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

Rabizadeh, Shervin; Gower, W. Adam; Payton, Kurlen S.E.; Miller, Kathryn; Vera, Kimberly; Serwint, Janet R.

doi:10.1177/0009922812461069

Cited by 30 publications

(43 citation statements)

References 24 publications

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“…Recent literature has shown that most healthcare errors are due to system-wide factors, and that individually focused analysis and correction leads to missed opportunities for sustained improvement. 24,25 Nonetheless, the perceived objectives and types of cases selected in the Andean region indicate that M&M conferences are frequently perceived as an opportunity to decide on next steps in an individual patient’s care. While this may be an important function, only a small portion of conferences included elements that were shown to be associated with an effective M&M conference: standardized case selection criteria, documentation of the discussion, and planned follow-up.…”

Section: Discussionmentioning

confidence: 99%

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Status of trauma quality improvement programs in the Andean region: What foundation do we have to build on

LaGrone

Pozo

Figueroa

et al. 2017

Injury

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Introduction Trauma quality improvement (QI) programs have been shown to improve outcomes and decrease cost. These are high priorities in low- and middle-income countries (LMICs), where 2,000,000 deaths due to survivable injuries occur each year. We sought to define areas for improvement in trauma QI programs in four LMICs. Methods We conducted a survey among trauma care providers in four Andean middle-income countries: Bolivia, Colombia, Ecuador, and Peru. Results 336 physicians, medical students, nurses, administrators and paramedical professionals responded to the cross-sectional survey with a response rate greater than 90% in all included countries except Bolivia, where the response rate was 14%. Eighty-seven percent of respondents reported morbidity and mortality (M&M) conferences occur at their hospital. Conferences were often reported as infrequent – 45% occurred less than every three months and poorly attended – 63% had five or fewer staff physicians present. Only 23% of conferences had standardized selection criteria, most lacked documentation – notes were taken at only 35% of conferences. Importantly, only 13% of participants indicated that discussions were routinely followed-up with any sort of corrective action. Multivariable analysis revealed the presence of standardized case selection criteria (OR 3.48, 95% CI 1.16–10.46), written documentation of the M&M conferences (OR 5.73, 95% CI 1.73–19.06), and a clear plan for follow-up (OR 4.80, 95% CI 1.59–14.50) to be associated with effective M&M conferences. Twenty-two percent of respondents worked at hospitals with a trauma registry. Fifty-two percent worked at institutions where autopsies were conducted, but only 32% of those reported the autopsy results to ever be used to improve hospital practice. Conclusions M&M conferences are frequently practiced in the Andean region of Latin America but often lack methodologic rigor and thus effectiveness. Next steps in the maturation of QI programs include optimizing use of data from autopsies and registries, and systematic follow-up of M&M conferences with corrective action to ensure that these activities result in appreciable changes in clinical care.

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Section: Discussionmentioning

confidence: 99%

“…24,24,27 It is worth noting that physical, financial, and human resources were not identified as primary limitations. Business management experts agree that in efforts to implement large-scale culture-changing maneuvers, participants need to experience early “wins”.…”

Section: Discussionmentioning

confidence: 99%

Status of trauma quality improvement programs in the Andean region: What foundation do we have to build on

LaGrone

Pozo

Figueroa

et al. 2017

Injury

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“…[3][4][5] In addition, the typical audience at M&M conferences is restricted to the service (mainly physicians or physicians in training) that was involved in the care of the patient, excluding other important members of the multidisciplinary patient care team. 6 To effectively address these shortcomings and to foster an environment focused on patient safety, some institutions have restructured M&M conferences, [7][8][9][10][11][12][13] utilizing an evidence-based systems issues approach, including a broad audience. Using these newer models as a framework, 11,14 the research team initiated a facility-level interdisciplinary improvement conference.…”

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confidence: 99%

Interdisciplinary Quality Improvement Conference

et al. 2014

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The Veterans Healthcare Administration (VA) has embraced patient safety and quality improvement in the quest to improve care for veterans. The New Mexico VA Health Care System introduced a new morbidity and mortality conference, called the Interdisciplinary Quality Improvement Conference (IQIC), using patient case presentations to focus on underlying systems in the clinical care environment. The revised conference design also effectively teaches the 6 Accreditation Council for Graduate Medical Education (ACGME) core requirements for resident education. A formal process was established for case selection, presentation, systems issue identification, tracking, and follow-up. The IQIC has enabled the identification of more than 20 system issues at the study institution. Outcome data show lasting improvement in system issues that were addressed by this mechanism. The VA IQIC is an effective method to both identify and correct systems issues that affect patient care and is an effective method for teaching residents the 6 ACGME requirements for residency education.

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“…When formatted as a nonhierarchical tool inviting contributions from all staff levels, the morbidity and mortality conference plays a key role in the system approach to medical errors. (Pediatr Crit Care Med 2016; 17:67-72) Key Words: adverse events; error and risk analysis; medical error; morbidity and mortality conference; patient safety; pediatric intensive care unit T he morbidity and mortality conference (MMC) served traditionally as an educational aid for medical trainees, but more recently, new emphasis has been placed on patient safety and quality improvement (1)(2)(3)(4)(5)(6)(7)(8), including critical incident monitoring (9), error and risk analysis (10), postincident team debriefings, and the monitoring of quality indicators and adverse events (11). By identifying adverse events and their cause(s), the MMC prompts intervention and may prevent patient harm (8,12,13).…”

Section: Measurements and Main Resultsmentioning

confidence: 99%

The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety

Frey

Doell

Klauwer

et al. 2016

Pediatric Critical Care Medicine

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OBJECTIVES: To present our experience in an interdisciplinary and interprofessional morbidity and mortality conference, with special emphasis on its usefulness in improving patient safety. DESIGN: Retrospective analysis. SETTING: Tertiary interdisciplinary neonatal PICU. PATIENTS: Morbidity and mortality conference minutes on 48 patients (newborns to 17 yr), January 2009 to June 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors' PICU implemented a morbidity and mortality conference guideline in 2009 using a system-based approach to identify medical errors, their contributing factors, and possible solutions. In the subsequent 5.5 years, there were 44 mortality conferences (of 181 deaths [27%] over the same period) and four morbidity conferences. The median death/morbidity event-morbidity and mortality conference interval was 90 days (range, 7 d to 1.5 yr). The median age of patients was 4 months (range, newborn to 17 years). In six cases, the primary reason for PICU admission was a treatment complication. Unsafe processes/medical errors were identified and discussed in 37 morbidity and mortality conferences (77%). In seven cases, new autopsy findings prompted the discussion of a possible error. The 48 morbidity and mortality conferences identified 50 errors, including 30 in which an interface problem was a contributing factor. Fifty-four improvements were identified in 34 morbidity and mortality conferences. Four morbidity and mortality conferences discussed specific ethical issues. CONCLUSIONS: From our experience, we have found that the interdisciplinary and interprofessional morbidity and mortality conference has the potential to reveal unsafe processes/medical errors, in particular, diagnostic and communication errors and interface problems. When formatted as a nonhierarchical tool inviting contributions from all staff levels, the morbidity and mortality conference plays a key role in the system approach to medical errors. Originally published at: Frey, Bernhard; Doell, Carsten; Klauwer, Dietrich; Cannizzaro, Vincenzo; Bernet, Vera; Maguire, Christine; Brotschi, Barbara (2016). The morbidity and mortality conference in pediatric intensive care as a means for improving patient safety. Pediatric Critical Care Medicine, 17(1):67-72.

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

Abstract: The successful change in the focus of the pediatric MMC conference resulted in significant hospital-wide system changes, quality improvements, enhanced education, and departmental satisfaction.

Cited by 30 publications

References 24 publications

Status of trauma quality improvement programs in the Andean region: What foundation do we have to build on

Status of trauma quality improvement programs in the Andean region: What foundation do we have to build on

Interdisciplinary Quality Improvement Conference

The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety

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