A Descriptive Study of Morbidity and Mortality Conferences and Their Conformity to Medical Incident Analysis Models: Results of the Morbidity and Mortality Conference Improvement Study, Phase 1

Aboumatar, Hanan; Blackledge, Charles G.; Dickson, Conan; Heitmiller, Eugenie S.; Freischlag, Julie A.; Pronovost, Peter J.

doi:10.1177/1062860607303292

Cited by 88 publications

(158 citation statements)

References 10 publications

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“…11,12 Despite this popularity, few studies have examined the characteristics of effective M&M conference 13,14 or proposed a standardized method for case selection or review. 15 In many ways, the catheterization laboratory is an ideal setting for M&M conference.…”

Section: Discussionmentioning

confidence: 99%

Morbidity and Mortality Conference for Percutaneous Coronary Intervention

Doll

Overton

Patel

et al. 2017

Circ: Cardiovascular Quality and Outcomes

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Background-Morbidity and mortality conference is a common educational and quality improvement activity performed in cardiac catheterization laboratories, but best practices for case selection and for maximizing the effectiveness of peer review have not been determined. Methods and Results-We reviewed the 10-year percutaneous coronary intervention morbidity and mortality conference experience of an academic medical center. Cases were triggered for review by the occurrence of prespecified procedural events. Summary reports from morbidity and mortality conference discussions were linked to clinical data from the Duke Databank for Cardiovascular Disease to compare baseline and procedural characteristics and to assess postdischarge outcomes. Of 11 786 procedures, from 2004 to 2013, 157 (1.3%) were triggered for review. The most frequent triggering events were cardioversion/defibrillation (72, 0.6%), unplanned use of mechanical circulatory support (64, 0.5%), and major dissection (41, 0.3%). Selected procedures were more likely to include high-risk features, such as ST-segmentelevation myocardial infarction, cardiogenic shock, and multivessel disease, and were associated with higher mortality at 30 days. Only a minority of triggering events were caused by controversial or unacceptable physician behavior. Conclusions-This 10-year experience outlines the processes for conduct of an effective percutaneous coronary intervention morbidity and mortality conference, including a novel approach to case selection and structured peer review leading to actionable quality interventions. The prespecified clinical triggers, captured in the natural workflow by laboratory staff, identified complex cases that were associated with poor patient outcomes. (Circ Cardiovasc Qual Outcomes.

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Section: Discussionmentioning

confidence: 99%

Morbidity and Mortality Conference for Percutaneous Coronary Intervention

Doll

Overton

Patel

et al. 2017

Circ: Cardiovascular Quality and Outcomes

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“…Moderators should be prepared not only to rephrase or moderate comments that are unsupportive or unsympathetic in tone but also to address the "tough" issues (1). We believe that they should have error and risk analysis experience and be able to apply it within the restricted MMC time frame to the following ends: 1) identifying probable adverse events/medical errors; 2) eliciting input from all staff involved in the case; 3) investigating underlying contributing factors; and 4) appointing persons responsible for following up corrective interventions (8,21).…”

Section: Discussionmentioning

confidence: 99%

The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety

Frey

Doell

Klauwer

et al. 2016

Pediatric Critical Care Medicine

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OBJECTIVES: To present our experience in an interdisciplinary and interprofessional morbidity and mortality conference, with special emphasis on its usefulness in improving patient safety. DESIGN: Retrospective analysis. SETTING: Tertiary interdisciplinary neonatal PICU. PATIENTS: Morbidity and mortality conference minutes on 48 patients (newborns to 17 yr), January 2009 to June 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors' PICU implemented a morbidity and mortality conference guideline in 2009 using a system-based approach to identify medical errors, their contributing factors, and possible solutions. In the subsequent 5.5 years, there were 44 mortality conferences (of 181 deaths [27%] over the same period) and four morbidity conferences. The median death/morbidity event-morbidity and mortality conference interval was 90 days (range, 7 d to 1.5 yr). The median age of patients was 4 months (range, newborn to 17 years). In six cases, the primary reason for PICU admission was a treatment complication. Unsafe processes/medical errors were identified and discussed in 37 morbidity and mortality conferences (77%). In seven cases, new autopsy findings prompted the discussion of a possible error. The 48 morbidity and mortality conferences identified 50 errors, including 30 in which an interface problem was a contributing factor. Fifty-four improvements were identified in 34 morbidity and mortality conferences. Four morbidity and mortality conferences discussed specific ethical issues. CONCLUSIONS: From our experience, we have found that the interdisciplinary and interprofessional morbidity and mortality conference has the potential to reveal unsafe processes/medical errors, in particular, diagnostic and communication errors and interface problems. When formatted as a nonhierarchical tool inviting contributions from all staff levels, the morbidity and mortality conference plays a key role in the system approach to medical errors. Originally published at: Frey, Bernhard; Doell, Carsten; Klauwer, Dietrich; Cannizzaro, Vincenzo; Bernet, Vera; Maguire, Christine; Brotschi, Barbara (2016). The morbidity and mortality conference in pediatric intensive care as a means for improving patient safety. Pediatric Critical Care Medicine, 17(1):67-72.

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“…Trainees use them as an educational method to learn clinical reasoning from patient presentations and diagnostic processes 19 . Clinical vignettes identify system issues affecting patient care outcomes, allowing for targeted quality improvement and patient safety efforts 20,21 . By presenting vignettes at academic meetings, fellows, residents and medical students develop writing, presentation, and communication skills, 6,8,11 and gain an opportunity for mentorship by faculty members 6 .…”

Section: Discussionmentioning

confidence: 99%

Selecting the Best Clinical Vignettes for Academic Meetings: Should the Scoring Tool Criteria be Modified?

et al. 2011

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BACKGROUND:The performance of scoring tools to select clinical vignettes for presentation at academic meetings has never been assessed. OBJECTIVE: To measure the psychometric properties of two scoring tools used to select clinical vignettes and to determine which elements are most helpful. DESIGN: Prospective observational study. (2007) using the average score of the five items with the number that would have been accepted using the simplified three items (relevance, teaching value, overall assessment) was almost perfect, with kappa 0.89 (95% confidence interval, 0.85 to 0.93). CONCLUSIONS: Both scoring tools performed well, but a simplified tool with three items (relevance, teaching value, and overall assessment) and detailed descriptors was optimal; the simplified tool could improve the reviewer efficiency and quality of clinical vignettes presented at national meetings.KEY WORDS: professional competence; internship and residency; education medical/methods; educational measurement/methods/ standards; congresses as topic; reproducibility of results.

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A Descriptive Study of Morbidity and Mortality Conferences and Their Conformity to Medical Incident Analysis Models: Results of the Morbidity and Mortality Conference Improvement Study, Phase 1

Cited by 88 publications

References 10 publications

Morbidity and Mortality Conference for Percutaneous Coronary Intervention

Morbidity and Mortality Conference for Percutaneous Coronary Intervention

The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety

Selecting the Best Clinical Vignettes for Academic Meetings: Should the Scoring Tool Criteria be Modified?

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