Mortality meetings in geriatric medicine: strategies for improvement

Dunbar, J. M.; George, James

doi:10.1136/bmjquality.u202625.w3247

Cited by 3 publications

(6 citation statements)

References 4 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…One way is for a senior clinician or mortality team to do a rapid review of all deaths and pick out cases in which there are care issues or adverse events 6. Another way is to organise the MMCs around varying themes—for example, end of life care, cardiac failure, sepsis, acute kidney injury, and so on, and to select appropriate patients for each meeting 34.…”

Section: Improving the MMC Processmentioning

confidence: 99%

“…However, a more narrative approach using change analysis may be better at picking up omission errors, particularly when there are multiple transitions of care 16. The cases can be presented in the form of 3–5 slides to the MMC, including any necessary radiological images and a summary of potential learning points 6. Finally, there needs to be a way of sharing the issues and lessons learnt through the hospital governance structure and perhaps through a ‘safety’ newsletter.…”

Section: Improving the MMC Processmentioning

confidence: 99%

“…Box 2 summarises the main recommendations derived from the literature review.

Recommendations for medical MMCsMultidisciplinary input and with a senior clinician to select cases, chair and lead discussions2 6 32Encouragement of a ‘safety culture’ with an atmosphere in which individuals feel free to identify and describe known safety threats and errors without fear of ‘blame’31A commitment to create and support safer systems31 32 33Use of a narrative approach to identify omission errors and track transitions of care,16 as well as a trigger tool11Use of themed MMCs—for example, end of life care, sepsis, acute kidney injury34Formal recording of learning points and communication of conclusions—for example, through a safety newsletter6Hospital governance links—for example, reports to Trust Safety Committee/Trust Board5Encouragement and support to the involvement of the junior doctors3MMC, morbidity and mortality conferences.…”

Section: Improving the MMC Processmentioning

confidence: 99%

“…Multidisciplinary input and with a senior clinician to select cases, chair and lead discussions2 6 32…”

Section: Improving the MMC Processmentioning

confidence: 99%

“…Formal recording of learning points and communication of conclusions—for example, through a safety newsletter6…”

Section: Improving the MMC Processmentioning

confidence: 99%

See 4 more Smart Citations

Medical morbidity and mortality conferences: past, present and future

George

2016

Postgraduate Medical Journal

View full text Add to dashboard Cite

Morbidity and mortality conferences (MMCs) have three potential aims-to improve patient safety by reducing adverse events and preventable deaths, to improve overall quality of care as part of the hospital governance structure and as educational learning events. At present, medical MMCs vary widely in format and attendance from hospital to hospital. The evidence for MMCs actually reducing adverse events and preventing avoidable deaths is disappointing. There is better evidence for their educational role. The majority of medical deaths in hospitals are frail older people with poor life expectancy in whom inadequate care is more likely to be due to errors of omission rather than commission. Medical MMCs should be multidisciplinary and led by a senior clinician to encourage discussion and reflection in a 'blame-free' environment. They should be learning events for both clinicians and the organisation as a whole with a structure to support this.

show abstract

Section: Improving the MMC Processmentioning

confidence: 99%

Section: Improving the MMC Processmentioning

confidence: 99%

“…Box 2 summarises the main recommendations derived from the literature review.

Section: Improving the MMC Processmentioning

confidence: 99%

“…Multidisciplinary input and with a senior clinician to select cases, chair and lead discussions2 6 32…”

Section: Improving the MMC Processmentioning

confidence: 99%

“…Formal recording of learning points and communication of conclusions—for example, through a safety newsletter6…”

Section: Improving the MMC Processmentioning

confidence: 99%

See 3 more Smart Citations

Medical morbidity and mortality conferences: past, present and future

George

2016

Postgraduate Medical Journal

View full text Add to dashboard Cite

show abstract

Implementation of an in situ simulation-based training adapted from Morbidity and Mortality conference cases: effect on the occurrence of adverse events—study protocol of a cluster randomised controlled trial

Michel

Bui‐Xuan

Bapteste

et al. 2022

Trials

View full text Add to dashboard Cite

Background Morbidity and Mortality conference provides the necessary improvement measures for patient safety. However, they are 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 effectiveness: 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 randomised controlled study will be performed at four study sites. The unit of randomisation is wards within the study sites. Fifteen wards will be randomly assigned to passive feedback, active feedback, or a standard MMC (control arm). 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”: an adverse event is defined as a patient’s stay with at least one positive trigger. 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 Clinicaltrials.gov NCT02771613. Registered on May 12, 2016. All items from the WHO Trial Registration Data Set can be found within the protocol.

show abstract

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

Michel

Bui‐Xuan

Bapteste

et al. 2021

Preprint

View full text Add to dashboard Cite

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.

show abstract

Mortality meetings in geriatric medicine: strategies for improvement

Cited by 3 publications

References 4 publications

Medical morbidity and mortality conferences: past, present and future

Medical morbidity and mortality conferences: past, present and future

Implementation of an in situ simulation-based training adapted from Morbidity and Mortality conference cases: effect on the occurrence of adverse events—study protocol of a cluster randomised controlled trial

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

Contact Info

Product

Resources

About