Morbidity and Mortality Conferences: A Mini Review and Illustrated Application in Veterinary Medicine

Abstract

This mini review presents current knowledge on the role of morbidity and mortality conferences (M&MCs) as a powerful educational tool and driver to improve patient care. Although M&MCs have existed since the early twentieth century, formal evaluation of their impact on education and patient care is relatively recent. Over time, M&MCs have evolved from single discipline discussions with a tendency to focus on individual errors and assign blame, to multidisciplinary, standardized presentations incorporating error analysis techniques, and educational theory. Current evidence shows that M&MCs can provide a valuable educational experience and have the potential to generate measurable improvements in patient care.

Ethical Challenges Posed by Advanced Veterinary Care in Companion Animal Veterinary Practice

“…Clinical audit should be cyclical, to ensure continuous improvement. Informal clinical audit may occur in the form of morbidity and mortality rounds [ 102 , 103 ]. The focus of the latter is typically adverse or unexpected outcomes in the morbidity and mortality rounds [ 102 ].…”

CIRSE Standards of Practice on Conducting Meetings on Morbidity and Mortality

“…M&M meetings should facilitate open discussion that allows objective and non-judgemental examination of adverse events. They are a forum for doctors and the wider multidisciplinary team to address errors and mistakes without fear of retribution or blame [6,32,33]. The discussion is therefore focussed on systems and processes rather than individual fault [13].…”

“…Increasing evidence suggests that a structured and transparent approach to M&M meeting results in measurable gains in user satisfaction and participation as well as educational benefit, overall patient safety and quality of care [12,20,33]. Tools that have been used to guide focussed and goal-directed discussion include the SBAR (Situation, Background, Assessment, Recommendations) model and Vincent, Taylor-Adams and Stanhope's framework for analysing medical error [10,11,32,34].…”

“…All recommendations should be SMART (Specific, Measurable, Achievable, Realistic, Timely) and assigned to a responsible party with an agreed timeframe for completion [7,10,11,19]. The implementation of an action plan may lead to a quality improvement project and a subsequent audit showing progress would close the loop of the patient safety feedback cycle [10][11][12]33].…”

Significant event reporting in veterinary practice

“…[10][11][12][13][14][15] Papers have investigated the use of checklists, incident reporting, clinical audit, morbidity and mortality rounds and the types of error in veterinary practice. [16][17][18][19][20][21][22][23][24][25][26][27][28] These studies have established a baseline from which to develop the concept of patient safety in the veterinary profession, but we still have a great deal of work to do.…”