Implementation of a pharmacy-focused morbidity, mortality, and improvement conference

Abstract

Purpose Review lessons learned during the development and implementation of a pharmacy-focused Morbidity, Mortality, and Improvement conference at an academic medical center. Summary Since the early 1900s, Morbidity and Mortality conferences have provided a forum for clinicians to discuss medical errors and adverse outcomes. Many institutions have now added “improvement” to the conference title to emphasize the goal of approaching these conferences in a systems-oriented manner. To date, a gap remains in the literature evaluating the impact of a pharmacy-focused Morbidity, Mortality, and Improvement (MM&I) conference. The primary goal in establishing this pharmacy-focused conference was to foster and strengthen the culture of medication safety within our department. In establishing our program, we identified an opportunity to leverage pharmacy residents similar to a medical resident–facilitated conference. After gaining leadership buy-in, a core planning team was formed to identify events and create conference materials. Primary metrics to gauge the success of implementation included event reporting trends and medication-safety strategic initiative tracking. The first year of MM&I conferences provided forward momentum for our department’s safety culture. Safety event reporting by pharmacy staff increased by 150% over the fiscal year, and more frontline staff expressed a personal interest in becoming involved in safety projects and initiatives outside of their normal shift responsibilities. Conclusion We have learned several important lessons that may be helpful to others, the primary of which is that improving a culture of safety takes time.

Medication use optimization in critical care through a pharmacy morbidity, mortality, and improvement program

“…As M&M conferences pivot into MMI programs aimed at systems‐based thinking for PI, inpatient pharmacy departments can provide both stakeholder weigh‐in and leadership 1–10 . ACCP and ASHP promote institutional pharmacist to improve the medication use process, but MMI programs are not specifically noted 13–15,18,19,21 .…”

“…As M&M conferences pivot into MMI programs aimed at systemsbased thinking for PI, inpatient pharmacy departments can provide both stakeholder weigh-in and leadership. [1][2][3][4][5][6][7][8][9][10] ACCP and ASHP promote institutional pharmacist to improve the medication use process, but MMI programs are not specifically noted. [13][14][15]18,19,21 The SCCM, ACCP, and ASHP joint position paper for critical care pharmacists describes medication safety quality improvement as a foundational activity.…”

“…Morbidity, mortality, and improvement (MMI) programs have transformed traditional Morbidity and Mortality (M&M) conferences from individual case‐based, didactic learning to interdisciplinary, systems‐based process improvement (PI) with root cause analysis 1–7 . Inpatient pharmacy services are incorporating MMI activities to champion PI from medication safety incidents 8–10 . Small, single‐center descriptions demonstrate that error monitoring programs and M&M conferences assist in surveillance and provide quality of care guidance within critical care 11,12 …”

“…[1][2][3][4][5][6][7] Inpatient pharmacy services are incorporating MMI activities to champion PI from medication safety incidents. [8][9][10] Small, single-center descriptions demonstrate that error monitoring programs and M&M conferences assist in surveillance and provide quality of care guidance within critical care. 11,12 Pharmacists are instrumental in patient-specific and systemsbased error mitigation throughout the medication use process.…”

Improving Reporting Culture Through Daily Safety Huddles

“…Among strategies employed by High Reliability Organizations is the huddle, a brief meeting before shared work to connect to purpose and measure achievement against goals 11-13. Conscripted conversations about safety, referred to as safety huddles, have been shown to mitigate risk for patients in the operating room, to decrease the number of catastrophic events, and to increase reporting 14-17…”