Safety and quality as a "way of life" in the PICU: where does the morbidity and mortality conference fit in?*

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.

Morbidity and Mortality Conferences: A Narrative Review of Strategies to Prioritize Quality Improvement

BACKGROUND

The morbidity and mortality conference (MMC) provides a valuable opportunity to review patient care processes and safety concerns, aligning with a growing quality improvement (QI) mandate. Yet the structure, processes, and aims of many MMCs are often ill-defined. This review summarizes strategies employed by medical, surgical, and critical care departments in the development of patient safety-centered MMCs.

METHODS

A structured narrative review of literature was conducted using combinations of the search terms "morbidity and mortality conference(s)," "morbidity and mortality meetings," or "morbidity and mortality round(s)." The titles and abstracts of 250 returned articles were screened; 76 articles were reviewed in full, with 32 meeting the full inclusion criteria.

RESULTS

The literature review elicited a number of methods used by medical, surgical, and critical care MMCs to emphasize QI and patient safety outcomes. A list of actionable changes made in each article was compiled. Five themes common to QI-centered MMCs were identified: (1) defining the role of the MMC, (2) involving stakeholders, (3) detecting and selecting appropriate cases for presentation, (4) structuring goal-directed discussion, and (5) forming recommendations and assigning follow-up. Innovative methods to pair adverse event screening with MMCs were superior to nonstructured voluntary reporting and case selection for overall morbidity detection. Structured case review, discussion, and follow-up were more likely to lead to implementing systems-based change, and interdisciplinary MMCs were associated with a greater likelihood of forming an action item.

CONCLUSION

The modern patient safety-centered MMC shares common themes of practices that can be adopted by institutions looking to create a venue for analysis of care processes, a platform to launch QI initiatives, and a culture of safety.

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.