From Morbidity and Mortality to Quality Improvement

Objective Measure the effects of a structured morbidity and mortality conference format on the attitudes of resident and faculty participants. Study Design Prospective cohort study. Setting Otorhinolaryngology–head and neck surgery residency training program. Subjects and Methods Two changes were implemented to the structure of our morbidity and mortality conference: (1) we adopted a recently described presentation framework called situation-background-assessment-recommendation and (2) appointed a faculty moderator to lead the conference. Surveys were distributed to residents and faculty before and after these modifications were implemented to measure changes in attitude of conference attendees. Results After implementing the above changes to the morbidity and mortality conference, participant engagement increased from “moderately engaged” to “extremely engaged” ( P < .01). Among both faculty and residents, the perceived educational value of conference also improved from “moderately educational” to “extremely educational” ( P < .01). Finally in the attending cohort, the impact on future patient care increased from “no change” to “greatly enhanced” ( P < .01). Conclusion By implementing the situation-background-assessment-recommendation framework and appointing a faculty moderator to morbidity and mortality conference, participants reported significantly enhanced engagement during the conference, increased educational value of the session, and a positive impact on future patient care.

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Enhancing the Educational Value and Faculty Attendance of a Morbidity and Mortality Conference

Journal of Surgical Education ◽

10.1016/j.jsurg.2020.02.001 ◽

2020 ◽

Vol 77 (4) ◽

pp. 905-910 ◽

Cited By ~ 2

Author(s):

Jad M. Abdelsattar ◽

John Mourany ◽

Faryal G. Afridi ◽

Kelsey Musgrove ◽

Linda Shaffer ◽

...

Keyword(s):

Morbidity And Mortality ◽

Educational Value ◽

Morbidity And Mortality Conference ◽

Mortality Conference

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Optimizing the Educational Value of Surgical Morbidity and Mortality Conference with the Addition of an Interesting Teaching Case

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2020.08.524 ◽

2020 ◽

Vol 231 (4) ◽

pp. e197

Author(s):

Rebecca L. Williams-Karnesky ◽

Jasmeet Singh Paul ◽

Erika R. Ketteler ◽

John C. Russell

Keyword(s):

Morbidity And Mortality ◽

Surgical Morbidity ◽

Educational Value ◽

Teaching Case ◽

Morbidity And Mortality Conference ◽

Mortality Conference

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Increasing Reporting of Adverse Events to Improve the Educational Value of the Morbidity and Mortality Conference

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2012.09.010 ◽

2013 ◽

Vol 216 (1) ◽

pp. 50-56 ◽

Cited By ~ 28

Author(s):

Terri P. McVeigh ◽

Peadar S. Waters ◽

Ruth Murphy ◽

Gerrard T. O'Donoghue ◽

Ray McLaughlin ◽

...

Keyword(s):

Adverse Events ◽

Morbidity And Mortality ◽

Educational Value ◽

Morbidity And Mortality Conference ◽

Mortality Conference

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To pimp or not to pimp: Increased interactive format for morbidity and mortality conference improves educational value and enhances resident confidence

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2006.05.198 ◽

2006 ◽

Vol 203 (3) ◽

pp. S75-S76

Author(s):

Jose M. Prince ◽

Raghuveer Vallabhaneni ◽

Andrew Watson ◽

Kenneth Lee ◽

Steven Hughes ◽

...

Keyword(s):

Morbidity And Mortality ◽

Educational Value ◽

Morbidity And Mortality Conference ◽

Mortality Conference

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Assessing educational validity of the Morbidity and Mortality Conference: A pilot study

Current Surgery ◽

10.1016/s0149-7944(02)00735-3 ◽

2003 ◽

Vol 60 (2) ◽

pp. 204-209 ◽

Cited By ~ 38

Author(s):

Donald A Risucci ◽

Thomas Sullivan ◽

Stephen DiRusso ◽

John A Savino

Keyword(s):

Pilot Study ◽

Morbidity And Mortality ◽

Morbidity And Mortality Conference ◽

Mortality Conference

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Trying to Improve Care: The Morbidity and Mortality Conference in a Division of Rheumatology

The Journal of Rheumatology ◽

10.3899/jrheum.140203 ◽

2014 ◽

Vol 41 (12) ◽

pp. 2452-2458 ◽

Cited By ~ 7

Author(s):

Michelle Batthish ◽

Shirley M.L. Tse ◽

Brian M. Feldman ◽

G. Ross Baker ◽

Ronald M. Laxer

Keyword(s):

Adverse Events ◽

Test Procedure ◽

Morbidity And Mortality ◽

Error Reporting ◽

Descriptive Data ◽

Medication Error Reporting ◽

Morbidity And Mortality Conference ◽

System Improvement ◽

Sick Children ◽

Mortality Conference

Objective.To describe the frequency and types of reported adverse events and system improvement recommendations in the Morbidity and Mortality Conference (M&MC) within the Division of Rheumatology at The Hospital for Sick Children, Toronto, Ontario, Canada (SickKids).Methods.A 5-year retrospective review of the M&MC within the Division of Rheumatology at SickKids was completed. Descriptive data including the number and types of events reported were collected. Events were categorized using an adaptation of the National Coordinating Council for Medication Error Reporting and Prevention Index. Recommendations were classified according to the Institute for Safe Medication Practices Canada.Results.Between January 2007 and December 2011, 30 regularly scheduled M&MC were held. Eighty-three cases were reviewed. The most common types of reported events were related to “miscommunication” (34.9%), “treatment/test/procedure” (22.9%), “adverse drug reactions” (12.0%), and “medication errors” (8.4%). Category A events (“an event that has the capacity to cause error”) were the most common with 39.8% of the cases, followed by Category C events (“an event occurred that reached the patient, but did not cause harm”) with 28.9%. Eighty-nine recommendations were made. Over half of these were classified as “information” (58.4%), followed by 11 “rules and policies” recommendations (12.4%). Of the 36 action items generated from these recommendations, most are either complete or ongoing.Conclusion.The M&MC within the Division of Rheumatology reviews a variety of events. Increased reporting of adverse events can lead to system improvements, and has the potential to improve and promote safer healthcare.

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Web-enabled morbidity and mortality conference improves specific competency yield

Journal of Surgical Research ◽

10.1016/j.jss.2005.11.365 ◽

2006 ◽

Vol 130 (2) ◽

pp. 287

Author(s):

D.S. Kwon ◽

A. Yoshida ◽

I. Rubinfeld ◽

A. Shepard ◽

J. Butler

Keyword(s):

Morbidity And Mortality ◽

Morbidity And Mortality Conference ◽

Specific Competency ◽

Mortality Conference

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Establishing safety huddles on a general adult acute psychiatric ward: staff's views and relation with restrictive practice

BJPsych Open ◽

10.1192/bjo.2021.485 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S178-S179

Author(s):

Sidra Chaudhry ◽

Nicoletta Lekka

Keyword(s):

Patient Care ◽

Positive Impact ◽

Team Building ◽

High Risk Patient ◽

Psychiatric Ward ◽

Clinical Activity ◽

Restrictive Practice ◽

Feedback Questionnaire ◽

Multidisciplinary Staff ◽

The Impact

AimsTo establish Safety Huddles (SH) on an acute general adult psychiatric ward, exploring links to restrictive practice. Additionally, to obtain multidisciplinary staff feedback on SH's impact on their workload/wellbeing and on patient care, and to identify barriers in implementation.Background: A SH is a multidisciplinary daily briefing focused on patients most at risk, held at a fixed time and place, lasting max 5-10 minutes. Effective SH involve agreed actions, are informed by multidisciplinary staff feedback of data and provide the opportunity to appreciate and celebrate success in reducing harm. SH are a valuable team building activity, promoting situational awareness and helping with prioritising daily tasks.MethodSH were introduced on September 2020. Templates were developed to prompt staff how to facilitate. Staff were encouraged to identify key goals and reflect on issues in the last and next 24 hours. Each participant was allocated a role, e.g. record keeping or dissemination of information. In December 2020, records of incidence of restrictive practice (numbers of restraints, seclusions and rapid tranquilisations) were obtained for the periods June-August 2020 and September-November 2020. Additionally, staff feedback was obtained through a short anonymous Survey Monkey questionnaire. It explored whether SH had an effect on patient care and staff's workload/wellbeing, and possible barriers to implementation.ResultComparing the two 3-month periods before and after SH implementation, restraint episodes were reduced from 47 to 21, seclusion episodes from 19 to 2, and rapid tranquilisation episodes from 10 to 3. Nine staff members responded to the feedback questionnaire. All believed SH had a positive impact on patient care, or had the potential to do so. Staff reported SH gave them insight into incidents, made them feel safer and prepared for the day, played a part in reducing restrictive practice, and empowered staff from all professional backgrounds by giving them a voice. Low or late participation, cancellation of SH because of clinical activity, and vague questions in the meeting template were identified as barriers in implementation.ConclusionAcute psychiatric wards regularly face challenges of high clinical activity, low staffing levels, bed pressures, and high-risk patient cohorts. SH contributed to reducing restrictive practice and creating a safer and more positive work environment. It is important to ensure SH are taking place daily, using an appropriate template to guide staff who may be new to facilitating. Accordingly, the impact on restrictive practice, patient care and staff wellbeing can be sustained long-term.

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