Dataset Information

Stop the Blame Game: Restructuring Morbidity and Mortality Conferences to Teach Patient Safety and Quality Improvement to Residents.

ABSTRACT:

Introduction

Adverse events leading to patient harm are rarely the result of an individual error but are instead due to a series of errors resulting from system breakdowns. Thus, the Accreditation Council for Graduate Medical Education requires all residents to participate in quality improvement and patient safety programs. However, a major reported obstacle to sustainable quality improvement and patient safety curricula, as well as meaningful practice improvement, is the small number of faculty with expertise or training in these topics.

Methods

This workshop provides a simple framework for redesigning traditional morbidity and mortality conferences for faculty who have minimal quality improvement training. The materials associated with this publication include a standardized presentation template, sample teaching points, and a faculty facilitator's guide.

Results

Between August 2014 and February 2015, 135 trainees from one of our tertiary training sites attended seven of these redesigned conferences. The largest gains were made in teaching residents how to use a systems-based approach to analyze medical error and how to identify corresponding error-reduction strategies. Residents also perceived themselves as more likely to put their knowledge into action through filing an incident report after attending the conference. The one item that did not change was the residents' perception of safety culture at their institution, suggesting that attendance at a monthly conference is not sufficient to change culture.

Discussion

Similarly formatted M&Mconferences may help institutions address several aspectof the ACGME CLER program that provides programswith periodic feedback regarding trainee education onpatient safety and quality improvement as well.

SUBMITTER: Walker M

PROVIDER: S-EPMC6464420 | biostudies-literature | 2016 Sep

REPOSITORIES: biostudies-literature

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Publications

Stop the Blame Game: Restructuring Morbidity and Mortality Conferences to Teach Patient Safety and Quality Improvement to Residents.

Walker Megan M Rubio David D Horstman Molly M Trautner Barbara B Stewart Diana D

MedEdPORTAL : the journal of teaching and learning resources 20160928

<h4>Introduction</h4>Adverse events leading to patient harm are rarely the result of an individual error but are instead due to a series of errors resulting from system breakdowns. Thus, the Accreditation Council for Graduate Medical Education requires all residents to participate in quality improvement and patient safety programs. However, a major reported obstacle to sustainable quality improvement and patient safety curricula, as well as meaningful practice improvement, is the small number of ...[more]

PMID: 31008253

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Project description:ObjectiveStudies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model.MethodMeta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies.ResultsForty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients' perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from 'grand' systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system.ConclusionOverall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or between the different staff involved in the care of an individual patient. Electronic systems can compromise safety when they override the opportunities for face-to-face communication. The circumstances under which guidelines or protocols are seen to either compromise or improve patient safety needs further investigation.

Dataset Information

Stop the Blame Game: Restructuring Morbidity and Mortality Conferences to Teach Patient Safety and Quality Improvement to Residents.

Introduction

Methods

Results

Discussion

Publications

Stop the Blame Game: Restructuring Morbidity and Mortality Conferences to Teach Patient Safety and Quality Improvement to Residents.

Similar Datasets

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