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

Enhancing patient safety: a system-based analysis of morbidity and mortality conferences in managing postoperative bleeding following gastric and pancreatic cancer surgery

Morbidity and mortality conferences (MMCs) have evolved beyond their traditional educational role to become instrumental in enhancing patient safety. System-based MMCs offer a unique perspective on patient safety by dissecting systemic factors contributing to adverse events. This paper reviews the impact of MMC in managing postoperative bleeding after gastric and pancreatic cancer surgery, within the constraints of limited resources. The study conducted at the National Institute of Oncology in Rabat, Morocco, analysed 18 MMC of haemorrhage following gastric and pancreatic surgeries and allowed to identify two patterns of cumulative factors contributing to adverse events. The first one relates to organisational issues and the second to postoperative management. Fifteen recommendations of improvement emerged from MMC addressing elements of these patterns with an implementation rate of 53.3%.

Implementation of morbidity and mortality conference in a community hospital NICU and narrative review

Background

The process of morbidity and mortality review (MMR) is recognized as an essential component of quality improvement, patient safety, attitudes towards patient safety, and continuing education. Despite the common use of MMR for all disciplines of medical care, recommendations have not been published regarding the implementation of MMR in a community hospital setting in the United States.

Objectives

Review the literature on MMR conferences. Describe the implementation of an MMR conference in a community hospital neonatal intensive care unit (NICU).

Conclusions

The establishment of a case overview method of MMR is feasible for a community hospital NICU. It increases staff and physician group awareness and education over common and complex mortality and morbidity etiologies, improves staff participation with unit management, links case presentation with open discussion and action items, and identifies opportunities for systemic changes to improve patient care.

Comparative Perspectives on Diagnostic Error Discussions Between Inpatient and Outpatient Pediatric Providers

Diagnostic error remains understudied and underaddressed despite causing significant morbidity and mortality. One barrier to addressing this issue remains provider discomfort. Survey studies have shown significantly more discomfort among providers in discussing diagnostic error compared with other forms of error. Whether the comfort in discussing diagnostic error differs depending on practice setting has not been previously studied. The objective of this study was to assess differences in provider willingness to discuss diagnostic error in the inpatient versus outpatient setting. A multicenter survey was sent out to 3881 providers between May and June 2018. This survey was designed to assess comfort level of discussing diagnostic error and looking at barriers to discussing diagnostic error. Forty-three percent versus 22% of inpatient versus outpatient providers (P = 0.004) were comfortable discussing short-term diagnostic error publicly. Similarly, 76% versus 60% of inpatient versus outpatient providers (P = 0.010) were comfortable discussing short-term diagnostic error privately. A higher percentage of inpatient (64%) compared with outpatient providers (46%) (P = 0.043) were comfortable discussing long-term diagnostic error privately. Forty percent versus 24% of inpatient versus outpatient providers (P = 0.018) were comfortable discussing long-term error publicly. No difference in barriers cited depending on practice setting. Inpatient providers are more comfortable discussing diagnostic error than their outpatient counterparts. More study is needed to determine the etiology of this discrepancy and to develop strategies to increase outpatient provider comfort.

The Morbidity and Mortality Conference: A Century-Old Practice with Ongoing Potential for Future Improvement

OBJECTIVE

 To discuss practical strategies to consider for morbidity and mortality conferences (M&M).

MATERIALS AND METHODS

 This article reflects on (i) insights that can be drawn from the M&M literature, (ii) practical aspects to consider when organizing M&M, and (iii) possible future directions for development for this long-standing practice for routine reflection.

RESULTS

 M&M offers the opportunity to learn from past cases in order to improve the care delivered to future patients, thereby serving both educational and quality improvement purposes. For departments seeking to implement or improve local M&M practice, it is difficult that a golden standard or best practice for M&M is nonexistent. This is partly because comparative research on different formats is hampered by the lack of objective outcome measures to evaluate the effectiveness of M&M. Common practical suggestions include the use of (i) a skillful and active moderator; (ii) structured formats for case presentation and discussion; and (iii) a dedicated committee to guide improvement plans that ensue from the meeting. M&M practice is affected by various sociological factors, for which qualitative research methods seem most suitable, but in the M&M literature these are sparsely used. Moreover, aspects influencing an open and blame-free atmosphere underline how local teams should tailor the format to best fit the local context and culture.

CONCLUSION

 This article presents practice guidance on how to organize and carry out M&M This practice for routine reflection needs to be tailored to the local setting, with attention for various sociological factors that are at play.

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.

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.

Implementation of an in situ simulation-based training adapted from Morbidity and Mortality conference cases: effect on the occurrence of adverse events-study protocol of a cluster randomised controlled trial

BACKGROUND

Morbidity and Mortality conference provides the necessary improvement measures for patient safety. However, they are an underused resource mainly because the conclusions to be drawn from the discussion and their implications for practice are not always well integrated by inpatient care teams. We therefore propose in this study two interventions to optimise their effectiveness: a passive feedback with wide dissemination by e-mail and/or on paper of the results of the Morbidity and Mortality conference to inpatient care teams and an active feedback with in situ inter-professional simulation-training programme in which scenarios will be based on cases studied in Morbidity and Mortality conference. In the present study, we hypothesise that the greatest reduction the occurrence of adverse event will be in the active feedback arm.

METHODS

A cluster randomised controlled study will be performed at four study sites. The unit of randomisation is wards within the study sites. Fifteen wards will be randomly assigned to passive feedback, active feedback, or a standard MMC (control arm). Passive feedback and active feedback arms will be compared to standard arm in terms of occurrence of adverse events. The trigger tool methodology used to identify adverse events is a retrospective review of inpatient records using "triggers": an adverse event is defined as a patient's stay with at least one positive trigger.

DISCUSSION

The in situ simulation training based on cases processed in Morbidity and Mortality conference is built according to the main topics identified for the successful implementation of healthcare simulation in patient safety programmes: technical skills, nontechnical skills, assessment, effectiveness, and system probing. The in situ simulation-training programme conducted as part of the study has the potential to improve patient safety during hospitalisation. We therefore expect the greatest reduction in the occurrence of adverse events in patients hospitalised in the active feedback arm. This expected result would have a direct impact on patient safety and would place in situ simulation at the highest level of the Kirkpatrick model.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02771613. Registered on May 12, 2016. All items from the WHO Trial Registration Data Set can be found within the protocol.

Analysis of the Interprofessional Clinical Learning Environment for Quality Improvement and Patient Safety From Perspectives of Interprofessional Teams

BACKGROUND

In 2018 the Clinical Learning Environment Review (CLER) Program reported that quality improvement and patient safety (QIPS) programs in graduate medical education (GME) were largely unsuccessful in their efforts to transfer QI knowledge and substantive interprofessional QIPS experiences to residents, and CLER 2.0 called for improvement. However, little is known about how to improve the interprofessional clinical learning environment (IP-CLE) for QIPS in GME.

OBJECTIVE

To determine the current state of the IP-CLE for QIPS at our institution with a focus on factors affecting the IP-CLE and resident integration into interprofessional QIPS teams.

METHODS

We interviewed an interprofessional group of residents, faculty, and staff of key units engaged in IP QIPS activities. We performed thematic analysis through general inductive approach using template analysis methods on transcripts.

RESULTS

Twenty individuals from 6 units participated. Participants defined learning on interprofessional QIPS teams as learning from and about each other's roles through collaboration for improvement, which occurs naturally when patients are the focus, or experiential teamwork within QIPS projects. Resident integration into these teams had various benefits (learning about other professions, effective project dissemination), barriers (difficult rotations or program structure, inappropriate assumptions), and facilitators (institutional support structures, promotion of QIPS culture, patient adverse events). There were various benefits (strengthened relationships, lowered bar for further collaboration), barriers (limited time, poor communication), and facilitators (structured meetings, educational culture) to a positive IP-CLE for QIPS.

CONCLUSIONS

Cultural factors prominently affected the IP-CLE and patient unforeseen events were valuable triggers for IP QIPS learning opportunities.

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.

Diagnostic Errors in Pediatric Critical Care: A Systematic Review

OBJECTIVES

To summarize the literature on prevalence, impact, and contributing factors related to diagnostic error in the PICU.

DATA SOURCES

Search of PubMed, EMBASE, and the Cochrane Library up to December 2019.

STUDY SELECTION

Studies on diagnostic error and the diagnostic process in pediatric critical care were included. Non-English studies with no translation, case reports/series, studies providing no information on diagnostic error, studies focused on non-PICU populations, and studies focused on a single condition/disease or a single diagnostic test/tool were excluded.

DATA EXTRACTION

Data on research design, objectives, study sample, and results pertaining to the prevalence, impact, and factors associated with diagnostic error were abstracted from each study.

DATA SYNTHESIS

Using independent tiered review, 396 abstracts were screened, and 17 studies (14 full-text, 3 abstracts) were ultimately included. Fifteen of 17 studies (88%) had an observational research design. Autopsy studies (autopsy rates were 20-47%) showed a 10-23% rate of missed major diagnoses; 5-16% of autopsy-discovered diagnostic errors had a potential adverse impact on survival and would have changed management. Retrospective record reviews reported varying rates of diagnostic error from 8% in a general PICU population to 12% among unexpected critical admissions and 21-25% of patients discussed at PICU morbidity and mortality conferences. Cardiovascular, infectious, congenital, and neurologic conditions were most commonly misdiagnosed. Systems factors (40-67%), cognitive factors (20-3%), and both systems and cognitive factors (40%) were associated with diagnostic error. Limited information was available on the impact of misdiagnosis.

CONCLUSIONS

Knowledge of diagnostic errors in the PICU is limited. Future work to understand diagnostic errors should involve a balanced focus between studying the diagnosis of individual diseases and uncovering common system- and process-related determinants of diagnostic error.

Evidence Review for the American College of Surgeons Quality Verification Part II: Processes for Reliable Quality Improvement

After decades of experience supporting surgical quality and safety by the American College of Surgeons, the American College of Surgeons Quality Verification Program was developed to help hospitals improve surgical quality, safety, and reliability. This review is the second of a 3-part review aiming to synthesize the evidence supporting the main principles of the American College of Surgeons Quality Verification Program. Evidence was systematically reviewed for 5 principles: case review, peer review, credentialing and privileging, data for surveillance, and continuous quality improvement using data. MEDLINE was searched for articles published from inception to January 2019 and 2 reviewers independently screened studies for inclusion in a hierarchical fashion, extracted data, and summarized results in a narrative fashion. A total of 9,098 studies across the 5 principles were identified. After exclusion criteria, a total of 184 studies in systematic reviews and primary studies were included for assessment. The identified literature supports the importance of standardized processes and systems to identify problems and improve quality of care.

Technical Aspects of Intensive Care Unit Management: A Single-Center Experience at a Tertiary Academic Hospital

Purpose

Special technical issues associated with the function and maintenance of medical devices arise in intensive care units (ICUs). This study explored the level of comfort of ICU staff in dealing with selected equipment, the factors that are associated with the staff’s ease of adaptation to new technologies, and the role of technical support staff.

Patients and Methods

This is a single-center cross-sectional questionnaire-based survey that was conducted in February 2018 and targeted nurses working in the ICUs of King Saud University Medical City in Riyadh, Saudi Arabia.

Results

Among the 297 nurses who completed the survey, almost all of the respondents (99.3%) were aware of the ICU equipment preventive maintenance program. Most of the nurses had received training on how to use infusion pumps (96.2%), cardiac monitoring systems (78.0%), and cardiac defibrillation devices (73.9%). Sixty nurses (20.2%) indicated that at least one super user was available for at least one device. About half of the staff reported one device whose user manual was available. Most nurses reported having no resources regarding updates on medical devices.

Conclusion

Our findings revealed an alarming need to address technical issues related to medical devices used in the ICU and to design a framework for the safe operation of medical devices based on international practices. It is necessary to empower the role of the super user and medical device clinical educator as well as to optimize communication between the national regulatory body of medical devices and healthcare providers, especially those working in acute care areas.

Quality Improvement Focused Morbidity and Mortality Rounds: An Integrative Review

Morbidity and mortality conference (MMC) is a century-old tradition in medicine that was initially primarily focused on the review of surgical outcomes and errors. In recent years, the value of MMC in quality improvement (QI) and patient safety initiatives has been realized and incorporated into the MMCs of some disciplines and institutions. Despite this, there is a need for a standardized structure of MMC that emphasizes both QI and patient safety.

The purpose of this integrative review is to synthesize the literature on MMC structure that is reflective of QI and patient safety.

An integrative literature search was carried out using PubMed and MEDLINE. Abstracts were reviewed and non-relevant articles were excluded. Exclusion criteria were no mention of MMC, analysis of specific case, no focus on QI or patient safety, and non-English language.

A total of 21 articles were identified for review. Articles were reviewed in their entirety for content regarding structuring of the MMC to reflect and further develop QI and patient safety. The follwing three themes emerged that were consistently identified as being important for restructuring MMCs: (1) the importance of careful case selection, (2) the format of discussion during the conferences, and (3) the action plans reflecting QI initiatives derived from the conferences.

The review suggests that one standardized method of MMC implementation that encompasses the three pivotal themes should be developed. Further research needs to focus on instituting measures of effectiveness for the new MMC model.

Identifying practical approaches to the normalisation of interprofessional collaboration in rural hospitals: A qualitative study among health professionals

This qualitative study explores the ideas and experiences of interprofessional collaboration (IPC) among health professionals in rural public hospitals and to propagate its normalization into practice by identifying existing or suggested solutions. The literature focuses largely on the barriers and facilitators to IPC in metropolitan areas and there is room to identify more practical responses for implementing solutions. Semi-structured interviews were conducted with 13 healthcare professionals (October 2018-March 2019). Interviews were audio-recorded, transcribed and underwent thematic analysis to identify themes derived from the dataset. Using the lens of the Normalization Process Theory (NPT) allowed for amalgamation of participant ideas and identification of solutions to implement IPC in practice. Participants' definitions of IPC and Interprofessional Teamwork were incongruous with the current literature, however when provided with formal definitions, participants agreed that they both participated and observed IPC with varying degrees of success. Factors influencing this success included good working relationships and positive workplace cultures, having an understanding of each professions' roles and needs and the hierarchy of professions in conjunction with attitudes of senior healthcare professionals. Solutions to improved IPC and its normalization included induction processes and informal introductions, formalized interprofessional interactions, interprofessional education and positive leadership, such as the 'assertive followership model'. Analyzed in the framework of the normalization process theory, this research shows that IPC is increasingly becoming a coherent, integrated aspect of the healthcare system but there is room for improvement, and cognitive participation in IPC varies across healthcare professionsals. In order to facilitate the normalization process, program and policy makers, hospital administrations and professional associations could consider formalized interprofessional team interactions, formalizing IPC through simple introductions, interprofessional education and positive leadership. Future research could explore through the NPT specific areas of care that benefit from IPC implementation such as community aged-care.

Improve Healthcare Quality Through Mortality Committee: Retrospective Analysis of Bambino Gesù Children Hospital's Ten Years' Experience 2008-2017

BACKGROUND

Healthcare quality improvements are one of the most important goals to reach a better and safer healthcare system. Reviewing in-hospital mortality data is useful to identify areas for improvement, and to monitor the impact of actions taken to avoid preventable cases, such as those related to healthcare associated infections (HAI).

METHODS

In this paper, we present the experience of the Mortality Committee of Bambino Gesù Children Hospital (OPBG). OPBG has instituted a process of systematic revision of all in-hospital deaths conducted by a multidisciplinary team. The goal is to identify system-wide issues that could be improved to reduce in-hospital preventable deaths. In this way, the mortality review goes alongside all the other risk management activities for the continuous quality improvement and patient safety.

RESULTS

In years 2008-2017, we performed a systematic analysis of 1148 inpatient deaths. In this time period, the overall mortality rate was 0.4%. Forty-seven deaths were caused due to infections, 10 of which involved patients with HAI transferred to OPBG from other facilities or patients with community- acquired infections. Six deaths related to HAI were followed by claims compensations. All these cases were not followed by compensation because the onset of HAI was considered an inevitable consequence of the underlying disease.

CONCLUSION

Introduction of the mortality review committee has proved to be a valid instrument to improve the quality of the care provided in a hospital, allowing early identification of care gaps that could lead to an increase in mortality rates. Article Highlights Box: Reduction of preventable deaths is one of the most important goals to be achieved for any health-care system and to improve the quality of care. • Several studies have shown that analysis of morbidity and mortality rate helps to detect any factors that can lead to an increase in in-hospital mortality rates. • The review of in-hospital deaths allows to learn how to improve the quality and safety of care through identification of critical issues that lead to an increase in mortality ratio. • In some medical areas, such as intensive care units or surgery, the implementation of the conference on mortality and morbidity is more useful for assessing procedures at high risk of errors. • The implementation of existing databases with data deriving from the systematic review of medical records and in-hospital deaths appears to be desirable. • Mortality Review Committees can represent a very useful tool for all the health facilities for the reduction of preventable deaths, such as those related to HAI.

Fellow-led SICU morbidity and mortality conferences address patient safety, quality improvement, interprofessional cooperation and ACGME milestones

BACKGROUND

Morbidity and mortality conferences (MMCs) promote patient safety, spur quality improvement (QI) projects, and enhance interprofessional cooperation. The use of MMCs to address the Accreditation Council for Graduate Medical Education's (ACGME's) six core competencies and specialty-specific milestones for surgical critical care (SCC) fellows has yet to be explored.

METHODS

We developed a monthly, interprofessional, case-based MMC program managed by SCC fellows. We assessed participants' experiences through post-conference surveys and semi-structured interviews.

RESULTS

After nine conferences, 95.1% of participants (n = 143) agree or strongly agree that the MMC improved their knowledge and clinical assessment skills. The MMC spurred two QI projects, increased interprofessional cooperation, and addressed all six ACGME core competencies and 16 specialty-specific milestones.

CONCLUSIONS

Interprofessional, case-based MMCs are an effective educational tool for SCC fellowship programs. They promote patient safety, QI, and interprofessional cooperation, and address ACGME core competencies and specialty-specific milestones for SCC fellows.

The Pediatric Index of Mortality as a Trigger Tool for the Detection of Serious Errors and Adverse Events

OBJECTIVES

To test the hypothesis that patients who die in a PICU despite a low predicted mortality at PICU admission are affected by serious errors and adverse events.

DESIGN

Retrospective cross-sectional review of medical records for serious errors and adverse events.

SETTING

Tertiary interdisciplinary neonatal PICU.

PATIENTS

All admissions to our PICU who died despite a low expected mortality (Pediatric Index of Mortality) of less than 10% (trigger-positive admissions). They were compared with a random sample of 100 PICU admissions with a Pediatric Index of Mortality of less than 10% who survived (trigger-negative admissions).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 7,383 admissions (91%) with a Pediatric Index of Mortality 2 below 10%. Seventy-two trigger-positive admissions and 100 trigger-negative admissions met the criteria for detailed chart review. Forty-five serious errors and adverse events were identified, 0.47 per trigger-positive admission and 0.11 per trigger-negative admission (p < 0.001). Nineteen serious errors and adverse events (42%) were related to clinical sepsis acquired during the PICU stay, 17 (89%) in trigger-positive admissions and two (11%) in trigger-negative admissions (p < 0.001). A further 18 serious errors and adverse events (40%) were intervention related, nine (50%) in trigger-positive admissions and nine (50%) in trigger-negative admissions (p = 0.46). Eight serious errors and adverse events (18%) were associated with medication use, all of which occurred in trigger-positive admissions (p = 0.001). The median (interquartile range) age for admissions with and without serious errors and adverse events was 0.3 months (0.0-4.6 mo) and 7.4 months (0.4-58.4 mo) (p < 0.001), and their median (interquartile range) duration of invasive ventilation was 140 hours (50-451 hr) and 2 hours (0-41 hr) (p < 0.001), respectively.

CONCLUSIONS

The records of PICU patients with a low expected mortality at admission and death in PICU should be reviewed routinely and/or discussed at morbidity and mortality meetings. These patients may have experienced more in-hospital safety-related events compared with PICU patients with a low Pediatric Index of Mortality who survived. Such adverse events may be amenable to system changes, thus improving patient care.

Clinician-Driven Design of VitalPAD-An Intelligent Monitoring and Communication Device to Improve Patient Safety in the Intensive Care Unit

The pediatric intensive care unit (ICU) is a complex environment, in which a multidisciplinary team of clinicians (registered nurses, respiratory therapists, and physicians) continually observe and evaluate patient information. Data are provided by multiple, and often physically separated sources, cognitive workload is high, and team communication can be challenging. Our aim is to combine information from multiple monitoring and therapeutic devices in a mobile application, the VitalPAD, to improve the efficiency of clinical decision-making, communication, and thereby patient safety. We observed individual ICU clinicians, multidisciplinary rounds, and handover procedures for 54 h to identify data needs, workflow, and existing cognitive aid use and limitations. A prototype was developed using an iterative participatory design approach; usability testing, including general and task-specific feedback, was obtained from 15 clinicians. Features included map overviews of the ICU showing clinician assignment, patient status, and respiratory support; patient vital signs; a photo-documentation option for arterial blood gas results; and team communication and reminder functions. Clinicians reported the prototype to be an intuitive display of vital parameters and relevant alerts and reminders, as well as a user-friendly communication tool. Future work includes implementation of a prototype, which will be evaluated under simulation and real-world conditions, with the aim of providing ICU staff with a monitoring device that will improve their daily work, communication, and decision-making capacity. Mobile monitoring of vital signs and therapy parameters might help improve patient safety in wards with single-patient rooms and likely has applications in many acute and critical care settings.

Barriers and facilitators to learn and improve through morbidity and mortality conferences: a qualitative study

OBJECTIVES

To explore barriers and facilitators to successful morbidity and mortality conferences (M&M), driving learning and improvement.

DESIGN

This is a qualitative study with semistructured interviews. Inductive, thematic content analysis was used to identify barriers and facilitators, which were structured across a pre-existing framework for change in healthcare.

SETTING

Dutch academic surgical department with a long tradition of M&M.

PARTICIPANTS

An interview sample of surgeons, residents and physician assistants (n=12).

RESULTS

A total of 57 barriers and facilitators to successful M&M, covering 18 themes, varying from 'case type' to 'leadership', were perceived by surgical staff. While some factors related to M&M organisation, others concerned individual or social aspects. Eight factors, of which four were at the social level, had simultaneous positive and negative effects (eg, 'hierarchy' and 'team spirit'). Mediating pathways for M&M success were found to relate to available information, staff motivation and realisation processes.

CONCLUSIONS

This study provides leads for improvement of M&M practice, as well as for further research on key elements of successful M&M. Various factors were perceived to affect M&M success, of which many were individual and social rather than organisational factors, affecting information and realisation processes but also staff motivation. Based on these findings, practical recommendations were formulated to guide efforts towards best practices for M&M.

The role of morbidity and mortality rounds in medical education: a scoping review

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.

House staff-led interdisciplinary morbidity and mortality conference promotes systematic improvement

BACKGROUND

Improvements in patient safety are critical to improving clinical outcomes. We present a resident-led interdisciplinary morbidity and mortality (M&M) conference utilizing postconference task forces to identify unique system issues, classify key contributors to interdisciplinary complications, and implement systems solutions. The conference also served to facilitate resident involvement in quality improvement projects.

MATERIALS AND METHODS

Members of the UNC Housestaff Council designed and implemented a hospital-wide M&M conference. Cases involving two or more service lines and resulting from systematic failures were selected for presentation by an interdisciplinary group of residents involved in the patient's care. Postconference task forces addressed problems and developed initiatives to improve care.

RESULTS

Of the 15 cases presented, 60% were attributable to an error in judgment, 26% to an error in diagnosis, and 13% to an error in technique. Communication (67%), coordination/care utilization (47%), poor process/workflow (40%), and inadequate training (33%) were the main associated contributing factors. Poor communication contributed to all complications resulting from an error in judgment. Inadequate training and poor workflow were the most common contributing factors with an error in technique. Poor utilization of care and inadequate processes were most common with an error in diagnosis. Postconference task forces identified system-based improvement projects in 73% (11 of 15) of cases with 82% (9 of 11) of projects successfully implemented or in process.

CONCLUSIONS

House staff-led interdisciplinary M&M conference utilizing postconference task forces is an ideal setting to identify unique system issues and implement system-based improvement strategies.