Dataset Information

Learning From Errors: Curriculum Guide for the Morbidity and Mortality Conference With a Focus on Patient Safety Concepts.

ABSTRACT:

Introduction

Morbidity and mortality conferences are Accreditation Council for Graduate Medical Education-required educational series that are part of all residency training programs. This conference offers trainees an opportunity to discuss patient cases where errors or complications may have occurred. Conventionally, most of the allotted time is spent on case presentation and therapeutic debates, which is a lost opportunity to teach fundamental principles of patient safety, error analysis, and strategies for system-wide improvement. The goal of this resource is to refocus the content of morbidity and mortality and transform it into a platform for teaching patient safety principles and emphasizing error reduction strategies.

Methods

It was delivered as a 1-hour workshop session once a month during usual conference times. The workshop includes a mortality case review followed by a small-group activity in which trainees are assigned specific safety tasks, including systematic analysis of an error, conducting root cause analysis, and resident peer review.

Results

Postsurveys demonstrated that 90% of the trainees either agreed or strongly agreed that the safety concepts they learned would likely improve the quality of care they provide to future patients.

Discussion

We learned that morbidity and mortality could be used to effectively teach principles of patient safety and could create system-wide improvements.

SUBMITTER: Garcia C

PROVIDER: S-EPMC6464434 | biostudies-literature | 2016 Sep

REPOSITORIES: biostudies-literature

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Publications

Learning From Errors: Curriculum Guide for the Morbidity and Mortality Conference With a Focus on Patient Safety Concepts.

Garcia Christine C Goolsarran Nirvani N

MedEdPORTAL : the journal of teaching and learning resources 20160923

<h4>Introduction</h4>Morbidity and mortality conferences are Accreditation Council for Graduate Medical Education-required educational series that are part of all residency training programs. This conference offers trainees an opportunity to discuss patient cases where errors or complications may have occurred. Conventionally, most of the allotted time is spent on case presentation and therapeutic debates, which is a lost opportunity to teach fundamental principles of patient safety, error analy ...[more]

PMID: 31008240

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Project description:ObjectiveMorbidity and mortality conference (M&M) is common in emergency medicine (EM) and an Accreditation Council for Graduate Medical Education (ACGME) requirement. We aimed to characterize the prevalence of elements of EM M&M conferences that foster a strong culture of safety.MethodsEmergency medicine residents at 33 programs across the United States were surveyed using questions adapted from a previously tested survey of EM program directors and the Agency for Healthcare Research and Quality (AHRQ) Culture of Safety Survey.ResultsThe survey response rate was 80.3% (1,002/1,248). A total of 60.3% (601/997) of residents had not submitted a case of theirs to M&M in the past year. A total of 7.6% (73/954) reported that issues raised at M&M always led to change while 88.3% (842/954) reported that they sometimes did and 4.1% (39/954) reported that they never did. A total of 56.2% (536/954) responded that changes made due to M&M were reported back to the residents. Of residents who had cases presented at M&M, 24.2% (130/538) responded that there was regular debriefing, 65.2% (351/538) responded that there was not, and 10.6% (57/578) were unsure. A total of 10.2% (101/988) of respondents agreed that M&M was punitive, 17.4% were neutral (172/988), and 72.4% (715/988) disagreed. A total of 18.0% (178/987) of residents agreed that they felt pressure to order unnecessary tests because of M&M, 22.3% (220/987) were neutral, and 59.6% (589/987) disagreed. A total of 87.4% (862/986) felt that M&M was a valuable educational didactic session, and 78.3% (766/978) believed that M&M contributes to a culture of safety in their institution.ConclusionsWhile most residents believe that M&M is a valuable didactic session and contributes to institutional culture of safety, there are opportunities to improve by communicating changes made in response to M&M, debriefing residents who have had cases presented, and taking steps to make M&M not feel punitive to some residents.

Project description:BACKGROUND: Morbidity and mortality (M&M) conferences provide a forum for discussing adverse events and systems-based practice (SBP) issues; however, few models for implementing multidisciplinary, systems-focused M&M conferences exist. OBJECTIVE: To implement a new systems-focused M&M conference and evaluate success in focusing on adverse events and systems issues in a nonpunitive, multidisciplinary manner. METHODS: We implemented a new M&M conference into our large university-based internal medicine residency program. Using content analysis, we qualitatively analyzed audio recordings of M&M conferences from the first year of implementation (2010-2011) to determine the frequency of adverse events (injury resulting from medical care), SBP discussion, and allocation of blame. Multidisciplinary attendance was evaluated by attendance logs. Surveys assessed change in interns' perceptions of M&M conferences before and after the conference series (measured by median Likert-scale response) and trainee/faculty attitudes regarding the goal of M&M conferences. RESULTS: There were 226 attendees (66 faculty, 160 residents/fellows) at 9 M&M conferences. Average attendance per conference was 71, with representation from 16 disciplines. All M&M conferences (100%) included adverse events, SBP discussion, and lacked explicit individual blame. Interns' perceptions improved, including their belief that the M&M conference's purpose is systems improvement (4.35 versus 4.71, P = .02) and complications are discussed without blame (3.81 versus 4.34, P = .01). After experiencing M&M conferences, trainees/faculty reported favorable ratings, including beliefs that the M&M conference is important for education (97%) and the purpose is systems improvement (95%). CONCLUSIONS: The implementation of a new systems-focused M&M conference resulted in a conference series focusing on adverse events and associated system issues in a nonpunitive, multidisciplinary context.

Dataset Information

Learning From Errors: Curriculum Guide for the Morbidity and Mortality Conference With a Focus on Patient Safety Concepts.

Introduction

Methods

Results

Discussion

Publications

Learning From Errors: Curriculum Guide for the Morbidity and Mortality Conference With a Focus on Patient Safety Concepts.

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