Implementation of an in Situ Simulation-based Training Adapted from Morbidity and Mortality Conference Cases: Effect on the Occurrence of Aevents – Study Protocol of a Cluster Randomized Controlled Trial

2021 ◽  
Author(s):  
Nicolas Michel ◽  
Bernard Bui-xuan ◽  
Lionel Bapteste ◽  
Thomas Rimmele ◽  
Marc Lilot ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Simulation Training ◽  
Training Programme ◽  
Morbidity And Mortality ◽  
In Situ Simulation ◽  
Active Feedback ◽  
Morbidity And Mortality Conference ◽  
Mortality Conference

Abstract Background: Morbidity and Mortality Conferences provides the necessary improvement measures required for patient safety. However, it is 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 efficacy; 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 randomized controlled study will be performed at four study sites. 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” to isolate potential adverse events. 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: T he study has been registered in Clinicaltrials.gov (NCT02771613). Registered on May 12, 2016.

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

2014 ◽  
Vol 41 (12) ◽  
pp. 2452-2458 ◽  
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.

Defining a new neurosurgical complication classification: lessons learned from a monthly Morbidity and Mortality conference

2020 ◽  
Vol 132 (1) ◽  
pp. 272-276 ◽  
Author(s):  
Yair M. Gozal ◽  
Erinç Aktüre ◽  
Vijay M. Ravindra ◽  
Jonathan P. Scoville ◽  
Randy L. Jensen ◽  
...  
Keyword(s):  
Adverse Events ◽  
Classification System ◽  
Medical Center ◽  
Classification Systems ◽  
Morbidity And Mortality ◽  
Neurosurgical Procedures ◽  
Critical Events ◽  
Technical Errors ◽  
Morbidity And Mortality Conference ◽  
Mortality Conference

OBJECTIVEThe absence of a commonly accepted standardized classification system for complication reporting confounds the recognition, objective reporting, management, and avoidance of perioperative adverse events. In the past decade, several classification systems have been proposed for use in neurosurgery, but these generally focus on tallying specific complications and grading their effect on patient morbidity. Herein, the authors propose and prospectively validate a new neurosurgical complication classification based on understanding the underlying causes of the adverse events.METHODSA new complication classification system was devised based on the authors’ previous work on morbidity in endovascular surgery. Adverse events were prospectively compiled for all neurosurgical procedures performed at their tertiary care academic medical center over the course of 1 year into 5 subgroups: 1) indication errors; 2) procedural errors; 3) technical errors; 4) judgment errors; and 5) critical events. The complications were presented at the monthly institutional Morbidity and Mortality conference where, following extensive discussion, they were assigned to one of the 5 subgroups. Additional subgroup analyses by neurosurgical subspecialty were also performed.RESULTSA total of 115 neurosurgical complications were observed and analyzed during the study period. Of these, nearly half were critical events, while technical errors accounted for approximately one-third of all complications. Within neurosurgical subspecialties, vascular neurosurgery (36.5%) had the most complications, followed by spine & peripheral nerve (21.7%), neuro-oncology (14.8%), cranial trauma (13.9%), general neurosurgery (12.2%), and functional neurosurgery (0.9%).CONCLUSIONSThe authors’ novel neurosurgical complication classification system was successfully implemented in a prospective manner at their high-volume tertiary medical center. By employing the well-established Morbidity and Mortality conference mechanism, this simple system may be easily applied at other neurosurgical centers and may allow for uniform analyses of perioperative morbidity and the introduction of corrective initiatives.

Identifying Adverse Events in Pediatric Surgery: Comparing Morbidity and Mortality Conference with the NSQIP-Pediatric System

2017 ◽  
Vol 224 (5) ◽  
pp. 945-953 ◽  
Author(s):  
Barrett P. Cromeens ◽  
Richard E. Lisciandro ◽  
Richard J. Brilli ◽  
Johanna R. Askegard-Giesmann ◽  
Brian D. Kenney ◽  
...  
Keyword(s):  
Adverse Events ◽  
Pediatric Surgery ◽  
Morbidity And Mortality ◽  
Morbidity And Mortality Conference ◽  
Mortality Conference

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

2013 ◽  
Vol 216 (1) ◽  
pp. 50-56 ◽  
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

The effect of in situ simulation training on the performance of tasks related to patient safety during sedation

2018 ◽  
Vol 32 (2) ◽  
pp. 300-304 ◽  
Author(s):  
Meital Ben-Ari ◽  
Gilad Chayen ◽  
Ivan P. Steiner ◽  
Dana Aronson Schinasi ◽  
Oren Feldman ◽  
...  
Keyword(s):  
Patient Safety ◽  
Simulation Training ◽  
In Situ Simulation

scholarly journals Leveraging a Redesigned Morbidity and Mortality Conference That Incorporates the Clinical and Educational Missions of Improving Quality and Patient Safety

2016 ◽  
Vol 91 (9) ◽  
pp. 1239-1243 ◽  
Author(s):  
Darlene B. Tad-y ◽  
Read G. Pierce ◽  
Jonathan M. Pell ◽  
Lindsie Stephan ◽  
Patrick P. Kneeland ◽  
...  
Keyword(s):  
Patient Safety ◽  
Morbidity And Mortality ◽  
Morbidity And Mortality Conference ◽  
Quality And Patient Safety ◽  
Mortality Conference

scholarly journals Systems-Based Content in Medical Morbidity and Mortality Conferences: A Decade of Change

2012 ◽  
Vol 4 (4) ◽  
pp. 438-444 ◽  
Author(s):  
Jed D. Gonzalo ◽  
Julius J. Yang ◽  
Grace C. Huang
Keyword(s):  
Adverse Events ◽  
Morbidity And Mortality ◽  
Average Percentage ◽  
The Past ◽  
Clinical Events ◽  
Audio Recordings ◽  
Morbidity And Mortality Conferences ◽  
Morbidity And Mortality Conference ◽  
Mortality Conference ◽  
Medical Morbidity

Abstract Background Following the Accreditation Council for Graduate Medical Education recommendations in 1999 to foster education in the systems-based practice (SBP) competency by examining adverse clinical events, institutions have modified the morbidity and mortality conference (MMC) to increase SBP-related discussion. We sought to examine the extent to which SBP-related content has increased in our department's MMCs compared with MMCs 10 years prior. Method We qualitatively analyzed audio recordings of our MMCs during 2 academic years, 1999–2000 (n  =  30) and 2010–2011 (n  =  30). We categorized comments and questions from moderators and faculty as SBP or non-SBP and characterized conferences by whether adverse events were presented and which systems issues were discussed. Results Compared with MMCs in 1999–2000, present-day MMCs included a greater average percentage of SBP comments stated (69% versus 12%; P ≤ .001) and questions asked (13% versus 1%; P  =  .001) by the moderator, SBP comments stated (44% versus 4%; P ≤ .001) and questions asked (19% versus 1%; P ≤ .001) by faculty, and were more likely to present adverse events (87% versus 13%; P < .001). Interrater reliability for the distinction between SBP and non-SBP content was good (κ  =  0.647). Most common categories of systems issues discussed in 2010–2011 were critical laboratory value processing and reporting, institutional policies, and hospital-based factors. Conclusions Over the past decade, our MMC has transformed to include more discussion of SBP-related content and adverse events. The MMC can be used to educate residents in SBP and can also serve as a cornerstone for departmental quality and safety initiatives.

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