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Jeffs E, Newall F, Delany C, Kinney S. Goals of Morbidity and Mortality meetings in paediatric acute care. A qualitative case study. J Child Health Care 2024:13674935241249597. [PMID: 38831718 DOI: 10.1177/13674935241249597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Morbidity and Mortality meetings are conducted in varied clinical contexts including paediatrics. Widely cited as an educational or quality improvement tool, the reality is more complex. In this qualitative study, the aim was to explore the perceived goals of the paediatric acute care Morbidity and Morbidity meeting. This study used semi-structured interviews and observation within a qualitative case study methodology. Data were collected in a large paediatric quaternary hospital. Analysis generated themes related to meeting observations and the participant's interpretation of meeting goals. A total of 44 interviews were conducted with 14 nurses, 29 doctors, and 1 allied health professional. Thirty-two meetings in six clinical departments were observed. Two themes were developed: complex and nuanced goals; and tensions and contest between and within goals. Meeting goals to evaluate care, learn, support, adhere, and change and respond were sometimes in competition and had varied interpretations. Morbidity and Mortality meetings in this setting are valued and occupy a complex role which reaches beyond identification of measurable patient safety interventions. Understanding goals more fully can lead to optimised conduct and meaningful measurement of efficacy. The strength in these meetings may be the way they promote an embedded safety culture, and an informed and skilled workforce.
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Affiliation(s)
- Emma Jeffs
- The Royal Children's Hospital, Parkville, VIC, Australia
- The University of Melbourne, Parkville, VIC, Australia
- The Women's and Children's Hospital Adelaide, Adelaide, SA, Australia
| | - Fiona Newall
- The Royal Children's Hospital, Parkville, VIC, Australia
- The University of Melbourne, Parkville, VIC, Australia
| | - Clare Delany
- The Royal Children's Hospital, Parkville, VIC, Australia
- The University of Melbourne, Parkville, VIC, Australia
| | - Sharon Kinney
- The Royal Children's Hospital, Parkville, VIC, Australia
- The University of Melbourne, Parkville, VIC, Australia
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Steel EJ, Janda M, Jamali S, Winning M, Dai B, Sellwood K. Systematic Review of Morbidity and Mortality Meeting Standardization: Does It Lead to Improved Professional Development, System Improvements, Clinician Engagement, and Enhanced Patient Safety Culture? J Patient Saf 2024; 20:125-130. [PMID: 38038688 DOI: 10.1097/pts.0000000000001184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
OBJECTIVES This systematic review sought to better understand the effect of standardized Morbidity and Mortality meetings (M&Ms) on learning, system improvement, clinician engagement, and patient safety culture. METHODS Three electronic databases were searched using a range of text words, synonyms, and subject headings to identify the major concepts of M&M meetings. Articles published between October 2012 (the end date of an earlier review) and February 2021 were assessed against the inclusion criteria, and thematic synthesis was conducted on the included studies. RESULTS After abstract and full-text review in Covidence, from 824 studies identified, 16 met the eligibility criteria. Studies were mostly surveys (n = 13) and evaluated effectiveness primarily from the perspectives of M&M chairs and participants, rather than assessment of objective improvement in patient outcomes. The most prevalent themes relating to the standardization of M&M processes were case selection (n = 15) and administration (n = 12). The objectives of quality improvement and education were equally prevalent (12 studies each), but several studies reported that these 2 objectives as conflicting rather than complementary. Clinician engagement, patient safety culture, and organizational governance and leadership were identified as facilitators of effective M&Ms. CONCLUSIONS There is insufficient evidence to guide best practice in M&Ms, but standardized structures and processes implemented with organizational leadership and administrative support are associated with M&Ms that address objectives related to learning and system improvement. Standardization of the structures and processes of M&Ms is perceived differently depending on participants' role and discipline, and clinician engagement is critical to support a culture of safety and quality improvement.
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Affiliation(s)
- Emily J Steel
- From the Clinical Governance, Risk and Legal Division, Metro South Health
| | - Monika Janda
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland
| | | | | | - Bryan Dai
- Princess Alexandra Hospital, Metro South Health, Brisbane, Queensland, Australia
| | - Kylie Sellwood
- From the Clinical Governance, Risk and Legal Division, Metro South Health
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Bralow L, McCaffery E, Leuchten S. Good Saves: How Emergency Medicine Residents are Learning From Success. Cureus 2023; 15:e49508. [PMID: 38152785 PMCID: PMC10752616 DOI: 10.7759/cureus.49508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 11/20/2023] [Indexed: 12/29/2023] Open
Abstract
INTRODUCTION The practice of learning from medical errors is well-established and well-researched in the literature on morbidity and mortality conferences. However, durable learning from case-based education occurs not only through the analysis of medical errors but also through the evaluation of how critical decisions were made to result in a positive clinical outcome, what we will call a "good save." The aim of the current study is to provide an overview of how US-based emergency medicine residencies are teaching using "good saves." METHODS A national survey of emergency medicine (EM) residency leadership was distributed through the Council of Residency Directors (CORD) and the Society of Academic Emergency Medicine (SAEM) listservs. A descriptive analysis of the results was undertaken. RESULTS Residency leadership representing 67 different US EM training programs participated in our survey. Of these, only 19 programs use formal learning objectives and dedicated education time to teach from "good saves." Thirty-six programs provide informal recognition, often in the form of a "shout-out." Residency leadership is motivated to provide this recognition and learning through efforts to promote wellness and resiliency among EM residents. Notably, the use of prizes and awards is not necessary. DISCUSSION Some EM residencies in the United States are making targeted efforts to promote the recognition of successful clinical care. This recognition and education are being used as tools both to promote wellness and to teach resiliency. However, there is wide heterogeneity in approaches. Our survey provides examples of the many ways that "good saves" can be incorporated into any EM residency curriculum with the potential for significant impact.
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Affiliation(s)
- Leah Bralow
- Emergency Medicine, St. Barnabas Hospital Health System, New York, USA
| | - Eleni McCaffery
- Emergency Medicine, Sophie Davis School of Medicine, City University of New York, New York, USA
| | - Scott Leuchten
- Emergency Medicine, St. Barnabas Hospital Health System, New York, USA
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Purdy E, Roseby R, Brinkmann M, Blackmore E, Meyer C, Cabrera D. Education as Culture: The Amazing and Awesome Case Conference. J Grad Med Educ 2021; 13:18-21. [PMID: 33680294 PMCID: PMC7901622 DOI: 10.4300/jgme-d-20-00407.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Chathampally Y, Cooper B, Wood DB, Tudor G, Gottlieb M. Evolving from Morbidity and Mortality to a Case-based Error Reduction Conference: Evidence-based Best Practices from the Council of Emergency Medicine Residency Directors. West J Emerg Med 2020; 21:231-241. [PMID: 33207171 PMCID: PMC7673891 DOI: 10.5811/westjem.2020.7.47583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 07/23/2020] [Indexed: 11/11/2022] Open
Abstract
Morbidity and mortality conferences are common among emergency medicine residency programs and are an important part of quality improvement initiatives. Here we review the key components of running an effective morbidity and mortality conference with a focus on goals and objectives, case identification and selection, session structure, and case presentation.
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Affiliation(s)
- Yashwant Chathampally
- The University of Texas Health Sciences Center at Houston, Department of Emergency Medicine, Houston, Texas
| | - Benjamin Cooper
- The University of Texas Health Sciences Center at Houston, Department of Emergency Medicine, Houston, Texas
| | - David B Wood
- Yale University Medical Center, Department of Emergency Medicine, New Haven, Connecticut
| | - Gregory Tudor
- University of Illinois College of Medicine at Peoria/OSF Healthcare, Department of Emergency Medicine, Peoria, Illinois
| | - Michael Gottlieb
- Rush University, Medical Center, Department of Emergency Medicine, Chicago, Illinois
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Abstract
Emergency medicine is a high-risk area of medical practice, with a high rate of preventable adverse events. This is multifactorial, hinging on the myriad system and processes issues that complicate emergency care. Strong teamwork and communication have been identified as critical components for safe care in emergency medicine. Health care professionals and leaders within emergency medicine can implement solutions aimed at cultivating a strong safety culture, creating processes and system-based approaches to improve patient safety. This article provides an overview of the evidence-based approaches to improve patient safety and communication.
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Affiliation(s)
- Dana Im
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, NH-2, Boston, MA 02115, USA.
| | - Emily Aaronson
- Massachusetts General Hospital, 55 Fruit Street, Bulfinch 290, Boston, MA 02114, USA
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Grubenhoff JA, Ziniel SI, Cifra CL, Singhal G, McClead RE, Singh H. Pediatric Clinician Comfort Discussing Diagnostic Errors for Improving Patient Safety: A Survey. Pediatr Qual Saf 2020; 5:e259. [PMID: 32426626 PMCID: PMC7190246 DOI: 10.1097/pq9.0000000000000259] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/22/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Meaningful conversations about diagnostic errors require safety cultures where clinicians are comfortable discussing errors openly. However, clinician comfort discussing diagnostic errors publicly and barriers to these discussions remain unexplored. We compared clinicians' comfort discussing diagnostic errors to other medical errors and identified barriers to open discussion. METHODS Pediatric clinicians at 4 hospitals were surveyed between May and June 2018. The survey assessed respondents' comfort discussing medical errors (with varying degrees of system versus individual clinician responsibility) during morbidity and mortality conferences and privately with peers. Respondents reported the most significant barriers to discussing diagnostic errors publicly. Poststratification weighting accounted for nonresponse bias; the Benjamini-Hochberg adjustment was applied to control for false discovery (significance set at P < 0.018). RESULTS Clinicians (n = 838; response rate 22.6%) were significantly less comfortable discussing all error types during morbidity and mortality conferences than privately (P < 0.004) and significantly less comfortable discussing diagnostic errors compared with other medical errors (P < 0.018). Comfort did not differ by clinician type or years in practice; clinicians at one institution were significantly less comfortable discussing diagnostic errors compared with peers at other institutions. The most frequently cited barriers to discussing diagnostic errors publicly included feeling like a bad clinician, loss of reputation, and peer judgment of knowledge base and decision-making. CONCLUSIONS Clinicians are more uncomfortable discussing diagnostic errors than other types of medical errors. The most frequent barriers involve the public perception of clinical performance. Addressing this aspect of safety culture may improve clinician participation in efforts to reduce harm from diagnostic errors.
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Affiliation(s)
- Joseph A. Grubenhoff
- From the Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Sonja I. Ziniel
- From the Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Christina L. Cifra
- Department of Pediatrics, University of Iowa Carver College of Medicine Stead Family, Iowa City, Iowa
| | - Geeta Singhal
- Department of Pediatrics, Baylor College of Medicine
| | - Richard E. McClead
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
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Aaronson EL, Wittels K, Dwyer R, Nadel E, Gallahue F, Baker O, Fee C, Tubbs R, Schuur J. The Impact of Anonymity in Emergency Medicine Morbidity and Mortality Conferences: Findings from a National Survey of Resident Physicians. West J Emerg Med 2019; 21:127-133. [PMID: 31913832 PMCID: PMC6948693 DOI: 10.5811/westjem.2019.10.44497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/11/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction Although the Accreditation Council for Graduate Medical Education mandates structured case review and discussion as a part of residency training, there remains little guidance on how best to structure these conferences to cultivate a culture of safety, promote learning, and ensure that system-based improvements can be made. We hypothesized that anonymous case discussion was associated with a more effective, and less punitive, morbidity and mortality (M&M) conference. Secondarily, we were interested in determining whether this core structural element was correlated with the culture of safety at an institution. Methods We conducted a national survey at 33 emergency medicine residency programs evaluating residents’ perceptions of M&M and the culture of safety at their institutions. Data was analyzed using descriptive statistics and bivariate analyses. We summarized Likert scores using mean and 95% confidence intervals. We also performed content analysis of the free-text comments and report on the themes identified. Results There were 1248 residents at the 33 programs surveyed. Of the 1002 who replied (80.3% response rate), 231 respondents reported anonymous case presentations and 744 reported non-anonymous case presentations. Residents at programs with anonymous case presentations were more likely to report that M&M was non-punitive. There were no other significant differences between anonymous and non-anonymous case presentations on any of the culture of safety domains measured. When these comments were systematically analyzed and coded, we found that the comments related to anonymity were both positive and negative. Among the themes identified were anonymity’s impact on punitive response to error, the ability to learn from cases, and professional responsibility. Conclusion Anonymous M&Ms are associated with a perception of a less-punitive M&M and with better ratings in several conference-specific outcomes; however, there appears to be no association between the other Agency for Healthcare Research and Quality culture of safety scores and anonymity in M&M.
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Affiliation(s)
- Emily L Aaronson
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts
| | - Kathleen Wittels
- Harvard Medical School, Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Richard Dwyer
- Harvard Medical School, Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Eric Nadel
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Fiona Gallahue
- University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
| | - Olesya Baker
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christopher Fee
- University of California San Francisco School of Medicine, Department of Emergency Medicine, San Francisco, California
| | - Robert Tubbs
- Warren Alpert Medical School at Brown University, Department of Emergency Medicine, Providence, Rhode Island
| | - Jeremiah Schuur
- Harvard Medical School, Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
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Skowron N, Wilke P, Bernhard M, Hegerl U, Gries A. [Workload in emergency departments : A Problem for personnel and patients?]. Anaesthesist 2019; 68:762-769. [PMID: 31690959 DOI: 10.1007/s00101-019-00686-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Apart from operating theaters, intensive care units and diagnostic services, the central emergency department is one of the areas of any hospital with a high workload, which is very susceptible to risk. The following aspects of routine daily work can lead to a great strain on the personnel working in the central emergency department: the need for quick, targeted decisions, especially for patients with life-threatening disorders, a high number of patients with insufficient available resources, dissatisfaction of patients with low treatment priority and longer waiting times and delayed inpatient admissions with long stays. Interruptions in the individual work process during activities are not uncommon but represent additional disruptive factors for employees and can lead to treatment errors. Furthermore, a workload that is permanently perceived as too high leads to psychological and physical disturbances for the team members. Suitable structural, organizational and personnel prerequisites as well as solution strategies for the central emergency department are necessary to avoid corresponding treatment errors and also as a duty of care for employees.
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Affiliation(s)
- N Skowron
- Zentrale Notaufnahme, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103, Leipzig, Deutschland.
| | - P Wilke
- Abteilung für Notfallmedizin, Havelland Kliniken GmbH, Nauen, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - U Hegerl
- Goethe-Universität Frankfurt, Frankfurt, Deutschland
| | - A Gries
- Zentrale Notaufnahme, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103, Leipzig, Deutschland
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