Morbidity and mortality conferences in general surgery: a narrative systematic review

Abstract

Background: In medical and surgical departments around the world, morbidity and mortality conferences (MMC) serve dual roles: they are cornerstones of quality-improvement programs and provide timely opportunities for education within the urgent context of clinical care. Despite the widespread adoption of MMCs, adverse events and preventable errors remain high or incompletely characterized, and opportunities to learn from and adjust to these events are frequently lost. This review examines the published literature on strategies to improve surgical MMCs. Methods:We searched OVID Medline, PubMed, Embase and CENTRAL. We defined our combination of search terms using a PICO (population, intervention, comparison, outcome) model, focusing on the use of MMCs in general surgery. Results:The MMC literature focused on 5 themes: educational value, error analysis, case selection and representation, attendance and dissemination. Strategies used to increase educational value included limiting case presentation time to 15-20 minutes, mandatory brief literature reviews, increasing audience interaction, and standardizing presentations using a PowerPoint template or SBAR (situation, background, assessment, recommendation) format. Interventions to improve error analysis included focused discussion on causative factors and taxonomic error analysis. Case selection was improved by using an electronic clinical registry, such as the National Surgery Quality Improvement Program, to better capture incidence of morbidity and mortality. Attendance was improved with teleconferencing. Dissemination strategies included MMC newsletters, incorporating MMCs into plan-do-check-act cycles, and surgeon report cards. Conclusion:Greater standardization of best practices may increase the quality improvement and educational impact of MMCs and provide a baseline to measure the effect of new MMC format innovations on the clinical and educational performance of surgical systems. Contexte : Dans les services de médecine et de chirurgie du monde entier, les conférences sur la morbidité et la mortalité (CMM) jouent 2 rôles : elles forment la pierre angulaire des programmes d'amélioration de la qualité de soins et fournissent l'occasion de faire de l'enseignement dans le contexte même des soins cliniques immédiats. Malgré la popularité grandissante des CMM, le nombre d'événements indési rables et d'erreurs évitables demeure élevé ou mal caractérisé et on perd beaucoup d'occasions d'apprendre de ces événements et d'apporter les changements qui s'imposent. La présente revue analyse la littérature publiée sur les stratégies d'amélioration des CMM en chirurgie. Méthodes : Nous avons interrogé OVID Medline, PubMed, Embase et CENTRAL. Nous avons défini nos combinaisons de mots clés à l'aide du modèle PICO (population, intervention, comparaison et résultat [outcome]), en mettant l'accent sur l'utilisation des CMM en chirurgie générale.Résultats : La littérature sur les CMM se concentrait sur 5 thèmes : valeur didactique, analyse des erreurs, sélection et représentation...

Type and impact of clinical incidents identified by a voluntary reporting system covering 130 small animal practices in mainland Europe

“…Morbidity and mortality meetings, malpractice claims, medical record review, practice surveillance, audits and incident reporting systems are examples of methods used to capture information relating to patient safety incidents. [9][10][11][12] All have varying ability to identify different types and causes of incidents. 13 Incident reporting systems provide a structure for incident processing and analysis, generating unique insights from the perspective of the practice team.…”

“…Morbidity and mortality meetings, malpractice claims, medical record review, practice surveillance, audits and incident reporting systems are examples of methods used to capture information relating to patient safety incidents 9–12 . All have varying ability to identify different types and causes of incidents 13 .…”

Evaluation of the implementation of a quality improvement program through morbidity and mortality reviews in a developing country

“…quality improvement and education). Cases should be selected based on predefined criteria and discussed using a standardized presentation format that is succinct, limiting both clinical history and literature review to only pertinent details to ensure ample time for discussion and analysis of the root causes of the adverse events [ 26 ]. Bal et al [ 4 , 5 , 7 ] confirmed that a well-structured and well-documented presentation allows to bring up all possible underlying contributing factors as a preliminary step to a systematic approach allowing a deep-dive into the root causes of adverse events identified.…”

“…However, MMRs should not be just an opportunity to deliver theoretical knowledge, strategies need to be developed to translate error analysis into meaningful QI initiatives [ 26 ]. This includes setting clear goals and measuring implementation which provides quantitative assessment of the quality improvement achieved by MMRs.…”

Beware of lethal Wernicke's encephalopathy after cytoreductive surgery with HIPEC for peritoneal pseudomyxoma: Case report of morbidity and mortality review

“…Morbidity and mortality reviews when conducted at a regular frequency, through a standardized procedure and case presentation with clearly defined goals [15] , [16] , [17] can identify system-based issues and allow for ample analysis of the root causes and possible underlying contributing factors of the adverse events [18] and thus, shifting MMR towards a quality improvement scope.…”