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

Falcone, John L.; Lee, Kenneth K.W.; Billiar, Timothy R.; Hamad, Giselle G.

doi:10.1016/j.jsurg.2011.10.007

Cited by 18 publications

(10 citation statements)

References 8 publications

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“…). The application of our selection criteria resulted in the inclusion of 67 studies, including eight surveys, four literature reviews, 33 case studies with no comparison or pre/post‐intervention evaluation, nine case studies with pre/post‐intervention evaluations, seven case studies with a comparison, one ethnography study, two qualitative observations and three opinion papers (Table ). Case studies took the form of descriptive programme reviews of an MMR model and related evaluations.…”

Section: Resultsmentioning

confidence: 99%

The role of morbidity and mortality rounds in medical education: a scoping review

et al. 2017

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Section: Resultsmentioning

confidence: 99%

The role of morbidity and mortality rounds in medical education: a scoping review

et al. 2017

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“…Failure to think critically, provide disciplined treatment strategies and recognise structural failures was recently reported to contribute to a high level of morbidity and mortality [27]. As a consequence, it is critical that M&MC participants feel free to discuss complications without fear of reprisals and focus on improving the quality of care [37]. …”

Section: Discussionmentioning

confidence: 99%

“…Selection of serious errors with potentially fatal outcomes (like accidental intrathecal injection of vincristine) was not controversial. The literature suggests that major adverse events are more likely to be listed than non-major adverse events [37]. M&MC structuration should comprise case preparation and review, analysis, discussion, classification and recommendations as well as case closure and follow-up [11].…”

Section: Discussionmentioning

confidence: 99%

Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Ranchon¹,

You²,

Salles³

et al. 2013

Chemotherapy

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Background: To reduce the occurrence of medication errors, a systemic approach was developed combining anti-neoplastic medication error reviews and morbidity and mortality conferences (M&MCs). We report the first experience of implementing this strategy in oncology. Methods: The case reports submitted to combined reviews were prepared by physicians and pharmacists, and medication error(s) were described and chronological and root-cause analyses were performed. Results: Ten combined reviews were conducted, which involved the departments of haematology, medical oncology, pneumology, gastroenterology and clinical oncology pharmacy. A total of 91 errors were analysed, of which 3 had reached the patient. Thirty-four corrective actions were proposed; 53% consisted of changes in practice, 35% in procedural reminders and 12% in on-ward education sessions. Conclusions: The combination of medication error reviews and M&MCs appears to be an efficient means of improving cancer patient safety and personnel proficiency. This multidisciplinary work is indispensable to improve future patient management through the critical analysis of past medical errors.

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“…study, ‘The ACGME core competency of practice-based learning and improvement was assessed with surgical M&MC.’[8] Retrospectively analyzing M&M reports prepared predominantly by 5th year general surgery residents, they evaluated the number of AE that occurred vs. those published in the literature. Their hypothesis was that ‘reporting patterns and incidence rates will remain constant over time.’ Over a 2-year period, 85 M&M reports were evaluated regarding how residents reported AE, their frequency and type.…”

Section: Retrospective Collection Of Morbidity and Mortality Conferenmentioning

confidence: 99%

Morbidity and mortality conferences: Their educational role and why we should be there

Epstein

2012

Surg Neurol Int

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Background:This article examines the value of morbidity and mortality (M&M) conferences, and the multiple factors that contribute to their efficacy. Physicians’ morbidity and mortality conferences (M&MCs) focus on education by reviewing individual adverse events (AE), M&M. Alternatively, Quality Assurance (QA) conferences better examine system-wide issues (e.g., the role institutions play) in attaining or maintaining acceptable levels of patient care. Other issues examined in this review include: whether prospective vs. retrospective M&M data collection are more accurate, and how most states offer ‘nondiscovery’ of M&M proceedings.Methods:Most studies emphasize the educational role of M&MCs, and differentiate their role from QA. Studies comparing the accuracy of prospective vs. retrospective collection of M&M data were reviewed along with the medicolegal issues surrounding the protection of M&M data (‘nondiscovery’).Results:Multiple review articles emphasized that QA conferences typically identify system-wide failures (e.g., hospital policies) while M&MCs focus on physicians’ AE/morbidity/mortality. Additionally, the prospective collection of M&M data proved to be more accurate than retrospective analysis. Finally, most states protect M&M confidentiality (‘nondisclosure’); a glaring exception is Florida, ‘The Sunshine State,’ that allows ‘full disclosure.’Conclusion:This study reviews how M&MCs, differentiated from QA meetings, and educate physicians. It also documents how prospective collection of M&M data is more accurate than retrospective analysis. Additionally, it documents how in most states, medicolegal protections against discovery are in place, with Florida, the ‘Sunshine State’ remaining a glaring exception.

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

Cited by 18 publications

References 8 publications

The role of morbidity and mortality rounds in medical education: a scoping review

The role of morbidity and mortality rounds in medical education: a scoping review

Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Morbidity and mortality conferences: Their educational role and why we should be there

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