Revues de morbi-mortalité (RMM) en anesthésie-réanimation : retour d’expérience au CHU de Nancy

Baumann, A.; Cuignet-Royer, E.; Bouaziz, Hervé; Borgo, Jimena; Claudot, Frédérique; Torrens, Joao; Audibert, Gérard; Amalberti, René; Mertès, Paul-Michel

doi:10.1016/j.annfar.2011.04.018

Cited by 10 publications

(4 citation statements)

References 21 publications

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“…Indeed, these patients frequently have a poor health status and are treated with drugs that have low therapeutic indexes. These patients are at risk of adverse events at least as much as patients in intensive care units, for whom M&MCs have already been widely developed [5,11]. Implementation of combined medication error reviews and oncology M&MCs would be facilitated by the pre-existing multidisciplinary team organisation, thereby limiting the need for extra time-consuming meetings.…”

Section: Discussionmentioning

confidence: 99%

“…Traditional systematic and collegial analyses of death or complications in hospital patients has resulted in valuable educational benefits in a medical training program for United States physicians [2,3,4]. M&MCs have further been recognised worldwide as valuable evaluation programs for fulfilling physician's obligations in assessing their professional practice [5,6]. …”

Section: Introductionmentioning

confidence: 99%

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Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Ranchon¹,

You²,

Salles³

et al. 2013

Chemotherapy

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Background: To reduce the occurrence of medication errors, a systemic approach was developed combining anti-neoplastic medication error reviews and morbidity and mortality conferences (M&MCs). We report the first experience of implementing this strategy in oncology. Methods: The case reports submitted to combined reviews were prepared by physicians and pharmacists, and medication error(s) were described and chronological and root-cause analyses were performed. Results: Ten combined reviews were conducted, which involved the departments of haematology, medical oncology, pneumology, gastroenterology and clinical oncology pharmacy. A total of 91 errors were analysed, of which 3 had reached the patient. Thirty-four corrective actions were proposed; 53% consisted of changes in practice, 35% in procedural reminders and 12% in on-ward education sessions. Conclusions: The combination of medication error reviews and M&MCs appears to be an efficient means of improving cancer patient safety and personnel proficiency. This multidisciplinary work is indispensable to improve future patient management through the critical analysis of past medical errors.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Ranchon¹,

You²,

Salles³

et al. 2013

Chemotherapy

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“…noted that meetings focused on ‘medical education (75%), corrective actions (62%), changes in procedures (48%), organization (5%), and research (e.g., methods for improvement).’[3] All deaths or ‘near deaths in the operating room,’ and other instructive cases were also included. During the study, benefits included the maintenance of M&M attendance rates, the experience of preparing cases for the conference with ‘expert colleagues,’ and the ‘participation of external morbidity mortality committee (MMC) experts.…”

Section: Retrospective Collection Of Morbidity and Mortality Conferenmentioning

confidence: 99%

Morbidity and mortality conferences: Their educational role and why we should be there

Epstein

2012

Surg Neurol Int

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Background:This article examines the value of morbidity and mortality (M&M) conferences, and the multiple factors that contribute to their efficacy. Physicians’ morbidity and mortality conferences (M&MCs) focus on education by reviewing individual adverse events (AE), M&M. Alternatively, Quality Assurance (QA) conferences better examine system-wide issues (e.g., the role institutions play) in attaining or maintaining acceptable levels of patient care. Other issues examined in this review include: whether prospective vs. retrospective M&M data collection are more accurate, and how most states offer ‘nondiscovery’ of M&M proceedings.Methods:Most studies emphasize the educational role of M&MCs, and differentiate their role from QA. Studies comparing the accuracy of prospective vs. retrospective collection of M&M data were reviewed along with the medicolegal issues surrounding the protection of M&M data (‘nondiscovery’).Results:Multiple review articles emphasized that QA conferences typically identify system-wide failures (e.g., hospital policies) while M&MCs focus on physicians’ AE/morbidity/mortality. Additionally, the prospective collection of M&M data proved to be more accurate than retrospective analysis. Finally, most states protect M&M confidentiality (‘nondisclosure’); a glaring exception is Florida, ‘The Sunshine State,’ that allows ‘full disclosure.’Conclusion:This study reviews how M&MCs, differentiated from QA meetings, and educate physicians. It also documents how prospective collection of M&M data is more accurate than retrospective analysis. Additionally, it documents how in most states, medicolegal protections against discovery are in place, with Florida, the ‘Sunshine State’ remaining a glaring exception.

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“…Ces programmes sont pérennese ti ntégrésd ans la routine des équipes. Cette tendance estobservéedans d'autres établissements [6,9,10], mais aussienmédecine générale où s'implantent des groupes d'échanges de pratique entrep airs et des RMM [11][12][13] [20]. Ce conceptest proche de celui quiaétémis en place au Canada sous le termed eDPC-autogéré [21].…”

Section: Discussionunclassified

De l’évaluation des pratiques professionnelles au développement professionnel continu : engagement et opinion des praticiens hospitaliers dans les activités d’évaluation des pratiques professionnelles

François¹,

Boussat²,

Guyomard³

et al. 2015

Santé Publique

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Revues de morbi-mortalité (RMM) en anesthésie-réanimation : retour d’expérience au CHU de Nancy

Cited by 10 publications

References 21 publications

Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Improving Cancer Patient Care with Combined Medication Error Reviews and Morbidity and Mortality Conferences

Morbidity and mortality conferences: Their educational role and why we should be there

De l’évaluation des pratiques professionnelles au développement professionnel continu : engagement et opinion des praticiens hospitaliers dans les activités d’évaluation des pratiques professionnelles

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