608 The Impact of a Nurse Morbidity and Mortality Meeting

Introduction Physicians have long held Morbidity and Mortality (M&M) conferences to discuss complications and deaths. The format for these conferences is to lay out the case, discuss the care performed, and generate discussion on areas of opportunity. Physician M&M usually focuses on teaching and the presenter may not be the caregiver. There is not much literature on the use of this teaching methodology in nursing. Due to the strong culture of safety on the unit, it was determined that creating a Nurse M&M could prove beneficial for discussion of complications, deaths, errors, and good catches as they related to nursing care. Methods Nurse M&M is held monthly for one hour. All personnel involved in the cases are informed ahead of time what will be discussed. They are given the opportunity to present the individual case or give personal testimony as to the situation from their point of view. Each case is presented in the same format. The initial slides cover background, history of present illness, and the origin of the report. Next is the pertinent review from the electronic medical record and discussions had with those involved in the case. The floor is then open for discussion. If there was a variation in practice, the policy that relates to the error is reviewed. Topics for Nurse M&M are gathered through many venues. The hospital uses an online reporting system for electronic submission of adverse events, variations in care, and good catches. The entire multidisciplinary team have all individually reported something they wanted discussed at Nurse M&M. If clarification is needed on a case, the question is directed to the appropriate decision maker and followed up on. Results Nurse M&M is the most highly attended, non-mandatory, meeting held on the unit. The nursing staff was surveyed to determine their perceptions on how the addition of Nurse M&M had effected them. The results were overwhelmingly positive. All nurses surveyed rated the statement, “I feel that Nurse M&M has had a positive outcome on the unit’s collective practice”, as agree or strongly agree. Over time, the notes taken have evolved from just the discussion to action items created off the case. The staff have will now self-report events before they are entered into the online system. Conclusions The nursing staff are highly engaged Nurse M&M. The staff are open to discussing errors in a way that fosters educational growth and critical thinking development. If the case being discussed is because of a personal error, more often than not, the person responsible will discuss why they made the decision they did and facilitate the discussion as to what could have been done differently. The nurses’ commitment to being present, engaged, and open minded are strong signs of the healthy work environment present on the unit. Applicability of Research to Practice The format of a nursing M&M conference is applicable to all units. Patient safety and nurse engagement are the top factors effected by Nurse M&M.