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Park E, Han S, Hart PA, Krishna SG, Makary MS, Shah Z, Tsai S, Papachristou GI, Keswani RN, Pfeil S, Lee PJ. Rethinking the Gastroenterology Morbidity and Mortality Conference: Insights from a Scoping Review. Gastroenterology 2024:S0016-5085(24)05291-0. [PMID: 39094746 DOI: 10.1053/j.gastro.2024.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 07/10/2024] [Accepted: 07/23/2024] [Indexed: 08/04/2024]
Affiliation(s)
- Erica Park
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mina S Makary
- Division of Interventional Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Zarine Shah
- Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Susan Tsai
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Rajesh N Keswani
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Sheryl Pfeil
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Peter J Lee
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Brook K, Agarwala AV, Tewfik GL. Reframing the Morbidity and Mortality Conference: The Impact of a Just Culture. J Patient Saf 2024; 20:280-287. [PMID: 38470962 DOI: 10.1097/pts.0000000000001224] [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: 03/14/2024]
Abstract
ABSTRACT Morbidity and mortality (M&M) conferences are prevalent in all fields of medicine. Historically, they arose out a desire to improve medical care. Nevertheless, the goals of M&M conferences are often poorly defined, at odds with one another, and do not support a just culture. We differentiate among the various possible goals of an M&M and review the literature for strategies that have been shown to achieve these goals. Based on the literature, we outline an ideal M&M structure within the context of just culture: The process starts with robust adverse event and near miss reporting, followed by careful case selection, excluding cases solely attributable to individual error. Prior to the M&M, the case should be openly discussed with involved members and should be reviewed using a selected framework. The goal of the M&M should be selected and clearly defined, and the presentation format and rules of conduct should all conform to the selected presentation goal. The audience should ideally be multidisciplinary and multispecialty. The M&M should conclude with concrete tasks and assigned follow-up. The entire process should be conducted in a peer review protected format within an environment promoting psychological safety. We conclude with future directions for M&Ms.
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Affiliation(s)
| | - Aalok V Agarwala
- Department of Anaesthesia, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - George L Tewfik
- Department of Anesthesiology, Rutgers-New Jersey Medical School, Newark, New Jersey
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Sajankila N, Javens T, Hampl J, Coleman C, Murnane J, Kenney BD, Besner GE. An Electronic Health Record-integrated Web Application Augments a QI-directed Morbidity & Mortality Conference and Improves Quality of Care. J Pediatr Surg 2024; 59:1190-1198. [PMID: 38413260 DOI: 10.1016/j.jpedsurg.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/27/2024] [Accepted: 02/12/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND In 2014, we developed a QI-directed Morbidity and Mortality (M&M) Conference, prioritizing discussion of individual and system failures, as well as development of action items to prevent failure recurrence. However, due to a reliance on individual electronic documents to store M&M data, our ability to assess trends in failures and action item implementation was hindered. To address this issue, in 2019, we created a secure electronic health record (EHR)-integrated web application (web app) to store M&M data. STUDY DESIGN In this study, we assessed the impact of our web app on efficient review and tracking of M&M data, including system failure occurrence and closure of action items. Additionally, in 2021, it was discovered that a backlog of action items existed. To address this issue, we implemented a QI initiative to reduce the backlog, and used the web app to compare action item closure over time. RESULTS Use of the web app dramatically improved review of M&M data. During the study period, there was a 67.0% reduction in the occurrence of the most common system failures. Additionally, our QI initiative resulted in a 97.7% reduction in the duration of time to complete a single action item and a 61.1% increase in the on-time closure rate for action items. CONCLUSIONS Integration of a web app into a QI-directed M&M Conference enhanced our ability to track system level failures and action item closure over time. Using this web app, we demonstrated that our M&M Conference achieved its intended goal of improving the quality of patient care. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Nitin Sajankila
- Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Thomas Javens
- Center for Clinical Excellence, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Josh Hampl
- Department of Information Services, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Courtney Coleman
- Center for Clinical Excellence, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Jami Murnane
- Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Brian D Kenney
- Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Gail E Besner
- Department of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
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Carsky K, Rindskopf D, Patel VM, Ansari P, Dechario SP, Giangola G, Coppa GF, Antonacci AC. Using Concurrent Complication Reporting to Evaluate Resident Critical Thinking and Enhance Adult Learning. JOURNAL OF SURGICAL EDUCATION 2024; 81:702-712. [PMID: 38556440 DOI: 10.1016/j.jsurg.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 12/26/2023] [Accepted: 02/02/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE Critical thinking and accurate case analysis is difficult to quantify even within the context of routine morbidity and mortality reporting. We designed and implemented a HIPAA-compliant adverse outcome reporting system that collects weekly resident assessments of clinical care across multiple domains (case summary, complications, error analysis, Clavien-Dindo Harm, cognitive bias, standard of care, and ACGME core competencies). We hypothesized that incorporation of this system into the residency program's core curriculum would allow for identification of areas of cognitive weakness or strength and provide a longitudinal evaluation of critical thinking development. DESIGN A validated, password-protected electronic platform linked to our electronic medical record was used to collect cases weekly in which surgical adverse events occurred. General surgery residents critiqued 1932 cases over a 4-year period from 3 major medical centers within our system. These data were reviewed by teaching faculty, corrected for accuracy and graded utilizing the software's critique algorithm. Grades were emailed to the residents at the time of the review, collected prospectively, stratified, and analyzed by post-graduate year (PGY). Evaluation of the resident scores for each domain and the resultant composite scores allowed for comparison of critical thinking skills across post-graduate year (PGY) over time. SETTING Data was collected from 3 independently ACGME-accredited surgery residency programs over 3 tertiary hospitals within our health system. PARTICIPANTS General surgery residents in clinical PGY 1-5. RESULTS Residents scored highest in properly identifying ACGME core competencies and determining Clavien-Dindo scores (p < 0.006) with no improvement in providing accurate and concise clinical summaries. However, residents improved in recording data sufficient to identify error (p < 0.00001). A positive linear trend in median scores for all remaining domains except for cognitive bias was demonstrated (p < 0.001). Senior residents scored significantly higher than junior residents in all domains. Scores > 90% were never achieved. CONCLUSIONS The use of an electronic standardized critique algorithm in the evaluation and assessment of adverse surgical case outcomes enabled the measure of residents' critical thinking skills. Feedback in the form of teaching faculty-facilitated discussion and emailed grades enhanced adult learning with a steady improvement in performance over PGY. Although residents improved with PGY, the data suggest that further improvement in all categories is possible. Implementing this standardized critique algorithm across PGY allows for evaluation of areas of individual resident weakness vs. strength, progression over time, and comparisons to peers. These data suggest that routine complication reporting may be enhanced as a critical thinking assessment tool and that improvement in critical thinking can be quantified. Incorporation of this platform into M&M conference has the potential to augment executive function and professional identity development.
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Affiliation(s)
- Katie Carsky
- Lenox Hill Hospital, Northwell Health, New York, New York.
| | - David Rindskopf
- City University of New York, Graduate School And University Center, New York, New York
| | - Vihas M Patel
- Northwell North Shore University Hospital/Long Island Jewish Medical Center Department of Surgery, Manhasset, New York; Zucker School of Medicine at Hofstra/Northwell Department of Surgery, Hempstead, New York
| | - Parswa Ansari
- Lenox Hill Hospital, Northwell Health, New York, New York
| | | | - Gary Giangola
- Lenox Hill Hospital, Northwell Health, New York, New York
| | - Gene F Coppa
- Lenox Hill Hospital, Northwell Health, New York, New York
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Tresselt E, Darnell Bowens C, Dhar A. An Innovative and Integrative Approach to Breaking Down Barriers to Traditional Morbidity and Mortality Conference. Clin Pediatr (Phila) 2024; 63:325-333. [PMID: 37148262 PMCID: PMC10893767 DOI: 10.1177/00099228231172486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Children are vulnerable to medical errors. Adverse events are leveraged as educational tools in Morbidity and Mortality (M&M) Conference. Traditionally, M&M has brought angst when discussing adverse events. Our goal was to transition M&M to an educational environment highlighting system failures. A survey was created to capture data on satisfaction, education, and system process improvement. Feedback from the surveys led to several changes, including fostering a multidisciplinary forum, prioritizing educational topics, and emphasizing process improvement. In 5 years, satisfaction with M&M Conference has increased by 29%, with an increase by 50% when asked if process improvement issues were addressed adequately, and 100% of faculty incorporate what they learn from M&M into their practice. By developing a hands-on approach to M&M, we have improved satisfaction and focused on education and system process improvement. This design could be used throughout the medical community to improve discussion of adverse events which should improve patient safety.
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Lingard MCH, Teo Y, Frampton CMA, Hooper GJ. Effect of surgeon-specific feedback on surgical outcomes: a systematic review of the literature. ANZ J Surg 2024; 94:47-56. [PMID: 37962076 DOI: 10.1111/ans.18772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/26/2023] [Accepted: 10/29/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Surgeon-specific outcome reporting provides an opportunity for quality assurance and improved surgical results. It is becoming increasingly prevalent and remains contentious amongst surgeons. The purpose of this systematic review was to evaluate the extent to which published literature supports the concept that feedback of surgeon-level outcomes reduces morbidity and/or mortality. No systematic reviews have previously been completed on this subject. METHODS Medline and Embase were systematically searched for studies published prior to the 1st of January 2022. Feedback was defined as a summary of clinical performance over a specified period of time provided in written, electronic or verbal format. Studies were required to provide surgeon-specific feedback to multiple individual consultant surgeons with the primary purpose being to determine if feedback improved outcomes. Primary outcome(s) needed to relate to surgical outcomes as opposed to process measures only. All surgical specialties and procedures were eligible for inclusion. RESULTS Seventeen studies were included in the review, traversing a wide range of specialties and procedures. Sixteen were non-randominsed and one randomized. Fifteen were before and after studies. The balance of the non-randomized studies support the concept that provision of surgeon-specific feedback can improve surgical outcomes, while the single randomized study suggests feedback may not be effective. CONCLUSIONS This systematic review supports the use of surgeon-level feedback to improve outcomes. The strength of this finding is limited by reliance on before and after studies, further randomized studies on this subject would be insightful.
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Affiliation(s)
- Morgan C H Lingard
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - Yahsze Teo
- Te Whatu Ora - Waitaha Canterbury, Canterbury, New Zealand
| | | | - Gary J Hooper
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
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Beaulieu-Jones BR, Wilson S, Howard DS, Rasic G, Rembetski B, Brotschi EA, Pernar LI. Defining a High-Quality and Effective Morbidity and Mortality Conference: A Systematic Review. JAMA Surg 2023; 158:1336-1343. [PMID: 37851458 DOI: 10.1001/jamasurg.2023.4672] [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: 10/19/2023]
Abstract
Importance Morbidity and mortality conferences (MMCs) are thought to advance trainee education, quality improvement (QI), and faculty development. However, there is considerable variability with regard to their completion. Objective To compile and analyze the literature describing the format, design, and other attributes of MMCs that appear to best advance their stated objectives related to QI and practitioner education. Evidence Review For this systematic review, a literature search with terms combining conference and QI or morbidity and mortality was performed in January 2022, using the PubMed, Embase, and ERIC (Education Resources Information Center) databases with no date restrictions. Included studies were published in English and described surgical or nonsurgical MMCs with explicit reference to quality or system improvement, education, professional development, or patient outcomes; these studies were classified by design as survey based, intervention based, or other methodologies. For survey-based studies, positively and negatively regarded attributes of conference design, format, and completion were extracted. For intervention-based studies, details of the intervention and their impact on stated MMC objectives were abstracted. Principal study findings were summarized for the other group. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI). Abstract screening, full-text review, and data extraction and analysis were completed between January 2022 and December 2022. Findings A total of 59 studies met appropriateness for study inclusion. The mean MERSQI score for the included studies was 6.7 (range, 5.0-9.5) of a maximum possible 18, which implied that the studies were of average quality. The evidence suggested that preparation and postconference follow-up regarding QI initiatives are equally as important as both (1) succinctly presenting case details, opportunities for improvement, and educational topics and (2) creating a constructive space for accountability, engagement, and multistakeholder discussion. Conclusions and Relevance These findings suggest that the published literature on MMCs provides substantial insight into the optimal format, design, and related attributes of an effective MMC. This systematic review provides a road map for surgical departments to improve MMCs in order to align their format and design with their principal objectives related to practitioner and trainee education, error prevention, and QI.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Spencer Wilson
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Daniel S Howard
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Gordana Rasic
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Ben Rembetski
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Erica A Brotschi
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Luise I Pernar
- Department of Surgery, Boston Medical Center, Boston, Massachusetts
- Section of Minimally Invasive Surgery, Boston Medical Center, Boston University, Boston, Massachusetts
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Kobritz M, Patel V, Rindskopf D, Demyan L, Jarrett M, Coppa G, Antonacci AC. Practice-Based Learning and Improvement: Improving Morbidity and Mortality Review Using Natural Language Processing. J Surg Res 2023; 283:351-356. [PMID: 36427445 DOI: 10.1016/j.jss.2022.10.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 09/21/2022] [Accepted: 10/18/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Practice-Based Learning and Improvement, a core competency identified by the Accreditation Council for Graduate Medical Education, carries importance throughout a physician's career. Practice-Based Learning and Improvement is cultivated by a critical review of complications, yet methods to accurately identify complications are inadequate. Machine-learning algorithms show promise in improving identification of complications. We compare a manual-supplemented natural language processing (ms-NLP) methodology against a validated electronic morbidity and mortality (MM) database, the Morbidity and Mortality Adverse Event Reporting System (MARS) to understand the utility of NLP in MM review. METHODS The number and severity of complications were compared between MARS and ms-NLP of surgical hospitalization discharge summaries among three academic medical centers. Clavien-Dindo (CD) scores were assigned to cases with identified complications and classified into minor (CD I-II) or major (CD III-IV) harm. RESULTS Of 7774 admissions, 987 cases were identified to have 1659 complications by MARS and 1296 by ms-NLP. MARS identified 611 (62%) cases, whereas ms-NLP identified 670 (68%) cases. Less than one-third of cases (299, 30.3%) were detected by both methods. MARS identified a greater number of complications with major harm (457, 46.30%) than did ms-NLP (P < 0.0001). CONCLUSIONS Both a prospectively maintained MM database and ms-NLP review of discharge summaries fail to identify a significant proportion of postoperative complications and overlap 1/3 of the time. ms-NLP more frequently identifies cases with minor complications, whereas prospective voluntary reporting more frequently identifies major complications. The educational benefit of reporting and analysis of complication data may be supplemented by ms-NLP but not replaced by it at this time.
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Affiliation(s)
- Molly Kobritz
- Northwell Health North Shore/Long Island Jewish General Surgery, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.
| | - Vihas Patel
- Northwell Health North Shore/Long Island Jewish General Surgery, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - David Rindskopf
- City University of New York, Graduate School And University Center, New York, New York
| | - Lyudmyla Demyan
- Northwell Health North Shore/Long Island Jewish General Surgery, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Mark Jarrett
- Northwell Health North Shore/Long Island Jewish General Surgery, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Gene Coppa
- Northwell Health North Shore/Long Island Jewish General Surgery, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Anthony C Antonacci
- Northwell Health North Shore/Long Island Jewish General Surgery, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Treacy PJ, Toonson P, Blackadder H. Effective peer review audit and identification of the surgeon outlier. ANZ J Surg 2023; 93:1176-1180. [PMID: 36809578 DOI: 10.1111/ans.18343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 01/31/2023] [Accepted: 02/09/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Surgical audit aims to identify ways to maintain and improve the quality of care for patients, in part by assessment of a surgeon's activities and outcomes. However effective data systems to facilitate audit are uncommon. We aimed to assess the effectiveness of a tool for Peer Review Audit. METHODS All General Surgeons in Darwin and the Top End were encouraged to self-record their surgical activity, including procedures and adverse events related to procedures, using the College's Morbidity Audit and Logbook Tool (MALT). RESULTS A total of 6 surgeons and 3518 operative events were recorded in MALT between 2018 and 2019. De-identified reports of each surgeon's activities, compared directly to the audit group, were created by each surgeon, with correction for complexity of procedures and ASA status. Nine complications Grade 3 and greater were recorded, plus 6 deaths, 25 unplanned returns to theatre (8% failure to rescue rate), 7 unplanned admissions to ICU and 8 unplanned readmissions. One surgeon outlier was identified (>3 standard deviation over group mean) for unplanned returns to theatre. This surgeon's specific cases were reviewed at our morbidity and mortality meeting using the MALT Self Audit Report and changes were implemented as a result, with future progress monitored. CONCLUSION The College's MALT system effectively enabled Peer Group Audit. All participating surgeons were readily able to present and validate their own results. A surgeon outlier was reliably identified. This led to effective practice change. The proportion of surgeons who participated was low. Adverse events were likely under-reported.
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Affiliation(s)
- P John Treacy
- Northern Territory Medical School, Flinders University of South Australia, Adelaide, South Australia, Australia.,Department of Surgery, Royal Darwin Hospital, Northern Territory Department of Health, Darwin, Northern Territory, Australia
| | - Philip Toonson
- Department of Surgery, Royal Darwin Hospital, Northern Territory Department of Health, Darwin, Northern Territory, Australia
| | - Helen Blackadder
- Department of Surgery, Royal Darwin Hospital, Northern Territory Department of Health, Darwin, Northern Territory, Australia
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Flaris AN, Carnabatu CJ, Smith A, Simms ER, Baker JW, Schroll R, Killackey M, Kandil E. A Sisyphean Task for Residents: Preparing Literature Reviews About Adverse Events Presented at Morbidity and Mortality Conferences. JOURNAL OF SURGICAL EDUCATION 2022; 79:1500-1508. [PMID: 35922256 DOI: 10.1016/j.jsurg.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/18/2022] [Accepted: 07/05/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Surgery Morbidity and Mortality (M&M) presentations include a thorough literature review. This requires a significant amount of time expenditure frequently incompatible with the current surgical resident work hours. Additionally, literature reviews can be redundant for commonly encountered adverse events. The goal of this study was to explore (a) how surgery residents perform literature reviews, and (b) how repetitive presented adverse events are. DESIGN A survey was sent out during the academic year 2019-2020. The Morbidity and Mortality repository for that academic year was indexed, and the proportion of adverse events having occurred more than once calculated. The amount of time spent on literature reviews, proportion of repetitive adverse events as well as degree of thoroughness of reviews was evaluated on a 1 to 5 Likert scale. SETTING Tulane University General Surgery program, New Orleans, LA, USA. PARTICIPANTS All clinically active residents. RESULTS All residents, filled out the survey. Seventeen out of 29 (58.6%) residents reported dedicating approximately one hour performing literature reviews. Median studying time was 1 hour (interquartile range: 1-1.5 hours). Seventeen out of 29 (58.6%) residents employed 2 resources. The most common combination of resources was PubMed and Google (11/29, 37.9%). Most residents (21/29, 72.4%) believed that their thoroughness was at most average (≤3/5 on a Likert scale) and 27/29 (93.1%) believed that their literature review could have been more thorough. More than half of the adverse events presented were found to be redundant during that academic year. CONCLUSIONS Time spent reviewing the literature does not allow for a thorough review, and a significant portion of adverse events presented are redundant. A central repository for literature reviews of adverse events would improve the quality of reviews and avoid duplicating efforts.
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Affiliation(s)
| | | | - Alison Smith
- General Surgery Department, Tulane University, New Orleans, Louisiana
| | - Eric R Simms
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - John W Baker
- General Surgery Department, Tulane University, New Orleans, Louisiana
| | - Rebecca Schroll
- General Surgery Department, Tulane University, New Orleans, Louisiana
| | - Mary Killackey
- General Surgery Department, Tulane University, New Orleans, Louisiana
| | - Emad Kandil
- General Surgery Department, Tulane University, New Orleans, Louisiana
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Antonacci AC, Antonacci CL, Dechario SP, Husk G, Schilling ME, Cifu-Tursellino K, Armellino D, Coppa G, Jarrett M. Reducing surgical site infections after colectomy: bundle item compliance, process, and outlier identification. Surg Endosc 2022; 36:6049-6058. [PMID: 35511342 DOI: 10.1007/s00464-022-09234-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 04/02/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to implement a checklist monitoring system and identify critical surgical checklist items associated with post-colectomy surgical site infections (SSI). The relationship between checklist compliance, infection rates, and identification of non-compliant surgeons was explored. MATERIALS AND METHODS National Health Safety Network (NHSN) data were imported annually to establish baseline incidence of post-colectomy SSI from 2016 to 2019. A colectomy checklist was used to monitor compliance for 1694 random colectomies (1274 elective; 420 emergency). Reports were generated monthly to profile system, hospital, surgeon-specific infection, and checklist compliance rates. RESULTS Checklist compliance improved in elective and emergent colectomies to > 90% for all items except oral antibiotic and mechanical bowel prep in elective cases. Annualized total SSI and organ space infection rates in elective cases decreased by 33% and 45%, respectively. Elective and emergency SSI's were reduced for Superficial Incisional Primary (SIP), Deep Incisional Primary (DIP), and Intra-Abdominal Abscess (IAB) by 66%, 60.4%, and 78.3%, respectively. Checklist compliance between low (< 3%) and high (> 3%) infection rate surgeons demonstrated significantly lower utilization of oral antibiotic prep (p < 0.03) and mechanical bowel prep (p < 0.02) in high infection rate surgeons. CONCLUSION Surgeons compliant with colectomy checklists decreased elective and emergency colectomy infection rates. Ceiling compliance rates > 95% for bundle items are suggested to achieve optimal reductions in SSIs and efforts should be focused on surgeons with NHSN infection rates > 3%. Oral antibiotic prep and mechanical bowel prep compliance rates in elective colectomy appeared to differentiate high infection rate surgeons from low infection rate surgeons.
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Affiliation(s)
- Anthony C Antonacci
- Northwell Health, 2000 Marcus Avenue, Manhasset, NY, 11030, USA.
- , New York, USA.
| | | | - Samuel P Dechario
- Institute for Spine & Scoliosis (ISS), 3100 Princeton Pike, Bldg. 1-D, Lawrenceville, NJ, 08648, USA
| | - Gregg Husk
- Northwell Health, 2000 Marcus Avenue, Manhasset, NY, 11030, USA
| | | | | | - Donna Armellino
- Northwell Health, 2000 Marcus Avenue, Manhasset, NY, 11030, USA
| | - Gene Coppa
- Northwell Health, 2000 Marcus Avenue, Manhasset, NY, 11030, USA
| | - Mark Jarrett
- Northwell Health, 2000 Marcus Avenue, Manhasset, NY, 11030, USA
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Antonacci AC, Dechario SP, Rindskopf D, Husk G, Jarrett M. Cognitive bias and severity of harm following surgery: Plan for workflow debiasing strategy. Am J Surg 2021; 222:1172-1177. [PMID: 34511201 DOI: 10.1016/j.amjsurg.2021.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/11/2021] [Accepted: 08/21/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION This study analyzes the relationship between cognitive bias (CB) and harm severity as measured by Clavien-Dindo Scores (CD). METHODS A prospectively collected series of 655 severity matched general surgical cases with complications were analyzed. Cases were evaluated for CB and assigned harm scores as defined by CD grade. Potentially mitigating "debiasing" strategies were identified for each bias attribution. RESULTS Among cases with CB, 24% (55/232) were CD(I-II) and 76% (177/232) were CD(III-V). Odds ratio suggests that serious complications occur nearly 60% more frequently when CB is identified. The CBs identified with severe harm were Overconfidence, Commission, Anchoring, Confirmation, and Diagnosis Momentum. Preliminary data on debiasing strategies suggest diagnosis review, linear reasoning and Type II thinking may be relevant in over 85% of complications. CONCLUSION The incidence of CB is increased in patients sustaining severe harm. Understanding the specific CBs identified and their mitigating debiasing strategies may improve outcomes.
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Affiliation(s)
| | - Samuel P Dechario
- Institute for Spine and Scoliosis (ISS), Lawrenceville, NJ 08648, USA.
| | - David Rindskopf
- City University of New York Graduate School and University Center, New York, NY, USA.
| | - Gregg Husk
- Northwell Health 2000 Marcus Avenue, Manhasset, NY, 11030, USA.
| | - Mark Jarrett
- Northwell Health 2000 Marcus Avenue, Manhasset, NY, 11030, USA.
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Alshyyab MA, FitzGerald G, Albsoul RA, Ting J, Kinnear FB, Borkoles E. Strategies and interventions for improving safety culture in Australian Emergency Departments: A modified Delphi study. Int J Health Plann Manage 2021; 36:2392-2410. [PMID: 34476834 DOI: 10.1002/hpm.3314] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 06/15/2021] [Accepted: 08/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patient safety and safety culture are critical for quality healthcare delivery in general and in Emergency Departments (EDs) in particular. The aim of this study is to identify strategies that may contribute to the improvement and maintenance of patient safety culture and which are considered most feasible in the ED environment. METHODS A two-step modified Delphi method with 11 experts' panel was performed to establish consensus. A list of potential expert participants with a background in patient safety culture in EDs was compiled through the professional networks of the supervisory team. Snowball sampling was used to identify additional possible participants. The expert panel included key leaders in the emergency medicine community in Queensland, Australia: patient safety experts and researchers, patient safety directors, and healthcare providers in an Australian ED The study ran from September 2018 to December 2018. The tool used in Round 1 in this study was developed through triangulating the outcomes of a review of literature, results from a survey of ED staff and findings from semi-structured interviews with key stakeholders in ED. The results from Round 1 informed the development of the Round 2 tool. The responses from the Delphi Round 1 tool were analysed as both qualitative data and quantitative data. The responses from the Delphi Round 2 tool were treated as quantitative data and analysed with the SPSS software. Consensus was calculated based on more than 80% agreement in collapsed categories 1 and 2 (or 4 and 5) of the five-point Likert scale. RESULTS Only six strategies out of 17 (35%) achieved consensus for both importance and feasibility. These strategies may therefore be considered the most important and feasible key strategies for improving safety culture in EDs. Seven strategies (41.1%) achieved consensus for importance, but not for feasibility and four strategies (23.55%) did not achieve consensus for either importance or feasibility. CONCLUSIONS This study offers practical solutions for safety culture improvement in the ED context. Six key strategies were seen as both important and feasible and these grouped into three main themes; leadership through agenda setting, operational management approaches to reinforce the agenda and commitment, and systems and structures to reinforce the agenda and monitor progress.
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Affiliation(s)
- Muhammad Ahmed Alshyyab
- Department of Public Health, School of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Gerard FitzGerald
- Department of Public Health and Social Work, School of Health, Brisbane, Queensland, Australia
| | - Rania Ali Albsoul
- Department of Family and Community Medicine, School of Medicine, The University of Jordan, Amman, Jordan
| | - Joseph Ting
- Department of Public Health and Social Work, School of Health, Brisbane, Queensland, Australia.,Department of Emergency Medicine, Mater Health Services, Brisbane, Queensland, Australia
| | - Frances B Kinnear
- Emergency Department, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Erika Borkoles
- Department of Public Health, School of Medicine, Public Health, Griffith University, Gold Coast Campus, Southport, Queensland, Australia
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Elective colectomy financial and opportunity cost analysis: diagnosis, case type, diversion, and complications. Eur Surg 2021. [DOI: 10.1007/s10353-021-00716-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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15
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Chun JY, Bharadwaz A, Kyaw Tun J, Bilhim T, Gonzalez-Junyent C, Kawa B. CIRSE Standards of Practice on Conducting Meetings on Morbidity and Mortality. Cardiovasc Intervent Radiol 2021; 44:1157-1164. [PMID: 34018022 DOI: 10.1007/s00270-021-02860-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/26/2021] [Indexed: 11/27/2022]
Abstract
This CIRSE Standards of Practice document is developed by an expert writing group under the guidance of the CIRSE Standards of Practice Committee. It aims to assist Interventional Radiologists in their daily practice by providing best practices for conducting meetings on morbidity and mortality.
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Affiliation(s)
- Joo-Young Chun
- Department of Radiology, St George's Hospital, London, UK.
| | - Arindam Bharadwaz
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jimmy Kyaw Tun
- Department of Interventional Radiology, Barts Health NHS Trust, London, UK
| | - Tiago Bilhim
- Interventional Radiology Unit, Centro Hospitalar Universitário de Lisboa Central, Saint Louis and CUF Hospital, Lisbon, Portugal
- Nova Medical School, Lisbon, Portugal
| | | | - Bhavin Kawa
- Department of Radiology, St George's Hospital, London, UK
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de Vos MS, Hamming JF, Marang-van de Mheen PJ. Learning From Morbidity and Mortality Conferences: Focus and Sustainability of Lessons for Patient Care. J Patient Saf 2021; 17:231-238. [PMID: 29087979 DOI: 10.1097/pts.0000000000000440] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE It remains unclear to what extent the morbidity and mortality conference (M&M) meets the objective of improving quality and safety of patient care. It has been suggested that M&M may be too focused on individual performance, hampering system-level improvement. The aim of this study was to assess focus and sustainability of lessons for patient care that were derived from M&M. METHODS This is an observational study of routinely collected data on evaluated complications and identified lessons at surgical M&M for 8 years, assessing type and recurrence of lessons and cases from which these were drawn. Semistructured interviews with clinicians were qualitatively analyzed to explore factors contributing to lesson focus and recurrence. RESULTS Three hundred eighteen lessons were drawn from 10,883 evaluated complications, primarily for those that were more severe, related to surgical or other treatment, and occurring in nonemergent, lower risk cases (all P < 0.001). Most lessons targeted intraoperative (43%) rather than preoperative or postoperative care as well as specifically technical (87%) and individual-level issues (74%). There were 43 recurring lessons (14%), mostly about postoperative care (47%) and medication management (50%). Interviewed clinicians attributed the intraoperative, technical focus primarily to greater appeal and control but identified an array of factors contributing to lesson recurrence, such as typical staff turnover in teaching hospitals. CONCLUSIONS This study provided empirical evidence that learning at M&M has a tendency to focus on intraoperative, technical performance, with challenges to sustain lessons for more system-level issues. Morbidity and mortality conference formats need to anticipate these tendencies to ensure a wide focus for learning with lasting and wide impact.
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Bruny J, Inge T, Rannie M, Acker S, Levitt G, Cumbler E, Brumbaugh D. Transforming surgical morbidity and mortality into a systematic case review. J Pediatr Surg 2021; 56:80-84. [PMID: 33139023 DOI: 10.1016/j.jpedsurg.2020.09.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE The surgical morbidity and mortality (M&M) conferences at a regional children's hospital achieved the goals of case by case peer review and education for trainees but provided limited data for trending and analysis. In 2019, an institution-wide effort was initiated to create an electronic case review system with the goals of improving event capture and real-time practice performance feedback. Surgical M&M was migrated to this structured case review format to provide a platform for surgical performance improvement. METHODS An online secure database was created with a 3-step classification system based on Clavien-Dindo severity score, peer review, and causality fishbone analysis. The data entered were available in an interactive dashboard. Retrospective tabulation of the 2018 M&M data was performed using the archived paper system used prior to 2019. RESULTS For the calendar year of 2019, the division of pediatric surgery captured and categorized 193 complications in the case review system. The capture rate was 50 per 1000 surgical procedures. For a similar time frame in 2018, the capture rate was 35 per 1000 surgical procedures. The dashboard provided run charts of the incidence and types of complications by procedure and by surgeon. Similar trend data were not available in 2018. The dashboard output has made possible the creation of (non- risk adjusted) individual surgeon performance reports. The output has been used to direct process improvement projects and educational content. CONCLUSION Creation of an online database with interactive dashboard has allowed surgical M&M to evolve into a systematic case review that greatly facilitates quality improvement efforts. This system increased the event capture rate and provided novel practice performance feedback, resulting in process improvement projects and educational objectives predicated on the trending data. These electronic reporting tools are now available to all surgical divisions and represent a transformative approach to surgical case review. TYPE OF STUDY Retrospective Historical control; Quality improvement. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jennifer Bruny
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO.
| | - Thomas Inge
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO
| | | | - Shannon Acker
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO
| | | | | | - David Brumbaugh
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO
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Cognitive Bias Impact on Management of Postoperative Complications, Medical Error, and Standard of Care. J Surg Res 2020; 258:47-53. [PMID: 32987224 DOI: 10.1016/j.jss.2020.08.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/31/2020] [Accepted: 08/26/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cognitive bias (CB) is increasingly recognized as an important source of medical error and up to 75% of errors in internal medicine are thought to be cognitive in origin (O'Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicans Edinb. 2018;48;225-232). However, primary data regarding the true incidence of bias is lacking. A prospective evaluation of CB in the management of surgical cases with complications has not been reported. This study reports the incidence and distribution of various types of CBs, and evaluates their impact on management errors and standard of care (SOC). METHODS A prospectively collected series of 736 general surgical cases with complications from three university hospitals was analyzed. Surgical residents evaluated cases for 22 types of CBs (Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775-780). Supervising quality officers validated all quality assessments. Data were assessed for the incidence of CBs, error assessments (diagnostic, technical, judgment, system, communication, therapeutic, and professionalism), and SOC. RESULTS CB was attributed in 32.7% (241/736) of all cases with complications. The most common CBs identified, both singly and in groups, were anchoring, confirmation, omission, commission, overconfidence, premature closure, hindsight, diagnosis momentum, outcome, and ascertainment bias. The attribution of CB was correlated to a statistically significant increase in the incidence of management errors by the surgical team and lower SOC assessments. CONCLUSIONS CBs are identified in the management of cases with complications and are associated with an increase in management errors and a degradation in SOC. Insight into the types of CBs and their association with the type and severity of management errors may prove useful in improving quality care.
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Taking Morbidity and Mortality Conferences to a Next Level: The Resilience Engineering Concept. Ann Surg 2020; 272:678-683. [PMID: 32889871 DOI: 10.1097/sla.0000000000004447] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To explore possibilities to improve morbidity and mortality conferences using advancing insights in safety science. SUMMARY BACKGROUND DATA Mortality and Morbidity conferences (M&M) are the golden practice for case-based learning. While learning from complications is useful, M&M does not meet expectations for system-wide improvement. Resilience engineering principles may be used to improve M&M. METHODS After a review of the shortcomings of traditional M&M, resilience engineering principles are explored as a new way to evaluate performance. This led to the development of a new M&M format that also reviews successful outcomes, rather than only complications. This "quality assessment meeting" (QAM) is presented and the first experiences are evaluated using local observations and a survey. RESULTS During the QAM teams evaluate all discharged patients, addressing team resilience in terms of surgeons' ability to respond to irregularities and to monitor and learn from experiences. The meeting was feasible to implement and well received by the surgical team. Observations reveal that reflection on both complicated and uncomplicated cases strengthened team morale but also triggered reflection on the entire clinical course. The QAM serves as a tool to identify how adapting behavior led to success despite challenging conditions, so that this resilient performance can be supported. CONCLUSIONS The resilience engineering concept can be used to adjust M&M, in which learning is focused not only on complications but also on how successful outcomes were achieved despite ever-present challenges. This reveals the actual ratio between successful and unsuccessful outcomes, allowing to learn from both to reinforce safety-enhancing behavior.
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Antonacci AC, Patel V, Dechario SP, Antonacci C, Standring OJ, Husk G, Coppa G, Jarrett M. Core Competency Self-Assessment Enhances Critical Review of Complications and Entrustable Activities. J Surg Res 2020; 257:221-226. [PMID: 32858323 DOI: 10.1016/j.jss.2020.07.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/03/2020] [Accepted: 07/17/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education has defined six core competencies (CCs) that every successful physician should possess. However, the assessment of CC achievement among trainees is difficult. This project was designed to prospectively evaluate the impact of resident identification of CC as a component of morbidity review on error identification and standard of care (SOC) assessments. The platform was assessed for its reliability as a measure of resident critical analysis of complication causality across postgraduate year (PGY). MATERIALS AND METHODS A total of 1945 general surgery cases with complications were assessed for error identification and SOC management between January 1, 2016, and December 31, 2018. CC identification was additionally assessed between January 1, 2019, and December 31, 2019, and included 708 general surgery cases. Data were evaluated for error assessments and overall SOC management. PGY4 and 5 residents were compared for number of cases and complications reviewed, severity, error causation, and CC relevance. RESULTS Study groups were equivalent by Clavien-Dindo scores. Error identification significantly increased in all categories: diagnostic (P < 0.001), technical (P < 0.05), judgment (P < 0.001), system (P < 0.001), and communication (P < 0.001). Overall SOC assessments validated by a supervising surgical quality officer were unchanged. An increased exposure to cases with severe complications, error causation, and CC relevance was noted across PGY. CONCLUSIONS The addition of CC assessment into morbidity review appears to improve the critical thinking of evaluating residents by increasing the identification of management errors. Used as an element of prospective self-assessment, teaching residents to identify CC principles in cases with complications may assist in learner progression toward clinical competence and critical thinking.
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Joseph CW, Garrubba ML, Melder AM. Informing best practice for conducting morbidity and mortality reviews: a literature review. AUST HEALTH REV 2019; 42:248-257. [PMID: 30021683 DOI: 10.1071/ah16193] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 02/24/2017] [Indexed: 11/23/2022]
Abstract
Objective Preventable hospital mortality is a critical public health issue, particularly when mortalities are associated with events that are preventable. Mortality and morbidity reviews (MMRs) provide a rigorous, systematic, open, collaborative and transparent review process for clinicians to examine areas of improvement. The aim of the present review was to explore the evidence for best practice when conducting MMRs. Methods Searches of published and grey literature from 2009 to February 2016 were conducted. This period was selected to update a previous review. Inclusion and exclusion criteria was established a priori and based on the Population-Intervention-Comparison-Outcome (PICO) framework. Specific search terms were generated and used to identify relevant articles, with reference lists and citing articles also screened for inclusions. Titles and abstracts were screened and duplicates removed. Study details regarding setting, study design, reported outcomes, tool type, clinicians present and the timing of MMRs were extracted and summarised. Results After screening, 31 documents were included in the present review: 20 peer-reviewed articles and 11 items from the grey literature. Specific outcomes reported included mortality rates, satisfaction, education, cost and quality of care. The most common features of MMRs included timing, leadership, attendees, case presentation format, terms of reference, agenda and governance. Conclusions MMRs decrease gross mortality rates and are effective in identifying and engaging clinicians in system improvements. MMRs should not focus on the actions of individuals, rather on education and/or quality improvement. MMRs should consist of a multidisciplinary team following a structured presentation format with an analysis of error process including actions to be followed-up. Further, it is possible for a single standardised MMR to be implemented hospital wide. What is known about the topic? MMRs are conducted in a variety of clinical settings to educate clinicians and improve patient care. What does this paper add? This review updates a previous review published in 2009 and summarises current evidence around morbidity and mortality reviews. This review also provides a framework for a standardised MMR to be implemented hospital wide. What are the implications for practitioners? This summary of the evidence can be used to guide the development, formation or conduct of MMRs in any healthcare setting.
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Affiliation(s)
- Corey W Joseph
- Centre for Clinical Effectiveness, Monash Health, 246 Clayton Road, Clayton, Vic. 3168, Australia.
| | - Marie L Garrubba
- Centre for Clinical Effectiveness, Monash Health, 246 Clayton Road, Clayton, Vic. 3168, Australia.
| | - Angela M Melder
- Centre for Clinical Effectiveness, Monash Health, 246 Clayton Road, Clayton, Vic. 3168, Australia.
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Who is dying after nephrectomy for cancer? Study of risk factors and causes of death after analyzing morbidity and mortality reviews (UroCCR-33 study). Prog Urol 2019; 29:282-287. [PMID: 30962141 DOI: 10.1016/j.purol.2019.02.009] [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] [Received: 09/04/2018] [Revised: 12/03/2018] [Accepted: 02/01/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND METHODS Nephrectomy is the treatment for renal cell cancer from T1-4 tumors but remains at risk. To determine the thirty-day mortality rate after nephrectomy for cancer and to identify causes and risk factors of death in order to find clinical applications. From 2014 to 2017, we performed a retrospective multicentric analysis of prospectively collected data study involving the French network for research on kidney cancer (UroCCR). All patients who died after nephrectomy for cancer during the first thirty days were identified. Patients' characteristics, causes of death and morbidity and mortality reviews reports were analyzed for each death. RESULTS AND LIMITATIONS In total, 2578 patients underwent nephrectomy and 35 deaths occurred. The thirty-day mortality rate was 1.4%. In univariate analysis, symptoms at diagnosis (P=0.006, OR=2.56 IC (1.3-5.03)), c stage superior to cT1 (P<0.0001, OR=6.13 IC (2.8-13.2)), cT stage superior to cT2 (P<0.0001, OR=8.8 IC (4.39-17.8)), nodal invasion (P<0.0001, OR=4.6 IC (1.9-10.7)), distant metastasis (P=0.001, OR=4.01 IC (1.7-8.9)), open surgery (P<0.0001, OR=0.272 IC (0.13-0.54)) and radical nephrectomy (P=0.007, OR=2.737 IC (1.3-5.7)) were risk factors of thirty-day mortality. In a multivariable model, only cT stage superior to T2 (P=0.015, OR=3.55 IC (1.27-10.01)) was a risk factor of thirty-day mortality. The main cause of postoperative death was pulmonary (n=15; 43%). The second cause was postoperative digestive sepsis for 7 patients (20%). Only 2 morbidity and mortality reviews had been done for the 35 deaths. Limitations are related to the thirty-day mortality criteria and descriptive study design. CONCLUSIONS Symptomatic patients, stage cTNM and type and techniques of surgery are determinants of thirty-day mortality after nephrectomy for cancer. The first cause of postoperative death is pulmonary. Morbidity and mortality reviews should be considered to better understand causes of death and to reduce early mortality after nephrectomy for cancer. LEVEL OF EVIDENCE 4.
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Cattanach DE, Wysocki AP, Ray-Conde T, Nankivell C, Allen J, North JB. Post-mortem general surgeon reflection on decision-making: a mixed-methods study of mortality audit data. ANZ J Surg 2018; 88:993-997. [DOI: 10.1111/ans.14796] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 07/05/2018] [Accepted: 07/09/2018] [Indexed: 12/23/2022]
Affiliation(s)
- Daniel E. Cattanach
- Department of Surgery; Hervey Bay Hospital; Hervey Bay Queensland Australia
- School of Medicine; Griffith University; Gold Coast Queensland Australia
| | - Arkadiusz P. Wysocki
- School of Medicine; Griffith University; Gold Coast Queensland Australia
- Queensland Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
- Department of Surgery; Logan Hospital; Logan City Queensland Australia
| | - Therese Ray-Conde
- Queensland Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
| | - Charles Nankivell
- Department of Surgery; Redland Hospital; Cleveland Queensland Australia
| | - Jennifer Allen
- Queensland Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
| | - John B. North
- Queensland Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
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Peer Review – kann man Risiken/Fehler erkennen und vermeiden? Urologe A 2018; 57:785-789. [DOI: 10.1007/s00120-018-0662-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Pang DSJ, Rousseau-Blass F, Pang JM. Morbidity and Mortality Conferences: A Mini Review and Illustrated Application in Veterinary Medicine. Front Vet Sci 2018; 5:43. [PMID: 29560359 PMCID: PMC5845710 DOI: 10.3389/fvets.2018.00043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/21/2018] [Indexed: 11/30/2022] Open
Abstract
This mini review presents current knowledge on the role of morbidity and mortality conferences (M&MCs) as a powerful educational tool and driver to improve patient care. Although M&MCs have existed since the early twentieth century, formal evaluation of their impact on education and patient care is relatively recent. Over time, M&MCs have evolved from single discipline discussions with a tendency to focus on individual errors and assign blame, to multidisciplinary, standardized presentations incorporating error analysis techniques, and educational theory. Current evidence shows that M&MCs can provide a valuable educational experience and have the potential to generate measurable improvements in patient care.
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Affiliation(s)
- Daniel S J Pang
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Frédérik Rousseau-Blass
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Jessica M Pang
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC, Canada
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Vreugdenburg TD, Forel D, Marlow N, Maddern GJ, Quinn J, Lander R, Tobin S. Morbidity and mortality meetings: gold, silver or bronze? ANZ J Surg 2018; 88:966-974. [DOI: 10.1111/ans.14380] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 11/27/2017] [Accepted: 12/10/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Thomas D. Vreugdenburg
- Research and Evaluation, Incorporating ASERNIP-S; Royal Australasian College of Surgeons; North Adelaide South Australia Australia
| | - Deanne Forel
- Research and Evaluation, Incorporating ASERNIP-S; Royal Australasian College of Surgeons; North Adelaide South Australia Australia
| | - Nicholas Marlow
- Research and Evaluation, Incorporating ASERNIP-S; Royal Australasian College of Surgeons; North Adelaide South Australia Australia
- Discipline of Surgery; The Queen Elizabeth Hospital, The University of Adelaide; Adelaide South Australia Australia
| | - Guy J. Maddern
- Research and Evaluation, Incorporating ASERNIP-S; Royal Australasian College of Surgeons; North Adelaide South Australia Australia
- Discipline of Surgery; The Queen Elizabeth Hospital, The University of Adelaide; Adelaide South Australia Australia
| | - John Quinn
- Royal Australasian College of Surgeons; Melbourne Victoria Australia
| | - Richard Lander
- Royal Australasian College of Surgeons; Melbourne Victoria Australia
| | - Stephen Tobin
- Royal Australasian College of Surgeons; Melbourne Victoria Australia
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Ferrah N, Ibrahim JE, Ranson DL, Beiles CB. Overview of surgical death investigations: could a dreaded experience be turned into an opportunity? ANZ J Surg 2017; 87:755-756. [PMID: 28975744 DOI: 10.1111/ans.14161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/12/2017] [Accepted: 06/27/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Noha Ferrah
- Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia
| | - Joseph E Ibrahim
- Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia
| | - David L Ranson
- Victorian Institute of Forensic Medicine, Melbourne, Victoria, Australia
| | - Charles Barry Beiles
- Victorian Audit of Surgical Mortality, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
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Abahuje E, Nzeyimana I, Rickard JL. Introducing a Morbidity and Mortality Conference in Rwanda. JOURNAL OF SURGICAL EDUCATION 2017; 74:621-629. [PMID: 28188004 DOI: 10.1016/j.jsurg.2017.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 12/15/2016] [Accepted: 01/16/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To assess the structure, format, and educational features of a morbidity and mortality (M&M) conference in Rwanda. To determine factors associated with adverse events and to define opportunities for improvement. DESIGN Retrospective, descriptive study of all cases presented at a surgical M&M conference over a 1-year period. Cases were reviewed for factors associated with adverse events and opportunities for improvement. Factors were characterized as delays in presentation, delays in diagnosis, delays in the operating room, errors in judgment, technical errors, advanced disease, and missing resources or malnutrition. Opportunities for improvement were categorized at the physician or hospital level. SETTING University Teaching Hospital of Kigali, a tertiary referral hospital in Rwanda. PARTICIPANTS Cases presented at the surgical M&M conference over a 1-year period. RESULTS Over a 1-year period, there were a total of 2231 operations with 131 in-hospital mortalities. There were 62 patients discussed at M&M conference. Of those discussed, there were 34 (55%) in-hospital deaths and 32 (52%) unplanned reoperations. Common diagnostic categories included 30 (48%) gastrointestinal, 15 (24%) trauma, and 10 (16%) neoplasm. Delays were commonly cited factors affecting outcomes. There were 22 (35%) delays in presentation, 23 (37%) delays in diagnosis or management, and 20 (32%) delays to the operating room. Errors in judgment occurred in 15 (24%) cases and technical errors occurred in 18 (29%) cases. Twenty-three (37%) patients had a critical resource missing and 17 (27%) patients had advanced disease. Malnutrition was associated with 11 (18%) adverse events. Participants identified opportunities for improvement in 48 (77%) cases. CONCLUSION M&M conference can be used in a low-resource setting as an educational tool to address core competencies of practice-based learning and improvement and systems-based practice. It can define factors associated with surgical adverse events and opportunities for improvement at the physician and hospital levels.
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Affiliation(s)
- Egide Abahuje
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda; Department of Surgery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Innocent Nzeyimana
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda; Department of Surgery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Jennifer L Rickard
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda; Department of Surgery, University of Minnesota, Minneapolis, Minnesota.
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Anderson JE, Goodman LF, Jensen GW, Salcedo ES, Galante JM. Restrictions on surgical resident shift length does not impact type of medical errors. J Surg Res 2017; 212:8-14. [DOI: 10.1016/j.jss.2016.12.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 12/04/2016] [Accepted: 12/30/2016] [Indexed: 01/28/2023]
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Benassi P, MacGillivray L, Silver I, Sockalingam S. The role of morbidity and mortality rounds in medical education: a scoping review. MEDICAL EDUCATION 2017; 51:469-479. [PMID: 28294382 DOI: 10.1111/medu.13234] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/21/2016] [Accepted: 10/11/2016] [Indexed: 06/06/2023]
Abstract
CONTEXT There is increasing focus on how health care professionals can be trained effectively in quality improvement and patient safety principles. The morbidity and mortality round (MMR) has often been used as a tool with which to examine and teach care quality, yet little is known of its implementation and educational outcomes. OBJECTIVES The objectives of this scoping review are to examine and summarise the literature on how the MMR is designed and delivered, and to identify how it is evaluated for effectiveness in addressing medical education outcomes. METHODS A literature search of the PubMed, MEDLINE, PsycInfo and Cochrane Library databases was conducted for articles published from 1980 to 1 June 2016. Publications in English describing the design, implementation and evaluation of MMRs were included. A total of 67 studies were identified, including eight survey-based studies, four literature reviews, one ethnographic study, three opinion papers, two qualitative observation studies and 49 case studies of education programmes with or without formal evaluation. Study outcomes were categorised using Donald Moore's framework for the evaluation of continuing medical education (CME). RESULTS There is much heterogeneity within the literature regarding the implementation, delivery and goals of the MMR. Common design components included explicit programme goals and objectives, the case selection process, case presentation models and some form of case analysis. Evaluation of CME outcomes for MMR were mainly limited to learner participation, satisfaction and self-assessed changes in knowledge. CONCLUSIONS The MMR is widely utilised as an educational tool to promote medical education, patient safety and quality improvement. Although evidence to guide the design and implementation of the MMR to achieve measurable CME outcomes remains limited, there are components associated with positive improvements to learning and performance outcomes.
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Affiliation(s)
- Paul Benassi
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lindsey MacGillivray
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ivan Silver
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Sanjeev Sockalingam
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
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Cromeens BP, Lisciandro RE, Brilli RJ, Askegard-Giesmann JR, Kenney BD, Besner GE. Identifying Adverse Events in Pediatric Surgery: Comparing Morbidity and Mortality Conference with the NSQIP-Pediatric System. J Am Coll Surg 2017; 224:945-953. [DOI: 10.1016/j.jamcollsurg.2017.02.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/05/2017] [Accepted: 02/06/2017] [Indexed: 12/21/2022]
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Giesbrecht V, Au S. Morbidity and Mortality Conferences: A Narrative Review of Strategies to Prioritize Quality Improvement. Jt Comm J Qual Patient Saf 2016; 42:516-527. [PMID: 28266920 DOI: 10.1016/s1553-7250(16)42094-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The morbidity and mortality conference (MMC) provides a valuable opportunity to review patient care processes and safety concerns, aligning with a growing quality improvement (QI) mandate. Yet the structure, processes, and aims of many MMCs are often ill-defined. This review summarizes strategies employed by medical, surgical, and critical care departments in the development of patient safety-centered MMCs. METHODS A structured narrative review of literature was conducted using combinations of the search terms "morbidity and mortality conference(s)," "morbidity and mortality meetings," or "morbidity and mortality round(s)." The titles and abstracts of 250 returned articles were screened; 76 articles were reviewed in full, with 32 meeting the full inclusion criteria. RESULTS The literature review elicited a number of methods used by medical, surgical, and critical care MMCs to emphasize QI and patient safety outcomes. A list of actionable changes made in each article was compiled. Five themes common to QI-centered MMCs were identified: (1) defining the role of the MMC, (2) involving stakeholders, (3) detecting and selecting appropriate cases for presentation, (4) structuring goal-directed discussion, and (5) forming recommendations and assigning follow-up. Innovative methods to pair adverse event screening with MMCs were superior to nonstructured voluntary reporting and case selection for overall morbidity detection. Structured case review, discussion, and follow-up were more likely to lead to implementing systems-based change, and interdisciplinary MMCs were associated with a greater likelihood of forming an action item. CONCLUSION The modern patient safety-centered MMC shares common themes of practices that can be adopted by institutions looking to create a venue for analysis of care processes, a platform to launch QI initiatives, and a culture of safety.
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Affiliation(s)
| | - Selena Au
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine
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Krahwinkel W, Schuler E, Liebetrau M, Meier-Hellmann A, Zacher J, Kuhlen R. The effect of peer review on mortality rates. Int J Qual Health Care 2016; 28:594-600. [DOI: 10.1093/intqhc/mzw072] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 05/12/2016] [Accepted: 06/14/2016] [Indexed: 11/13/2022] Open
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Kwok ESH, Calder LA, Barlow-Krelina E, Mackie C, Seely AJE, Cwinn AA, Worthington JR, Frank JR. Implementation of a structured hospital-wide morbidity and mortality rounds model. BMJ Qual Saf 2016; 26:439-448. [DOI: 10.1136/bmjqs-2016-005459] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/10/2016] [Accepted: 06/10/2016] [Indexed: 11/04/2022]
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Cromeens B, Brilli R, Kurtovic K, Kenney B, Nwomeh B, Besner GE. Implementation of a pediatric surgical quality improvement (QI)-driven M&M conference. J Pediatr Surg 2016; 51:137-42. [PMID: 26581322 DOI: 10.1016/j.jpedsurg.2015.10.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 10/09/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND/PURPOSE The M&M conference at Nationwide Children's Hospital (NCH) categorized failures as technical error or patient disease, but failure modes were never captured, action items rarely assigned, and follow-up rarely completed. In 2013 a QI-driven M&M conference was developed, supporting implementation of directed actions to improve quality of care. METHODS A classification was developed to enhance analysis of complications. Each complication was analyzed for identification of failure modes with subcategorization of root cause, a level of preventability assigned, and action items designated. Failure determinations from 11/2013-10/2014 were reviewed to evaluate the distribution of failure modes and action items. RESULTS Two-hundred thirty-seven patients with complications were reviewed. One-hundred thirty patients had complications attributed to patient disease with no individual or system failure identified, whereas 107 patients had identifiable failures. Eighty-five patients had one failure identified, and 22 patients had multiple failures identified. Of the 142 failures identified in 107 patients, 112 (78.9%) were individual failures, and 30 (21.1%) were system failures. One-hundred forty-seven action items were implemented including education initiatives, establishing criteria for interdisciplinary consultation, resolving equipment inadequacies, removing high risk medications from formulary, restructuring physician handoffs, and individual practitioner counseling/training. CONCLUSIONS Development of a QI-driven M&M conference allowed us to categorize complications beyond surgical or patient disease categories, ensuring added focus on system solutions and a reliable accountability structure to ensure implementation of assigned interventions intended to address failures. This may lead to improvement in the processes of patient care.
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Affiliation(s)
- Barrett Cromeens
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard Brilli
- Department of Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kelli Kurtovic
- Department of Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH, USA
| | - Brian Kenney
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Benedict Nwomeh
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Gail E Besner
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
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At the Crossroad with Morbidity and Mortality Conferences: Lessons Learned through a Narrative Systematic Review. Can J Gastroenterol Hepatol 2016; 2016:7679196. [PMID: 27446868 PMCID: PMC4904689 DOI: 10.1155/2016/7679196] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 09/19/2015] [Indexed: 02/07/2023] Open
Abstract
Objective. To determine the process and structure of Morbidity and Mortality Conference (MMC) and to provide guidelines for conducting MMC. Methods. Using a narrative systematic review methodology, literature search was performed from January 1, 1950, to October 2, 2012. Original articles in adult population were included. MMC process and structure, as well as baseline study demographics, main results, and conclusions, were collected. Results. 38 articles were included. 10/38 (26%) pertained to medical subspecialties and 25/38 (66%) to surgical subspecialties. 15/38 (40%) were prospective, 14/38 (37%) retrospective, 7/38 (18%) interventional, and 2/38 (5%) cross-sectional. The goals were quality improvement and education. Of the 10 medical articles, MMC were conducted monthly 60% of the time. Cases discussed included complications (60%), deaths (30%), educational values (30%), and system issues (40%). Recommendations for improvements were made frequently (90%). Of the 25 articles in surgery, MMCs were weekly (60% of the time). Cases covered mainly complications (72%) and death (52%), with fewer cases dedicated to education (12%). System issues and recommendations were less commonly reported. Conclusion. Fundamental differences existed in medical versus surgical departments in conducting MMC, although the goals remained similar. We provide a schematic guideline for MMC through a summary of existing literature.
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Morbidity-mortality conference for adverse events associated with totally implanted venous access for cancer chemotherapy. Support Care Cancer 2015; 24:1857-63. [PMID: 26454864 DOI: 10.1007/s00520-015-2969-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 09/28/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Although considered safer than central venous catheters for administration of cancer chemotherapy, totally implanted venous access (TIVA) is associated with adverse events that may impair prognosis and quality of life of patients receiving chemotherapy. Our aim was to assess the feasibility and interest of surveillance of cancer chemotherapy TIVA-adverse events (AE), associated with morbidity-mortality conferences (MMCs) on TIVA-AE. METHODS We performed a prospective interventional study in two hospitals (a university hospital and a comprehensive care center). For each cancer chemotherapy care pathway within each hospital, we set up surveillance of TIVA-AE and MMC on these events. Patients included in surveillance were those with a TIVA either placed or used for chemotherapy cycles in one of the participating wards. Feasibility of MMC was assessed by the number of MMC meetings that actually took place and the number of participants at each meeting. The interest of MMC was assessed by the number of TIVA-AE identified and analyzed, and the number and type of improvement actions selected and actually implemented. RESULTS We recorded 0.41 adverse events per 1000 TIVA-day. MMCs were implemented in all care pathways, with sustained pluriprofessional attendance throughout the survey; 39 improvement actions were identified during meetings, and 18 were actually implemented. CONCLUSIONS Surveillance of TIVA-AE associated with MMC is feasible and helps change practices. It could be useful for improving care of patients undergoing cancer chemotherapy.
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Safety and quality as a "way of life" in the PICU: where does the morbidity and mortality conference fit in?*. Crit Care Med 2014; 42:2306-8. [PMID: 25226129 DOI: 10.1097/ccm.0000000000000562] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Vyas D, Hozain AE. Clinical peer review in the United States: History, legal development and subsequent abuse. World J Gastroenterol 2014; 20:6357-6363. [PMID: 24914357 PMCID: PMC4047321 DOI: 10.3748/wjg.v20.i21.6357] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 04/03/2014] [Indexed: 02/07/2023] Open
Abstract
The Joint Commission on Accreditation requires hospitals to conduct peer review to retain accreditation. Despite the intended purpose of improving quality medical care, the peer review process has suffered several setbacks throughout its tenure. In the 1980s, abuse of peer review for personal economic interest led to a highly publicized multimillion-dollar verdict by the United States Supreme Court against the perpetrating physicians and hospital. The verdict led to decreased physician participation for fear of possible litigation. Believing that peer review was critical to quality medical care, Congress subsequently enacted the Health Care Quality Improvement Act (HCQIA) granting comprehensive legal immunity for peer reviewers to increase participation. While serving its intended goal, HCQIA has also granted peer reviewers significant immunity likely emboldening abuses resulting in Sham Peer Reviews. While legal reform of HCQIA is necessary to reduce sham peer reviews, further measures including the need for standardization of the peer review process alongside external organizational monitoring are critical to improving peer review and reducing the prevalence of sham peer reviews.
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Surgeon-Specific Performance Reports in General Surgery: An Observational Study of Initial Implementation and Adoption. J Am Coll Surg 2013; 217:636-647.e1. [DOI: 10.1016/j.jamcollsurg.2013.04.040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 04/29/2013] [Accepted: 04/29/2013] [Indexed: 11/19/2022]
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Aziato L, Adejumo O. An Insight Into the Preoperative Experiences of Ghanaian General Surgical Patients. Clin Nurs Res 2013; 23:171-87. [DOI: 10.1177/1054773813475447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The unknown outcome of surgery has always been a source of anxiety for patients and their relatives. However, the experiences of Ghanaian surgical patients have not been adequately explored. This study sought to have an in-depth exploration of the preoperative experiences of Ghanaian general surgical patients to inform effective preoperative care. The study employed an ethnographic design and was conducted at two hospitals in Accra. Thirteen general surgical patients were purposively recruited and interviewed. Data analysis occurred concurrently and themes that emerged included reaction to impending surgery with subthemes of inappropriate disclosure, fear of death, readiness for surgery, and effect of waiting in the theatre. Also, the theme information gap had subthemes of preoperative care, expectations at the theatre, and undue delays. The study emphasized the need for health professionals to provide effective education to the public and patients, on surgery and its effects, to curb negative perceptions about surgery.
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Rabizadeh S, Gower WA, Payton K, Miller K, Vera K, Serwint JR. Restructuring the Morbidity and Mortality Conference in a Department of Pediatrics to serve as a vehicle for system changes. Clin Pediatr (Phila) 2012; 51:1079-86. [PMID: 23034949 DOI: 10.1177/0009922812461069] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Morbidity and Mortality conference (MMC) serves an important role in medical care and education. We restructured our Department of Pediatrics MMC to focus on multidisciplinary participation and improved communication among disciplines, quality improvement, and system changes for safer clinical care and enhanced learning from adverse outcomes. METHOD The structure and philosophy of the Department of Pediatrics MMC was changed. We present guiding principles for the restructuring process and evaluation results postrestructuring, which examined achievement of conference goals, including quality improvement. RESULTS The MMC led to system changes within the Department of Pediatrics as well as other parts of the hospital. Satisfaction with these changes was high among conference participants, who felt that the conference achieved its goals of including multiple disciplines and creating system changes. CONCLUSIONS 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.
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Chan LS, Elabiad M, Zheng L, Wagman B, Low G, Chang R, Testa N, Hall SL. A medical staff peer review system in a public teaching hospital--an internal quality improvement tool. J Healthc Qual 2012; 36:37-44. [PMID: 22646743 DOI: 10.1111/j.1945-1474.2012.00208.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Peer review of the quality of care of the medical staff in a healthcare delivery system, properly executed and utilized, can bring about changes that improve the quality and safety of patient care, enhance clinical performance, and augment physician education. Although all healthcare facilities are mandated to conduct peer reviews, the process of how it is conducted, reported, and utilized varies widely. In 2007, our institution, a large public teaching acute care facility, developed and implemented an electronic Medical Staff Peer Review System (MS-PRS) that replaced the existing paper-based system and created a centralized database for all peer review activities. Despite limited resources and mounting known challenges, we have developed and implemented a system that includes 100% mortality reviews, an ongoing random review for reappointment and operative procedures, and morbidity peer reviews. Parallel to the 4-year implementation of the system, we observed a steady, significant downward trend in the medical malpractice claim rate, which can be attributable in part to the implementation of MS-PRS. In this paper, we share our experiences in the development, outcomes, challenges encountered, and lessons learned from MS-PRS and provide our recommendations to similar institutions for the development of such a system.
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Falcone JL, Lee KKW, Billiar TR, Hamad GG. Practice-based learning and improvement: a two-year experience with the reporting of morbidity and mortality cases by general surgery residents. JOURNAL OF SURGICAL EDUCATION 2012; 69:385-392. [PMID: 22483142 DOI: 10.1016/j.jsurg.2011.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 09/12/2011] [Accepted: 10/12/2011] [Indexed: 05/31/2023]
Abstract
BACKGROUND The Accreditation Council for Graduate Medical Education (ACGME) core competency of practice-based learning and improvement can be assessed with surgical Morbidity and Mortality Conference (MMC). We aim to describe the MMC reporting patterns of general surgery residents, describe the adverse event rate for patients and compare that with existing published rates, and describe the nature of our institutional adverse events. We hypothesize that reporting patterns and incidence rates will remain constant over time. METHODS In this retrospective cohort study, archived MMC case lists were evaluated from January 1, 2009 to December 31, 2010. The reporting patterns of the residents, the adverse event ratios, and the specific categories of adverse events were described over the academic years. χ(2) and Fisher's exact tests were used to compare across academic years, using an α = 0.05. RESULTS There were 85 surgical MMC case lists evaluated. Services achieved a reporting rate above 80% (p < 0.001). The most consistent reporting was done by postgraduate year (PGY) 5 level chief residents for all services (p > 0.05). Out of 11,368 patients evaluated from complete MMC submissions, 289 patients had an adverse event reported (2.5%). This was lower than published reporting rates for patient adverse event rates (p < 0.001). Adverse event rates were consistent for residents at the postgraduate year 2, 4, and 5 levels for all services (p > 0.05). Over 2 years, 522 adverse events were reported for 461 patients. A majority of adverse events were from death (24.1%), hematologic and/or vascular events (16.7%), and gastrointestinal system events (16.1%). CONCLUSIONS Surgery resident MMC reporting patterns and adverse event rates are generally stable over time. This study shows which adverse event cases are important for chief residents to report.
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Affiliation(s)
- John L Falcone
- University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Department of Surgery, Pittsburgh, Pennsylvania 15213, USA.
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Schwarz D, Schwarz R, Gauchan B, Andrews J, Sharma R, Karelas G, Rajbhandari R, Acharya B, Mate K, Bista A, Bista MG, Sox C, Smith-Rohrberg Maru D. Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement. BMJ Qual Saf 2011; 20:1082-8. [PMID: 21949441 PMCID: PMC3228264 DOI: 10.1136/bmjqs-2011-000273] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Problem In hospitals in rural, resource-limited settings, there is an acute need for simple, practical strategies to improve healthcare quality. Setting A district hospital in remote western Nepal. Key measures for improvement To provide a mechanism for systems-level reflection so that staff can identify targets for quality improvement in healthcare delivery. Strategies for change To develop a morbidity and mortality conference (M&M) quality improvement initiative that aims to facilitate structured analysis of patient care and identify barriers to providing quality care, which can subsequently be improved. Design The authors designed an M&M involving clinical and non-clinical staff in conducting root-cause analyses of healthcare delivery at their hospital. Weekly conferences focus on seven domains of causal analysis: operations, supply chain, equipment, personnel, outreach, societal, and structural. Each conference focuses on assessing the care provided, and identifying ways in which services can be improved in the future. Effects of change Staff reception of the M&Ms was positive. In these M&Ms, staff identified problem areas in healthcare delivery and steps for improvement. Subsequently, changes were made in hospital workflow, supply procurement, and on-site training. Lessons learnt While widely practiced throughout the world, M&Ms typically do not involve both clinical and non-clinical staff members and do not take a systems-level approach. The authors' experience suggests that the adapted M&M conference is a simple, feasible tool for quality improvement in resource-limited settings. Senior managerial commitment is crucial to ensure successful implementation of M&Ms, given the challenging logistics of implementing these programmes in resource-limited health facilities.
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Landriel Ibañez FA, Hem S, Ajler P, Vecchi E, Ciraolo C, Baccanelli M, Tramontano R, Knezevich F, Carrizo A. A new classification of complications in neurosurgery. World Neurosurg 2011; 75:709-15; discussion 604-11. [PMID: 21704941 DOI: 10.1016/j.wneu.2010.11.010] [Citation(s) in RCA: 179] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Revised: 10/20/2010] [Accepted: 11/02/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To define and grade neurosurgical and spinal postoperative complications based on their need for treatment. METHODS Complications were defined as any deviation from the normal postoperative course occurring within 30 days of surgery. A four-grade scale was proposed based on the therapy used to treat the complications: grade I, any non-life-threatening complications treated without invasive procedures; grade II, complications requiring invasive management such as surgical, endoscopic, and endovascular procedures; grade III, life-threatening adverse events requiring treatment in an intensive care unit (ICU); and grade IV, deaths as a result of complications. Each grade was classified as a surgical or medical complication. An observational test of this system was conducted between January 2008 and December 2009 in a cohort of 1190 patients at the Hospital Italiano de Buenos Aires. RESULTS Of 167 complications, 129 (10.84%) were classified as surgical, and 38 (3.19%) were classified as medical complications. Grade I (mild) complications accounted for 31.73%, grade II (moderate) complications accounted for 25.74%, and grade III (severe) complications accounted for 34.13%. The overall mortality rate was 1.17%; 0.84% of deaths were directly related to surgical procedures. CONCLUSIONS The authors present a simple, practical, and easy to reproduce way to report negative outcomes based on the therapy administered to treat a complication. The main advantages of this classification are the ability to compare surgical results among different centers and times, the ability to compare medical and surgical complications, and the ability to perform future meta-analyses.
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Edwards MT. The Objective Impact of Clinical Peer Review on Hospital Quality and Safety. Am J Med Qual 2010; 26:110-9. [DOI: 10.1177/1062860610380732] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Houkin K, Baba T, Minamida Y, Nonaka T, Koyanagi I, Iiboshi S. QUANTITATIVE ANALYSIS OF ADVERSE EVENTS IN NEUROSURGERY. Neurosurgery 2009; 65:587-94; discussion 594. [DOI: 10.1227/01.neu.0000350860.59902.68] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Kiyohiro Houkin
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Takeo Baba
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | | | - Tadashi Nonaka
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Izumi Koyanagi
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
| | - Satoshi Iiboshi
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Japan
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