conference · Liver transplantation · Healthcare quality improvement · Medical error · Patient safety Summary Background: Morbidity and mortality conferences (MMCs) provide powerful opportunities for learning, reflection, and improvement. The current literature gives examples of how MMCs can be designed; however, no systematic review of cases and no original data related to liver transplantation are available. Liver transplantation requires a multidisciplinary approach to case identification, presentation, and analysis. Framework structures that guide case investigation are needed to successfully follow up on outcome measures and provide the basis for quality assessment and transparency in transplant programs. Methods: All cases presented at our department's transplant-related MMCs in the years 2014 and 2015 were analyzed. Patient data were collected from our electronic database and meeting minutes. Cases were summarized according to type of transplantation. Liver-related transplant cases were analyzed for in-house deaths and time from death until presentation at an MMC. A literature review was performed, and our center's MMC design was compared with the literature available on conducting MMCs and improving patient safety and quality of care. Results: Within 2 years, 15 MMCs were held at our department. 38 cases were discussed of which 25 were liver transplant-related. Most cases were in-house postoperative deaths, mainly due to

Humanizing the Morbidity and Mortality Conference

“…(See Table 1 for a summary of recent MMC research. [4][5][6][7][8][9][10] ) This is also a period when the scope of the MMC moved from individual errors to systemwide failures. Because the structure of MMCs is highly variable, studies have advocated for the standardization of roles of different members of the MMC, such as the moderators and discussants, and routine collection of outcomes at MMCs.…”

Risk Factors for Sepsis Based on Sepsis-3 Criteria after Orthotopic Liver Transplantation

“…While the LT procedure has been standardized to a considerable extent, the management of postoperative complications remains a major challenge. In particular, LT patients are at elevated risk of developing sepsis, a systemic inflammation and immune system dysregulation [ 5 – 7 ]. Without proper and timely treatment, LT-related sepsis can result in longer hospital stays and even death.…”

Evidence Review for the American College of Surgeons Quality Verification Part II: Processes for Reliable Quality Improvement

“…After title, abstract, and reference review, 3 SRs and 14 additional studies were included for synthesis, covering a total of 79 unique studies (Table 2). [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] The 14 additional studies included 1 singleinstitution prospective analysis, 12 single-institution retrospective reviews, and 1 mixed-methods study.…”

“…[2][3][4][5] Five studies also defined this as a data-driven identification of complications based on predefined criteria rather than voluntary report. 2,4,[6][7][8] Use of clinical registry or other predefined case criteria for case review input resulted in more adverse outcomes identified and more actionable items than traditional self-report case review processes. 2,4,7 Adverse-event-centered case review (including morbidity or near misses) detected greater proportion of preventable events than mortality-centered case review.…”