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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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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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Taheri Moghadam S, Sheikhtaheri A, Hooman N. Patient safety classifications, taxonomies and ontologies, part 2: A systematic review on content coverage. J Biomed Inform 2023; 148:104549. [PMID: 37984548 DOI: 10.1016/j.jbi.2023.104549] [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: 07/16/2022] [Revised: 10/11/2023] [Accepted: 11/16/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Content coverage of patient safety ontology and classification systems should be evaluated to provide a guide for users to select appropriate ones for specific applications. In this review, we identified and compare content coverage of patient safety classifications and ontologies. METHODS We searched different databases and ontology/classification repositories to identify these classifications and ontologies. We included patient safety-related taxonomies, ontologies, classifications, and terminologies. We identified and extracted different concepts covered by these systems and mapped these concepts to international classification for patient safety (ICPS) and finally compared the content of these systems. RESULTS Finally, 89 papers (77 classifications or ontologies) were analyzed. Thirteen classifications have been developed to cover all medical domains. Among specific domain systems, most systems cover medication (16), surgery (8), medical devices (3), general practice (3), and primary care (3). The most common patient safety-related concepts covered in these systems include incident types (41), contributing factors/hazards (31), patient outcomes (29), degree of harm (25), and action (18). However, stage/phase (6), incident characteristics (5), detection (5), people involved (5), organizational outcomes (4), error type (4), and care setting (3) are some of the less covered concepts in these classifications/ontologies. CONCLUSION Among general systems, ICPS, World Health Organization's Adverse Reaction Terminology (WHO-ART), and Ontology of Adverse Events (OAE) cover most patient safety concepts and can be used as a gold standard for all medical domains. As a result, reporting systems could make use of these broad classifications, but the majority of their covered concepts are related to patient outcomes, with the exception of ICPS, which covers other patient safety concepts. However, the ICPS does not cover specialized domain concepts. For specific medical domains, MedDRA, NCC MERP, OPAE, ADRO, PPST, OCCME, TRTE, TSAHI, and PSIC-PC provide the broadest coverage of concepts. Many of the patient safety classifications and ontologies are not formally registered or available as formal classification/ontology in ontology repositories such as BioPortal. This study may be used as a guide for choosing appropriate classifications for various applications or expanding less developed patient safety classifications/ontologies. Furthermore, the same concepts are not represented by the same terms; therefore, the current study could be used to guide a harmonization process for existing or future patient safety classifications/ontologies.
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Affiliation(s)
- Sharare Taheri Moghadam
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Abbas Sheikhtaheri
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Nakysa Hooman
- Aliasghar Clinical Research Development Center (AACRDC), Aliasghar Children Hospital, Department of Pediatrics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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Timing of Adverse Events Within 90 Days of Hip Fracture Surgery: A Database Study. J Am Acad Orthop Surg 2023; 31:245-251. [PMID: 36821080 DOI: 10.5435/jaaos-d-22-00368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 10/23/2022] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Hip fracture surgery is associated with notable morbidity. Understanding the timing of adverse events can inform strategies for prevention and management. Owing to database limitations, many studies have limited postoperative follow-up to 30 days. However, adverse events may not have plateaued by this time. This study evaluated adverse events after hip fracture surgery out to 90 days. METHODS Hip fracture surgeries in patients 65 years or older were identified in the 2010 to 2020 Q3 M91Ortho PearlDiver data set using administrative codes. The 90-day incidence and time of diagnosis of 10 common adverse events were determined and used to calculate median, interquartile range, and middle 80% for time of diagnosis. The number of events occurring before and after 30 days was also determined. RESULTS A total of 258,834 hip fracture surgery patients were identified. On average, 70% of adverse events occurred in postoperative days 0 to 30 and 30% occurred in days 31 to 90. The percentage of events in days 31 to 90 ranged from 8% (transfusion) to 42% (wound dehiscence). Compared with patients with a 0- to 30-day adverse event, those with 31- to 90-day adverse events had higher average Elixhauser Comorbidity Index scores (8.6 vs. 7.8, P < 0.001) and a slightly greater proportion of men (31.5% vs. 30.2%, P < 0.001).For specific adverse events, the time of diagnosis (median; interquartile range; middle 80%) were as follows: transfusion (2 days; 1 to 4 days; 1 to 24 days), acute kidney injury (5; 2 to 26; 1 to 55), cardiac event (9; 3 to 35; 1 to 64), urinary tract infection (13; 3 to 39; 1 to 65), hematoma (14; 6 to 28; 3 to 52), pneumonia (15; 5 to 39; 2 to 66), venous thromboembolism (16; 5 to 40; 2 to 64), surgical site infection (23; 14 to 37; 7 to 56), sepsis (24; 9 to 48; 3 to 71), and wound dehiscence (26; 15 to 41; 7 to 64). DISCUSSION Nearly one-third of 90-day adverse events after hip fracture surgery were found to occur after postoperative day 30. An understanding of the timing of adverse events is important for improving patient counseling and optimizing patient care.
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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: 0] [Impact Index Per Article: 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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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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Patient safety classification, taxonomy and ontology systems: A systematic review on development and evaluation methodologies. J Biomed Inform 2022; 133:104150. [PMID: 35878822 DOI: 10.1016/j.jbi.2022.104150] [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: 12/13/2021] [Revised: 06/11/2022] [Accepted: 07/19/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Patient safety classifications/ontologies enable patient safety information systems to receive and analyze patient safety data to improve patient safety. Patient safety classifications/ontologies have been developed and evaluated using a variety of methods. The purpose of this review was to discuss and analyze the methodologies for developing and evaluating patient safety classifications/ontologies. METHODS Studies that developed or evaluated patient safety classifications, terminologies, taxonomies, or ontologies were searched through Google Scholar, Google search engines, National Center for Biomedical Ontology (NCBO) BioPortal, Open Biological and Biomedical Ontology (OBO) Foundry and World Health Organization (WHO) websites and Scopus, Web of Science, PubMed, and Science Direct. We updated our search on 30 February 2021 and included all studies published until the end of 2020. Studies that developed or evaluated classifications only for patient safety and provided information on how they were developed or evaluated were included. Systems with covered patient safety terms (such as ICD-10) but are not specifically developed for patient safety were excluded. The quality and the risk of bias of studies were not assessed because all methodologies and criteria were intended to be covered. In addition, we analyzed the data through descriptive narrative synthesis and compared and classified the development and evaluation methods and evaluation criteria according to available development and evaluation approaches for biomedical ontologies. RESULTS We identified 84 articles that met all of the inclusion criteria, resulting in 70 classifications/ontologies, nine of which were for the general medical domain. The most papers were published in 2010 and 2011, with 8 and 7 papers, respectively. The United States (50) and Australia (23) have the most studies. The most commonly used methods for developing classifications/ontologies included the use of existing systems (for expanding or mapping) (44) and qualitative analysis of event reports (39). The most common evaluation methods were coding or classifying some safety report samples (25), quantitative analysis of incidents based on the developed classification (24), and consensus among physicians (16). The most commonly applied evaluation criteria were reliability (27), content and face validity (9), comprehensiveness (6), usability (5), linguistic clarity (5), and impact (4), respectively. CONCLUSIONS Because of the weaknesses and strengths of the development/evaluation methods, it is advised that more than one method for development or evaluation, as well as evaluation criteria, should be used. To organize the processes of developing classification/ontologies, well-established approaches such as Methontology are recommended. The most prevalent evaluation methods applied in this domain are well fitted to the biomedical ontology evaluation methods, but it is also advised to apply some evaluation approaches such as logic, rules, and Natural language processing (NLP) based in combination with other evaluation approaches. This research can assist domain researchers in developing or evaluating domain ontologies using more complete methodologies. There is also a lack of reporting consistency in the literature and same methods or criteria were reported with different terminologies.
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A Novel System to Improve Case Capture for Surgery Morbidity and Mortality Conference. J Surg Res 2022; 278:395-403. [PMID: 35700668 DOI: 10.1016/j.jss.2022.05.016] [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: 12/30/2021] [Revised: 04/01/2022] [Accepted: 05/21/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Complications are often under-reported at surgical morbidity and mortality (M&M) conferences due to the sole reliance on voluntary case submission. While most institutions have databases used for targeted initiatives in quality improvement, these are not routinely used for M&M. We aimed to increase case capture for M&M conferences by developing a novel system that augments the existing case submission system with cases representing complications from quality improvement databases and the electronic health record (EHR). METHODS We developed and implemented a novel system for increasing the capture rate of complications for M&M conferences by developing custom software that combines data from the following sources: an existing voluntary case submission system for M&M, local quality databases-National Surgical Quality Improvement Program and Vizient, and an EHR-based case capture tool. We evaluated this system on a retrospective cohort of all postoperative complications at a single center in a 32-mo period and in a prospective cohort over a 4-mo period after system implementation. RESULTS In the retrospective cohort, we identified 433 complications among all data sources. Inclusion of the new system introduced 280 new potential cases for M&M review over the 32-mo period. After implementation, the system provided 31% of cases presented at M&M conference that would have otherwise been omitted. CONCLUSIONS A novel system that includes complications identified in the EHR and quality improvement databases increased the case capture volume for surgical M&M conference, which provides an objective case referral system that can identify complementary quality improvement opportunities.
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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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Lazzara EH, Salisbury M, Hughes AM, Rogers JE, King HB, Salas E. The Morbidity and Mortality Conference: Opportunities for Enhancing Patient Safety. J Patient Saf 2022; 18:e275-e281. [PMID: 34951610 DOI: 10.1097/pts.0000000000000765] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ABSTRACT Since the 20th century, health care institutions have used morbidity and mortality conferences (MMCs) as a forum to discuss complicated cases and fatalities to capitalize on lessons learned. Medical technology, health care processes, and the teams who provide care have evolved over time, but the format of the MMC has remained relatively unchanged. The present article outlines 5 key areas for improvement within the MMC along with prescriptive and actionable recommendations for mitigating these challenges. This work incorporates the contributions of numerous researchers and practitioners from the educational, training, debrief, and health care fields. With the best practices and lessons learned from various domains in mind, we recommend optimizing the MMC by (1) encouraging a culture that leverages expertise from multiple sources, (2) allocating ample time for innovative thinking, (3) using a global approach that considers individual, team, and system-level factors, (4) leveraging learnings from errors as well as near misses, and (5) promoting communication, innovative thinking, and actionable planning. The 5 evidence-based recommendations herein serve to ensure that MMCs are structured learning events that promote, encourage, and support safe, reliable care. Furthermore, the outlined recommendations seek to capitalize upon the MMC's opportunity to engage early discovery as well as proactive risk assessment and action-oriented solutions.
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Affiliation(s)
- Elizabeth H Lazzara
- From the Department of Human Factors and Behavioral Neurobiology, Embry Riddle Aeronautical University, Daytona Beach, Florida
| | | | - Ashley M Hughes
- Department of Biomedical and Health Information Sciences, University of Illinois at Chicago, Chicago, IL
| | - Jordan E Rogers
- From the Department of Human Factors and Behavioral Neurobiology, Embry Riddle Aeronautical University, Daytona Beach, Florida
| | - Heidi B King
- U.S. Department of Defense Patient Safety Program, Defense Health Agency, Falls Church, Virginia
| | - Eduardo Salas
- Department of Psychology, Rice University, Houston, Texas
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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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12
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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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13
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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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Welling SE, Katz CB, Goldberg MJ, Bauer JM. NSQIP versus institutional morbidity and mortality conference: complementary complication reporting in pediatric spine fusion. Spine Deform 2021; 9:113-118. [PMID: 32880097 DOI: 10.1007/s43390-020-00197-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/25/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Other fields of medicine have demonstrated underreported surgical complication rates by institutional M&M compared to NSQIP. However, a study comparing surgical complication rates in the pediatric spine population, using an identical set of patients rather than nationally extrapolated, has not been performed. METHODS A single institution's ASC-NSQIP Pediatric spine fusion cases and its departmental team-reported M&M database for the same were reviewed for January 1, 2012 to December 31, 2018. Differences in surgical complication reporting between the two databases for the identical patient cohort were recorded. RESULTS NSQIP identified 50 pediatric spine fusion patients with complications out of 386 NSQIP-algorithm-sampled cases (13%). Of these complications, 23 were not reported in the M&M conference database (6% of NSQIP-sampled cases, 2.5% of all M&M cases). The most common under-reported complication categories include pneumonia (100% under-reported), clostridium difficile (100%), urinary tract infection (83%), and superficial wound disruption (67%). During the same 7 years, M&M covered 924 spine fusions and identified 162 complications. Of these 162 patients, 22 were included in the NSQIP sampling and were not reported as complications (6% of NSQIP sampled patients). CONCLUSION Recognizing complication rates is central to implement strategies for delivering better quality care. NSQIP data may serve as an important quality check for pediatric spine institutional M&M data, but both may not include all complications even within its sampled patients. In general, NSQIP's protocols identified more medical complications, while M&M has a surgical focus, benefits from the limitless follow-up, and involves timely departmental awareness of complications.
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Affiliation(s)
| | | | - Michael J Goldberg
- Department of Orthopaedic Surgery, Department of Orthopaedics and Sports Medicine, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
| | - Jennifer M Bauer
- Department of Orthopaedic Surgery, Department of Orthopaedics and Sports Medicine, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
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Comprehensive Complication Index or Clavien-Dindo Classification: Which is Better for Evaluating the Severity of Postoperative Complications Following Pancreatectomy? World J Surg 2020; 45:849-856. [PMID: 33191470 DOI: 10.1007/s00268-020-05859-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complications are important indicators of immediate postoperative outcomes. The Clavien-Dindo classification (CDC) is a widely used index for the classification of surgical complications. More recently, the comprehensive complication index (CCI) has also been introduced for classifying postoperative complications. The aim of this study was to compare the relationship of CCI and CDC with clinical or economic parameters. METHODS The study prospectively enrolled patients from April 2015 to October 2016. Two hundred and twenty-two patients underwent pancreatectomy during the enrolled period. Complications were ranked according to CDC and CCI indices. After analyzing the correlation between CCI and CDC, the correlations of length of stay (LOS) and cost with CCI and CDC were compared. Finally, differences between the correlation coefficients of CDC and CCI parameters were calculated. RESULTS Complications occurred in 211 patients (95.0%). The correlation between CDC and CCI was r = 0.938. (p < 0.001) Compared to the CDC, CCI showed significantly stronger correlations with LOS and cost of complications (LOS: CCI vs. CDC, r = 0.725 vs. r = 0.630, p < 0.001; cost: CCI vs. CDC, r = 0.774 vs. r = 0.723, p < 0.001). CONCLUSION CCI is a more accurate classification index, compared to CDC, for evaluating the risk of postoperative complications.
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17
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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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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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Al Saiegh F, Mazza J, Hafazalla K, Baldassari MP, Theofanis T, Ye D, Hoelscher C, Harrop JS, Evans JJ, Jabbour P, Rosenwasser RH, Sharan AD. Developing standardized titles to classify the adverse events in 7,418 cranial and spinal neurosurgical procedures. Clin Neurol Neurosurg 2020; 198:106121. [PMID: 32818755 DOI: 10.1016/j.clineuro.2020.106121] [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: 06/30/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Neurosurgical procedures are life- and function-saving but carry a risk of adverse events (AE) which can cause permanent neurologic deficits. Unfortunately, there is lack of clearly defined AEs associated with given procedures, and their reporting is non-uniform and often arbitrary. However, with an increasing number of neurosurgical procedures performed, there is a need for standardization of AEs for systematic tracking. Such a system would establish a baseline for future quality improvement strategies. OBJECTIVE To review our institutional AEs and devise standardized titles specific to the spine, tumor, functional, and vascular neurosurgery divisions. METHODS A review of prospective monthly-reported morbidity and mortality (M&M) conference data within the Department of Neurological Surgery was conducted from January 2017 to December 2019. An AE was defined as any mortality, an "unintended and undesirable diagnostic or therapeutic event", "an event that prolongs the patient's hospital stay", or an outcome with permanent or transient neurologic deficit. RESULTS A total of 1096 AEs from 7418 total procedures (14.8 %) were identified. Of those, 418 (5.6 %) were in cerebrovascular, 249 (3.4 %) were in neuro-oncology and 429 (5.8 %) were in the spine & functional divisions. The most common AEs across all divisions were infection (17 %), hemorrhage (11 %) and cerebrospinal fluid (CSF) leak (7.8 %). Other AEs were indirectly related to the neurosurgical procedure, such as deep vein thrombosis or pulmonary embolism (2.7 %), or pneumothorax (0.3 %). CONCLUSION This work illustrates standardized AEs can be implemented universally across the spectrum of neurological surgery. Standardization can help identify recurring AE patterns through better tracking.
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Affiliation(s)
- Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Jacob Mazza
- Department of Neurological Surgery, Rush University, Chicago, IL 60612
| | - Karim Hafazalla
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael P Baldassari
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thana Theofanis
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Donald Ye
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Christian Hoelscher
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - James J Evans
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ashwini D Sharan
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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Rybkin I, Azizkhanian I, Gary J, Cole C, Schmidt M, Gandhi C, Al-Mufti F, Anderson P, Santarelli J, Bowers C. Unique Neurosurgical Morbidity and Mortality Conference Characteristics: A Comprehensive Literature Review of Neurosurgical Morbidity and Mortality Conference Practices with Proposed Recommendations. World Neurosurg 2020; 135:48-57. [DOI: 10.1016/j.wneu.2019.11.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/04/2019] [Accepted: 11/05/2019] [Indexed: 12/21/2022]
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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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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: 6] [Impact Index Per Article: 0.8] [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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Flynn-O'Brien KT, Mandell SP, Eaton EV, Schleyer AM, McIntyre LK. Surgery and Medicine Residents' Perspectives of Morbidity and Mortality Conference: An Interdisciplinary Approach to Improve ACGME Core Competency Compliance. JOURNAL OF SURGICAL EDUCATION 2015; 72:e258-66. [PMID: 26143516 DOI: 10.1016/j.jsurg.2015.05.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 05/17/2015] [Accepted: 05/27/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Morbidity and mortality conferences (MMCs) are often used to fulfill the Accreditation Council for Graduate Medical Education practice-based learning and improvement (PBLI) competency, but there is variation among institutions and disciplines in their approach to MMCs. The objective of this study is to examine the trainees' perspective and experience with MMCs and adverse patient event (APE) reporting across disciplines to help guide the future implementation of an institution-wide, workflow-embedded, quality improvement (QI) program for PBLI. DESIGN Between April 1, 2013, and May 8, 2013, surgical and medical residents were given a confidential survey about APE reporting practices and experience with and attitudes toward MMCs and other QI/patient safety initiatives. Descriptive statistics and univariate analyses using the chi-square test for independence were calculated for all variables. Logistic regression and ordered logistic regression were used for nominal and ordinal categorical dependent variables, respectively, to calculate odds of reporting APEs. Qualitative content analysis was used to code free-text responses. SETTING A large, multihospital, tertiary academic training program in the Pacific Northwest. PARTICIPANTS Residents in all years of training from the Accreditation Council for Graduate Medical Education-accredited programs in surgery and internal medicine. RESULTS Survey response rate was 46.2% (126/273). Although most respondents agreed or strongly agreed that knowledge of and involvement in QI/patient safety activities was important to their training (88.1%) and future career (91.3%), only 10.3% regularly or frequently reported APEs to the institution's established electronic incident reporting system. Senior-level residents in both surgery and medicine were more likely to report APEs than more junior-level residents were (odds ratio = 4.8, 95% CI: 3.1-7.5). Surgery residents had a 4.9 (95% CI: 2.3-10.5) times higher odds than medicine residents had to have reported an APE to their MMC or service, and a 2.5 (95% CI: 1.0-6.2) times higher odds to have ever reported an APE through any mechanism. The most commonly cited reason for not reporting APEs was "finding the reporting process cumbersome." Overall, 87% of respondents agreed or strongly agreed that MMCs were valuable, educational, and contributed to improving patient outcomes, but many cited opportunities for improvement. CONCLUSIONS Although the perceived value of MMCs is high among both surgical and medicine trainees, there is significant variability across disciplines and level of training in APE reporting and experience with MMCs. This study presents a multidisciplinary resident perspective on optimizing APE reporting, MMCs, and PBLI compliance.
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Affiliation(s)
- Katherine T Flynn-O'Brien
- Department of Surgery, University of Washington Medical Center, Seattle, Washington; Harborview Injury Prevention and Research Center, Seattle, Washington.
| | - Samuel P Mandell
- Department of Surgery, University of Washington Medical Center, Seattle, Washington; Harborview Injury Prevention and Research Center, Seattle, Washington; Division of Trauma and Burn Surgery, Harborview Medical Center, Seattle, Washington
| | - Erik Van Eaton
- Department of Surgery, University of Washington Medical Center, Seattle, Washington; Division of Trauma and Burn Surgery, Harborview Medical Center, Seattle, Washington
| | - Anneliese M Schleyer
- Department of Medicine, University of Washington, Seattle, Washington; Department of Medicine, Harborview Medical Center, Seattle, Washington
| | - Lisa K McIntyre
- Department of Surgery, University of Washington Medical Center, Seattle, Washington; Division of Trauma and Burn Surgery, Harborview Medical Center, Seattle, Washington
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van Ramshorst GH, Vos MC, den Hartog D, Hop WCJ, Jeekel J, Hovius SER, Lange JF. A comparative assessment of surgeons' tracking methods for surgical site infections. Surg Infect (Larchmt) 2013; 14:181-7. [PMID: 23485257 DOI: 10.1089/sur.2012.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The incidence of surgical site infections (SSI) is considered increasingly to be an indicator of quality of care. We conducted a study in which daily inspection of the surgical incision was performed by an independent, trained team to monitor the incidence of SSI using U.S. Centers for Disease Control and Prevention (CDC) definitions, as a gold-standard measure of care. In the department of surgery, two registration systems for SSI were used routinely by the surgeon: An electronic and a plenary tracking system. The results of the independent team were compared with the outcomes provided by two registration systems for SSI, so as to evaluate the reliability of these systems as a possible alternative for indicating quality of care. METHODS The study was an incidence study conducted from May 2007 to January 2009 that included 1,000 adult patients scheduled to undergo open abdominal surgery in an academic teaching hospital. Surgical incisions were inspected daily to check for SSI according to definitions of health care-associated infections established by the CDC. Follow-up after discharge was done at the outpatient clinic of the hospital by telephone or letter in combination with patient diaries and reviews of patient charts, discharge letters, electronic files, and reported complications. Univariate and multivariable analyses were done to identify putative risk factors for missing registrations. RESULTS Of the 1,000 patients in the study, 33 were not evaluated. Surgical site infections were diagnosed in 26.8% of the 967 remaining patients, of which 18.0% were superficial incisional infections, 5.4% were deep incisional infections, and 3.4% were organ/space infections. More than 60% of SSIs were unreported in either of the department's two tracking systems for such infections. For these two systems, independent major risk factors for missing registrations were (1) the lack of occurrence of an SSI, (2) transplantation surgery, and (3) admission to non-surgical departments. CONCLUSIONS Most SSIs were not tracked with the department's two systems. These systems proved poor alternatives to the gold-standard method of quantifying the incidence of Surgical Site Infection SSI and, therefore, the quality of care. Both protocolized wound assessment and on-site documentation are mandatory for realistic quantification of the incidence of SSI.
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Increasing Reporting of Adverse Events to Improve the Educational Value of the Morbidity and Mortality Conference. J Am Coll Surg 2013; 216:50-6. [DOI: 10.1016/j.jamcollsurg.2012.09.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 09/13/2012] [Accepted: 09/13/2012] [Indexed: 11/21/2022]
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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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Thomas MK, McDonald RJ, Foley EF, Weber SM. Educational value of morbidity and mortality (M&M) conferences: are minor complications important? JOURNAL OF SURGICAL EDUCATION 2012; 69:326-329. [PMID: 22483132 DOI: 10.1016/j.jsurg.2011.11.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 11/08/2011] [Accepted: 11/30/2011] [Indexed: 05/31/2023]
Abstract
BACKGROUND Often, minor complications are not reported in morbidity and mortality (M&M) conference because they are considered insignificant to patient outcome. As part of an effort to improve the quality of the M&M conference, we sought to integrate a specific, focused intervention to improve the reporting of minor complications and to evaluate the perception of its educational value. MATERIALS AND METHODS To provide evidence-based training in recognizing, treating, and preventing minor complications, a presentation strategy was created. Surgical faculty identified 20 complications as minor complications. Each month, a junior resident was assigned to give a 10-minute presentation, assessing 1 of the 20 minor complications in depth during the M&M conference. To assess the impact of the intervention, we surveyed residents and faculty about the educational value of M&M conferences before and after implementation. RESULTS Before introducing minor complication presentations into the M&M conference, only 58% of respondents indicated that minor complications should be reported at the conference. After the changes were implemented in minor complication reporting, 95% of respondents said that minor complications should be reported (p < 0.01). Eighty-nine percent of respondents found the minor complication presentations to be educationally beneficial. In addition, postsurvey respondents were also more likely than presurvey respondents to identify that a purpose of an M&M conference was to improve patient care (29% vs 71%, p < 0.05). CONCLUSIONS A formal, evidence-based presentation of minor complications can increase both the faculty and residents' perception of the importance of reporting minor complications at an M&M conference. Focused minor complication reporting should be incorporated into M&M curriculum.
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Affiliation(s)
- Marie K Thomas
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53792, USA
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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: 175] [Impact Index Per Article: 13.5] [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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Steiger HJ, Stummer W, Hänggi D. Can systematic analysis of morbidity and mortality reduce complication rates in neurosurgery? Acta Neurochir (Wien) 2010; 152:2013-9. [PMID: 20936313 DOI: 10.1007/s00701-010-0822-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 09/23/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Morbidity and mortality conferences (M&MC) are a traditional part of residency programs in a large number of countries to increase the training quality. The purpose of the present publication is to report our experience with a monthly M&MC over a 5-year period and, in particular, to describe the methods to identify critical cases, the system of analysis, classification of morbidity and mortality, and the resulted impact. METHOD Monthly identification of M&M was done through a system of electronically coding hospital course at the time of discharge. Morbidity was classified as moderate if sequels resolved within 3 months or otherwise as severe. Morbidity included management complications not directly related the neurosurgical procedure, such as pneumonia or thromboembolism. Mortality was classified as related to surgery or unrelated, e.g., after severe trauma. Mortality in relation to surgery was subclassified in terms of causal relation or not. Statistical comparison of incidence rates was calculated statistically. RESULTS Overall management morbidity rate was 7.1%, and mortality with causal relation to surgery was 0.38%. The leading cause of morbidity was additional neurological deficit (25%) followed by postoperative hemorrhage (23%) and second unplanned surgery due to incomplete result of the primary procedure (14%). Overall, the monthly incidence varied without a discernable annual pattern. Over the years, there were only a handful of guideline updates triggered by incidents. CONCLUSION Our system to identify complication proved to be reliable. During the study period, the M&MC developed into a well-accepted instrument of quality control and problem-oriented teaching, but the impact on quality improvement remained questionable.
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Affiliation(s)
- Hans-Jakob Steiger
- Department of Neurosurgery, Heinrich-Heine-Universität, Düsseldorf, Germany.
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Systematic Classification of Morbidity and Mortality After Thoracic Surgery. Ann Thorac Surg 2010; 90:936-42; discussion 942. [DOI: 10.1016/j.athoracsur.2010.05.014] [Citation(s) in RCA: 248] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Revised: 04/30/2010] [Accepted: 05/05/2010] [Indexed: 11/22/2022]
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Chukuezi AB, Nwosu JN. Mortality pattern in the surgical wards: a five year review at Federal Medical Centre, Owerri, Nigeria. Int J Surg 2010; 8:381-3. [PMID: 20538084 DOI: 10.1016/j.ijsu.2010.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 04/27/2010] [Accepted: 05/18/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To identify deaths in the surgical wards, elicit the cause of death and suggest changes that will ensure improved surgical care of patients and outcome. STUDY DESIGN Retrospective. METHODS Records collected from the theatre operation registers, ward registers and case notes of all patients who were admitted into the surgical wards Federal Medical Centre, Owerri whether elective or emergency from January 1997 to December 2001 were reviewed. Data extracted included date of admission, age, sex, educational status, residence; surgical diagnosis and clinical cause of death Data obtained were analyzed and presented in tabular and descriptive forms. RESULTS There were 4583 surgical admissions in all the surgical wards of which males were 2751 and females 1832. During this period there were 419 deaths with an overall death per admission crude mortality rate of 9.14%. The leading causes of death were acute abdomen (22.20%), RTA with head injury (18.14%) and malignances (14.56%). Of the 419 deaths males were 305 (72.79%) and females 114 (27.21%) in a ratio of 2.68:1. CONCLUSION Aggressive enlightenment and healthcare campaigns, health education, improvement of healthcare facilities and accessibility to healthcare facilities are highlighted. Structured study in the management of surgical cases is emphasized.
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Affiliation(s)
- Anelechi B Chukuezi
- Department of Otolaryngology, Imo State University Teaching Hospital, PMB 8, Orlu Imo State, Nigeria.
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Dierks MM, Huang ZS, Siracuse JJ, Tolchin S, Moorman DW. Diagnostic, surgical judgment, and systems issues leading to reoperation: mining administrative databases. Am J Surg 2010; 199:324-9; discussion 329-30. [DOI: 10.1016/j.amjsurg.2009.09.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Revised: 09/18/2009] [Accepted: 09/18/2009] [Indexed: 10/19/2022]
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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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Abstract
BACKGROUND AND AIMS The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the complication. The principle of the classification was to be simple, reproducible, flexible, and applicable irrespective of the cultural background. The aim of the current study was to critically evaluate this classification from the perspective of its use in the literature, by assessing interobserver variability in grading complex complication scenarios and to correlate the classification grades with patients', nurses', and doctors' perception. MATERIAL AND METHODS Reports from the literature using the classification system were systematically analyzed. Next, 11 scenarios illustrating difficult cases were prepared to develop a consensus on how to rank the various complications. Third, 7 centers from different continents, having routinely used the classification, independently assessed the 11 scenarios. An agreement analysis was performed to test the accuracy and reliability of the classification. Finally, the perception of the severity was tested in patients, nurses, and physicians by presenting 30 scenarios, each illustrating a specific grade of complication. RESULTS We noted a dramatic increase in the use of the classification in many fields of surgery. About half of the studies used the contracted form, whereas the rest used the full range of grading. Two-thirds of the publications avoided subjective terms such as minor or major complications. The study of 11 difficult cases among various centers revealed a high degree of agreement in identifying and ranking complications (89% agreement), and enabled a better definition of unclear situations. Each grade of complications significantly correlated with the perception by patients, nurses, and physicians (P < 0.05, Kruskal-Wallis test). CONCLUSIONS This 5-year evaluation provides strong evidence that the classification is valid and applicable worldwide in many fields of surgery. No modification in the general principle of classification is warranted in view of the use in ongoing publications and trials. Subjective, inaccurate, or confusing terms such as "minor or major" should be removed from the surgical literature.
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