The morbidity and mortality conference in PICUs in the United States: a national survey

An Innovative and Integrative Approach to Breaking Down Barriers to Traditional Morbidity and Mortality Conference

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.

Defining a High-Quality and Effective Morbidity and Mortality Conference: A Systematic Review

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.

A Survey-Based Assessment of the Practices Governing Morbidity and Mortality Conferences and the Effects of the COVID-19 Pandemic

BACKGROUND

Morbidity and mortality (M&M) conferences are essential components for resident education and provide a valuable tool to improve patient safety and quality of care. M&M conferences help identify important gaps in safety and reduce avoidable events in future patient care. Active methods to improve the utilization of M&M conferences have been shown to enhance their educational value for residents, faculty and multidisciplinary teams in healthcare institutions.

OBJECTIVE

The purpose of this study was to use a survey-based methodology to assess how morbidity and mortality conferences are conducted in residency programs, including characteristics such as frequency, involvement of personnel and the effects of COVID-19.

METHODS

From February to October 2021, a validated 19 question survey was electronically distributed to residency program directors in anesthesiology, emergency medicine and general surgery, after a search for email addresses in the ACGME database. The survey was created and hosted on Google Forms.

RESULTS

A total of 125 of 713 program directors (17.5%) responded to the survey. Eighty-three percent of respondent programs reported mandatory participation for residents, with residents providing most of the presentations. Case presentations utilized various formats including SBAR, adverse event analysis and root cause analysis as the most common modalities. Though most programs reported no change in frequency of M&M conferences due to COVID-19, most respondents reported a shift to a virtual or hybrid platform.

CONCLUSION

M&M conferences are an important educational and quality improvement modality, and many residency directors changed practice to incorporate virtual platforms due to the COVID-19 pandemic to maintain uninterrupted educational sessions. Nonetheless, significant variation still exists in how these conferences are conducted between different institutions.

Making the most of a Morbidity and Mortality meeting

BACKGROUND

Morbidity and Mortality meetings (M&Ms) are a fundamental element of surgical practice. However, there has been little investigation into best practices, to maximise education and improvement outcomes.

OBJECTIVE

Create a new, evidence-based M&M methodology, that facilitates standardised analysis of errors in a non-judgemental fashion, and highlights areas for improvement.

METHODS

A Quality Improvement (QI) methodology was used. This project encompassed a literature review and two sequential QI cycles. A literature review and initial survey highlighted best practice and identified areas for improvement. From this information, a new standardised format was created, which centred around a new modified Fishbone framework, incorporating the London Protocol methodology. The project then sequentially tested new formats, with feedback collected for every new format.

RESULTS

The literature review and surveys guided improvement of the M&M. The need for standardisation was highlighted. The new PowerPoint template and modified Fishbone ensured presentations and analysis were consistent and systematic. Participants reported that M&Ms were more engaging, interactive and structured, ensuring improved discussion of errors. The modified Fishbone framework reinforced a blame-free, system-focused analysis.

CONCLUSION

M&Ms are a critical aspect of patient safety. This project utilised simple QI tools to encourage collaborative reflection, learning and improvement.

Parent Participation in Morbidity and Mortality Review: Parent and Physician Perspectives

This study examined Morbidity and Mortality (M&M) review practices and perspectives of physicians and parents regarding parent participation in M&M review. Surveys were distributed to parents of children with a prior hospitalization for congenital heart disease (CHD) and physicians caring for pediatric CHD patients. Response distributions and Fisher’s exact tests were performed to compare parent and physician responses. Qualitative survey data were thematically analyzed. Ninety-two parent and 36 physician surveys were analyzed. Physicians reported parent input or participation was rarely sought in M&M review. Parents with direct experience of adverse events or death of their child reported providers discussed events with them in a timely manner and answered their questions; however, nearly half wished their healthcare team had done something differently during the disclosure. There was no statistical difference between groups regarding transparency ( P = .37, .79); however, there was a significant difference in perspectives regarding parental involvement in the M&M review ( P < .001). Common themes important to parents which emerged from the qualitative analysis were being adequately informed, feeling their perspectives were acknowledged and respected, having attentive and empathetic providers, and receiving consistent messaging. Although rarely included in current practice, parent participation in M&M could offer unique insight and increase accountability to proposed change elucidated by M&M review.

The Morbidity and Mortality Conference: Opportunities for Enhancing Patient Safety

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.

Mortality and Morbidity rounds in neonatology: Providers' experiences and perspectives

AIM

To describe how Canadian level III neonatal intensive care units (NICU) organise mortality and morbidity rounds (M&MR) and explore clinicians' perspectives.

METHODS

This questionnaire study, including open-ended questions, examined the following domains: (1) M&MR format, (2) ethical issues and (3) limitations and perceived effectiveness.

RESULTS

Sixteen out of twenty (80%) level III NICUs participated. All deaths and 64% of morbidities were discussed. M&MR occurred monthly (69%) with 3-5 patients discussed hourly (63%) and usually (75%) physician led. Wide variations of practice between centres existed for practical issues, such as administrative support and attendance. 44% of centres allowed nurses to participate. Goals reported by participants were also heterogeneous: reducing medical error (56%), educational (50%), improving communication (44%) and peer review (23%). Practical barriers were time (75%) and lack of resources/structure (25%). Four main themes were as follows: the role of M&MR, the ongoing blame culture, communication issues and the distinction between mortality and morbidity.

CONCLUSION

Goals and format of M&MR vary widely. M&MR remains physician-centric, where the blame culture still endures. Neonatal M&MR models should be adapted to the modern NICU to ensure the M&MR stays relevant. It could also benefit from lessons learned in quality improvement.

What are the participants' perspective and the system-based impact of a standardized, inter-professional morbidity/mortality-conferences in a children's hospital?

Background

Morbidity and mortality conferences (MMC) are well established but little data exists on inter-professional aspects, system-based outcomes and characteristics in pediatric departments. Our study aim was to analyze the system-based impact and to assess participant's perspectives on standardized, inter-professional MMCs in a children's hospital.

Methods

In a prospective observational analysis the inter-professional MMCs held at a tertiary teaching children's hospital in Switzerland were analyzed for (I) resulting clinical consequences and (II) participants perception on format, usefulness and no-blame atmosphere.

Results

Eighteen MMC, discussing 29 cases were analyzed. Twenty-seven clinical errors/problems were identified and 17 clinical recommendations were developed: ten new or changed clinical guidelines, two new therapeutic alternatives, three new teaching activities, and two guidelines on specific diagnostics. Altogether, the 466 participants evaluated the conferences favorably. Little differences were seen in the evaluations of physicians of different disciplines or seniority but non-physicians scored all questions lower than physicians. Overall, three quarters of the participants felt that there was a no-blame culture during the conferences but results varied depending on the cases discussed.

Conclusions

An inter-professional MMC can have relevant impact on clinical practice and affect system-based changes. Inter-professional conferences are profitable for all participants but evaluated differently according to profession. A standardized format and the presence of a moderator are helpful, but not a guarantee for a no-blame culture. Highly emotional cases are a risk factor to relapse to "blame and shame". A time gap between the event and the MMC may have a beneficial effect.

Keywords

Inter-professional communication; inter-professional health care; learning from failure; morbidity and mortality conference (MMC); patient safety; psychological safety.

Structured Chart Review: Assessment of a Structured Chart Review Methodology

BACKGROUND AND OBJECTIVES

Chart reviews are frequently used for research, care assessments, and quality improvement activities despite an absence of data on reliability and validity. We aim to describe a structured chart review methodology and to establish its validity and reliability.

METHODS

A generalizable structured chart review methodology was designed to evaluate causes of morbidity or mortality and to identify potential therapeutic advances. The review process consisted of a 2-tiered approach with a primary review completed by a site physician and a short secondary review completed by a central physician. A total of 327 randomly selected cases of known mortality or new morbidities were reviewed. Validity was assessed by using postreview surveys with a Likert scale. Reliability was assessed by percent agreement and interrater reliability.

RESULTS

The primary reviewers agreed or strongly agreed in 94.9% of reviews that the information to form a conclusion about pathophysiological processes and therapeutic advances could be adequately found. They agreed or strongly agreed in 93.2% of the reviews that conclusions were easy to make, and confidence in the process was 94.2%. Secondary reviewers made modifications to 36.6% of cases. Duplicate reviews (n = 41) revealed excellent percent agreement for the causes (80.5%-100%) and therapeutic advances (68.3%-100%). κ statistics were strong for the pathophysiological categories but weaker for the therapeutic categories.

CONCLUSIONS

A structured chart review by knowledgeable primary reviewers, followed by a brief secondary review, can be valid and reliable.

Use of Active Learning and Sequencing in a Weekly Continuing Medical Education/Graduate Medical Education Conference

INTRODUCTION

Active learning and sequencing have been described as effective techniques for improving educational conferences. However, few departmental continuing medical education/graduate medical education (CME/GME) conferences, such as Grand Rounds (GR), have adopted these techniques. The purpose of this study was to describe the development, implementation, and evaluation of Friday Forum (FF), a weekly CME/GME conference that incorporated active learning and sequencing techniques into a new educational offering, complementary to GR, within a medium-sized academic pediatrics department.

METHODS

Implemented in 2013, FF was designed to address 5 medically relevant themes in a sequential, rotating, interactive format, and included: (1) clinical reasoning, (2) evidence-based medicine, (3) morbidity & mortality, (4) research in progress, and (5) ethics. In 2018, at the conclusion of its fifth year, a survey and focus groups of faculty, residents, and fellows explored the relative value of FF compared with the departmental GR.

RESULTS

Survey response rates for residents/fellows and faculty were 37/76 (48.7%) and 57/112 (50.9%), respectively. FF was rated highly for helping participants develop rapport with colleagues, exposing participants to interactive strategies for large-group teaching and value for time spent. GR was rated highly for helping participants learn about academic endeavors outside the department and emerging challenges in pediatrics. Qualitatively, two key themes emerged for FF: desire for interaction (community building) and topical variety.

DISCUSSION

Using active learning and sequencing techniques, we implemented a novel CME/GME conference that enhanced our learning community by integrating the education of faculty and trainees, and achieved complementary objectives to GR.

Implementation status of morbidity and mortality conferences in Swiss hospitals: a national cross-sectional survey study

Objective

To determine the implementation status and current practice of morbidity and mortality conferences (M&MCs) in Switzerland.

Design

A national cross-sectional online survey was conducted in spring 2017. The questionnaire focused on overall goals, structure and procedures of hospital M&MCs. Further topics included satisfaction, perceived effectiveness and support requirements.

Setting

A total of 913 chief physicians of surgery and internal medicine, and specialist fields of obstetrics and gynaecology, anaesthesiology and intensive care from Swiss acute care hospitals were invited to the survey. 321 completed the questionnaire, resulting in a 35.2% response rate.

Participants

Chief or senior physicians in charge of the M&MCs in their department.

Intervention

No intervention

Main Outcome Measures

Numbers and percentages of M&MCs within the surveyed disciplines fulfilling certain characteristics and procedural features.

Results

Among 321 respondents, the majority are conducting M&MCs in their departments. Within and between the medical disciplines considerable heterogeneity was found in structural and procedural features of M&MCs. Only a small part of the reported M&MCs is following a systematic approach and meeting recommended procedural features. Although the respondents are satisfied and perceive the M&MCs as an efficient tool, they agree that there is a need for professionalization and standardization.

Conclusion

M&MCs are widely used to promote medical education, patient safety and quality improvements. However, the term M&MC seems to cover different types of meetings. Although the overall goals are similar, various types of M&MCs are used in practice and different objectives are pursued. Tools such as checklists, guidelines and templates are considered helpful.

Are morbidity and mortality case review practices in Scottish intensive care units aligned to national standards?

INTRODUCTION

Both Scottish and UK standards guidelines recommend that intensive care units should hold regular, structured, multidisciplinary morbidity and mortality meetings. The aim of this survey was to ascertain the nature of current practice with regards to morbidity and mortality case reviews and meetings in all intensive care units in Scotland.

METHODS

Semi-structured telephone interviews were conducted with a consultant from all Scottish intensive care units. A list of intensive care units in Scotland was obtained from the Scottish Intensive Care Society Audit Group annual report.

RESULTS

All 24 intensive care units (100%) in Scotland were surveyed. The interviews took an average of 20 min. The three cardiac intensive care units were excluded from analysis. All other intensive care units had morbidity and mortality meetings and 18 units had a morbidity and mortality clinical lead. Nineteen intensive care units held joint morbidity and mortality meetings, eight of which were regular. In all intensive care units, meetings were attended by consultants and trainees. In 14 intensive care units, meetings were attended by nurses, seven by allied health professionals, 1 by a manager and 11 by other professionals. All mortality cases in intensive care unit were discussed in 19 intensive care units, in the other two intensive care units, 10-20% of mortality cases were discussed.

CONCLUSION

There is a wide variation in the processes of reviewing mortality cases and significant events in intensive care units across Scotland, and in the way morbidity and mortality meetings are organised and held. Based on this survey, there is scope for improving the consistency of approach to morbidity and mortality case reviews and meetings in order to improve education and facilitate shared learning.

A Service evaluation of a hospital child death review process to elucidate understanding of contributory factors to child mortality and inform practice in the English National Health Service

OBJECTIVE

To describe a novel approach to hospital mortality meetings to elucidate understanding of contributory factors to child death and inform practice in the National Health Service.

DESIGN

All child deaths were separately reviewed at a meeting attended by professionals across the healthcare pathway, and an assessment was made of contributory factors to death across domains intrinsic to the child, family and environment, parenting capacity and service delivery. Data were analysed from a centrally held database of records.

SETTING

All child deaths in a tertiary children's hospital between 1 April 2010 and 1 April 2013.

MAIN OUTCOME MEASURES

Descriptive data summarising contributory factors to child deaths.

RESULTS

95 deaths were reviewed. In 85% cases, factors intrinsic to the child provided complete explanation for death. In 11% cases, factors in the family and environment and, in 5% cases, factors in parenting capacity, contributed to patient vulnerability. In 33% cases, factors in service provision contributed to patient vulnerability and in two patients provided complete explanation for death. 26% deaths were classified as potentially preventable and in those cases factors in service provision were more commonly identified than factors across other domains (OR: 4.89; 95% CI 1.26 to 18.9).

CONCLUSIONS

Hospital child death review meetings attended by professionals involved in patient management across the healthcare pathway inform understanding of events leading to a child's death. Using a bioecological approach to scrutinise contributory factors the multidisciplinary team concluded most deaths occurred as a consequence of underlying illness. Although factors relating to service provision were commonly identified, they rarely provided a complete explanation for death. Efforts to reduce child mortality should be driven by an understanding of modifiable risk factors. Systematic data collection arising from a standardised approach to hospital reviews should be the basis for national mortality review processes and database development.

Using internal and external reviewers can help to optimise neonatal mortality and morbidity conferences

AIM

This study determined whether there was a difference in the conclusions reached by neonatologists in morbidity and mortality conferences based on their level of involvement in a case.

METHODS

All neonatal deaths occurring between August 2014 and September 2015 at the neonatal intensive care unit of Sainte-Justine Hospital, Montreal, Quebec, Canada, were reviewed by internal physicians involved in the case and external physicians who were not. The reviewers were asked to identify positive and negative clinical practice items and provide written recommendations. These were classified into eight categories and compared for each case.

RESULTS

During the study, 55 patients died leading to 110 reviews and a total of 590 positive and negative items. Most items were in the communication (25.2%), ethical decision-making (16.7%) and clinical management (14.8%) categories. Both the internal and external reviewers were in agreement 48.5% of the time for positive items and 44.8% for negative items. There were 242 written recommendations, which differed significantly among the internal and external reviewers.

CONCLUSION

Reviews of neonatal deaths by two independent reviewers, internal physicians and external physicians, led to different positive and negative practice items and recommendations. This could allow for a richer discussion and improve recommendations for patient care.

Professional Responsibility, Consensus, and Conflict: A Survey of Physician Decisions for the Chronically Critically Ill in Neonatal and Pediatric Intensive Care Units

OBJECTIVE

To describe neonatologist and pediatric intensivist attitudes and practices relevant to high-stakes decisions for children with chronic critical illness, with particular attention to physician perception of professional duty to seek treatment team consensus and to disclose team conflict.

DESIGN

Self-administered online survey.

SETTING

U.S. neonatal ICUs and PICUs.

SUBJECTS

Neonatologists and pediatric intensivists.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We received 652 responses (333 neonatologists, denominator unknown; 319 of 1,290 pediatric intensivists). When asked about guiding a decision for tracheostomy in a chronically critically ill infant, only 41.7% of physicians indicated professional responsibility to seek a consensus decision, but 73.3% reported, in practice, that they would seek consensus and make a consensus-based recommendation; the second most common practice (15.5%) was to defer to families without making recommendations. When presented with conflict among the treatment team, 63% of physicians indicated a responsibility to be transparent about the decision-making process and reported matching practices. Neonatologists more frequently reported a responsibility to give decision making fully over to families; intensivists were more likely to seek out consensus among the treatment team.

CONCLUSIONS

ICU physicians do not agree about their responsibilities when approaching difficult decisions for chronically critically ill children. Although most physicians feel a professional responsibility to provide personal recommendations or defer to families, most physicians report offering consensus recommendations. Nearly all physicians embrace a sense of responsibility to disclose disagreement to families. More research is needed to understand physician responsibilities for making recommendations in the care of chronically critically ill children.

Set of Quality Indicators of Pediatric Intensive Care in Spain: Delphi Method Selection

INTRODUCTION

This study objective was to identify, select, and define a basic set of quality indicators for pediatric intensive care in Spain.

METHODS

(1) Review of the literature to identify quality indicators and their defining elements and (2) selection of indicators by consensus of a group of experts using basic Delphi methodology (2 rounds) and forms distributed by email among experts from the Spanish society of pediatric intensive care.

RESULTS

We selected quality indicators according to their relevance and feasibility and the experts' agreement on their incorporation in the final set. We included only those indicators whose assessment was within the highest tertile and greater than or equal to 70% evaluator agreement in the final selection. Starting from an initially proposed set of 136 indicators, 31 experts first selected 43 indicators for inclusion in the second round. Twenty indicators were selected for the final set. This "top 20" set comprised 9 process indicators, 9 of results (especially treatment-associated adverse effects), and 2 indicators of structure. Several of them are classical indicators in intensive care medicine (rates of hospital-acquired infections, pressure ulcers, etc.), whereas others are specifically pediatric (eg, unrestricted parent visitation or training the parents of technology-dependent children).

CONCLUSIONS

We reached a consensus on a set of 20 essential quality indicators for pediatric intensive care in Spain. A significant subset reflects the peculiarities of pediatric care. We consider this subset as a starting point for future projects of network collaboration between pediatric intensive care units in Spain.

Multicenter study on the prognosis associated with respiratory support for children with acute hypoxic respiratory failure

The objective of the present study was to explore the factors influencing the outcomes related to respiratory support of children with acute hypoxic respiratory failure (AHRF) in 30 hospitals. This was a non-controlled prospective and collaborative multicenter clinical study conducted from June, 2010 to May, 2011 (each hospital for 12 consecutive months). Children aged from 29 days to 6 years and who met the diagnostic standards of AHRF were enrolled as subjects for the study. After patients were enrolled, general parameters including disease diagnosis, treatment and prognosis were recorded. Then we analyzed the differences in prognosis and respiratory therapy of patients with AHRF. During the study period, 13,906 cases of AHRF were admitted among the 30 hospitals, accounting for 75.3% of the total number of patients with AHRF. The proportion in different hospitals ranged from 16 to 98%. A total of 492 children with hypoxic respiratory failure were admitted among the 30 hospitals. The prevalence rate was 3.54%, and the incidence of AHRF in each hospital was 4.54%. Tidal volume and respiratory support treatment were compared with the results from a 2006 study, and the differences were statistically significant in positive end-expiratory pressure (5 vs. 4, P=0.018), fraction of inspire O₂ (0.5 vs. 0.4, P<0.001), pressure of artery O₂ (70 vs. 60 mmHg, P<0.001) and peak inspiratory pressure (20 vs. 24 cm H₂Ο, P<0.001). In conclusion, academic background and the level of regional economic development are factors which influence the prognosis of children with AHRF. On the basis of unapparent differences between academic background and the level of regional economic development, there is a substantial difference in the prognosis from different forms of respiratory support management for AHRF. Therefore, it is essential to develop respiratory support and the level of critical management of pediatric intensive care units.

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

OBJECTIVES

To present our experience in an interdisciplinary and interprofessional morbidity and mortality conference, with special emphasis on its usefulness in improving patient safety.

DESIGN

Retrospective analysis.

SETTING

Tertiary interdisciplinary neonatal PICU.

PATIENTS

Morbidity and mortality conference minutes on 48 patients (newborns to 17 yr), January 2009 to June 2014.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The authors' PICU implemented a morbidity and mortality conference guideline in 2009 using a system-based approach to identify medical errors, their contributing factors, and possible solutions. In the subsequent 5.5 years, there were 44 mortality conferences (of 181 deaths [27%] over the same period) and four morbidity conferences. The median death/morbidity event-morbidity and mortality conference interval was 90 days (range, 7 d to 1.5 yr). The median age of patients was 4 months (range, newborn to 17 years). In six cases, the primary reason for PICU admission was a treatment complication. Unsafe processes/medical errors were identified and discussed in 37 morbidity and mortality conferences (77%). In seven cases, new autopsy findings prompted the discussion of a possible error. The 48 morbidity and mortality conferences identified 50 errors, including 30 in which an interface problem was a contributing factor. Fifty-four improvements were identified in 34 morbidity and mortality conferences. Four morbidity and mortality conferences discussed specific ethical issues.

CONCLUSIONS

From our experience, we have found that the interdisciplinary and interprofessional morbidity and mortality conference has the potential to reveal unsafe processes/medical errors, in particular, diagnostic and communication errors and interface problems. When formatted as a nonhierarchical tool inviting contributions from all staff levels, the morbidity and mortality conference plays a key role in the system approach to medical errors.

Transforming the Morbidity and Mortality Conference to Promote Safety and Quality in a PICU

OBJECTIVE

Determine the effectiveness of a structured systems-oriented morbidity and mortality conference in improving the process of reviewing and responding to adverse events in a PICU.

DESIGN

Prospective time series analysis before and after implementation of a systems-oriented morbidity and mortality conference.

SETTING

Single tertiary referral PICU in Baltimore, MD.

PATIENTS

Thirty-three patients discussed before and 31 patients after implementation of a systems-oriented morbidity and mortality conference over a total of 20 morbidity and mortality conferences, from April 2013 to March 2014.

INTERVENTIONS

Systems-oriented morbidity and mortality conference incorporating elements of medical incident analysis.

MEASUREMENTS AND MAIN RESULTS

There was a significant increase in meeting attendance (mean, 12 vs 31 attendees per morbidity and mortality conference; p < 0.001) after the systems-oriented morbidity and mortality conference was instituted. There was no significant difference in the mean number of cases suggested (4.2 vs 4.6) or discussed (3.3 vs 3.1) per morbidity and mortality conference. There was also no significant difference in the mean number of adverse events identified per morbidity and mortality conference (3.4 vs 4.3). However, there was an increase in the proportion of cases discussed using a standard case review tool, but this did not reach statistical significance (27% vs 45%; p = 0.231). Nevertheless, we observed a significant increase in the mean number of quality improvement interventions suggested (2.4 vs 5.6; p < 0.001) and implemented (1.7 vs 4.4; p < 0.001) per morbidity and mortality conference. All adverse event categories identified had corresponding interventions suggested after the systems-oriented morbidity and mortality conference was instituted compared with before (80% vs 100%). Intervention-to-adverse event ratios per category were also higher (mean, 0.6 vs 1.5).

CONCLUSIONS

A structured systems-oriented PICU morbidity and mortality conference incorporating elements of medical incident analysis improves the process of reviewing and responding to adverse events by significantly increasing quality improvement interventions suggested and implemented. Future work would involve testing locally adapted versions of the systems-oriented morbidity and mortality conference in multiple inpatient settings.

Multidisciplinary OBGYN morbidity and mortality conference

BACKGROUND AND PURPOSE

Obstetrics and gynecology (OB-GYN) morbidity and mortality conferences allow for review of cases with poor or avoidable outcomes. Little data exist on standardized formats for presentation and evaluation. We designed a multidisciplinary morbidity and mortality conference. We formally evaluated resident performance using the milestones format, and evaluated resident understanding of case concepts with a pre- and post-conference survey.

METHODOLOGY

Our monthly conference was redesigned to incorporate the entire, residency program, OBGYN department members, nurses, midlevel providers, risk management, quality nurse director, and any additional staff who were involved in the case. Residents functioned as reviewers and presenters, and were then evaluated with a standard milestones-based evaluation by faculty members. Residents were also evaluated with a 10-point Likert scale for understanding of key case concepts, pre- and post-conference.

RESULTS

Using a standardized format for presentation and evaluation improved resident presentation skills and ability to organize a vast amount of information from a chart into a valuable learning experience. Over a 6-month period, six cases were presented, and six actions were initiated for quality improvement. Resident understanding of concepts statistically improved after conference.

CONCLUSION

M&M plays a crucial role not only in patient care, but also in resident education.