The Experience of Conducting Mortality and Morbidity Reviews in a Pediatric Interventional Radiology Service: A Retrospective Study

Tuong, Betty; Shnitzer, Ziv; Pehora, Carolyne; Choi, Perry; Levine, Mark; Krishnamurthy, G.; Chait, Peter; Temple, Michael; John, Philip; Amaral, João; Connolly, Bairbre

doi:10.1016/j.jvir.2008.09.013

Cited by 16 publications

(18 citation statements)

References 14 publications

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“…[353][354][355][356][357][358][359] Therefore, each facility should maintain records that track all adverse events and significant interventions, such as desaturation; apnea; laryngospasm; need for airway interventions, including the need for placement of supraglottic devices such as an oral airway, nasal trumpet, or LMA; positivepressure ventilation; prolonged sedation; unanticipated use of reversal agents; unplanned or prolonged hospital admission; sedation failures; inability to complete the procedure; and unsatisfactory sedation, analgesia, or anxiolysis. 360 Such events can then be examined for the assessment of risk reduction and improvement in patient/family satisfaction.…”

Section: Continuous Quality Improvementmentioning

confidence: 99%

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

Coté¹,

Wilson²

2016

Pediatrics

240

199

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The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age-and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, suffi cient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the

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Section: Continuous Quality Improvementmentioning

confidence: 99%

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

Coté¹,

Wilson²

2016

Pediatrics

240

199

View full text Add to dashboard Cite

show abstract

“…In particular, sedation/anesthesia during diagnostic and therapeutic radiology has been recognized as one of the largest fields in pediatric anesthesia [10]. Several studies have suggested that anesthetic management of pediatric interventional radiology is relatively safe [11,12,13]. Mason et al [11] proposed that a nurse-provided sedation protocol could become an alternative to an anesthesiologist-managed general anesthesia for pediatric interventional radiological procedures, although the pediatric population receiving sedation/anesthesia in non-OR-based settings is categorized into the highest risk and the lowest error tolerance subgroup [14,15].…”

Section: Discussionmentioning

confidence: 99%

Initial Experience with the Use of Remote Control Monitoring and General Anesthesia during Radiosurgery for Pediatric Patients

et al. 2011

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The demand for general anesthesia in pediatric radiosurgery has been increasing, but the issues involved are not highlighted well in the medical literature. We developed remotely controlled monitoring and anesthesia techniques, and applied our system to three pediatric patients who underwent Gamma Knife radiosurgery with automated settings. Based on the perioperative safety management, the following issues are of considerable concern: to avoid emotional trauma associated with the treatment, to secure airway patency in a variety of head positions, and to apply all standard monitors. In this report, we describe the details of our project with a comprehensive literature review.

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“…After obtaining IRB exemption, we retrospectively reviewed the topics presented since the inception of the MM&M conference, grouping them into one of seven categories adapted from previously published reports[10]. We then evaluated the patient care improvements that resulted from the sessions.…”

Section: Methodsmentioning

confidence: 99%

“…The multidisciplinary nature fosters efficient communication and improves the efficiency of care delivered. Multidisciplinary M&M conferences have been used to focus on patient safety, highlight system-issues that may adversely affect patient outcome, and create solutions to address these issues [5, 10–12]. We believe that the use of a Multi-disciplinary Morbidity and Mortality (MM&M) conference presents a unique opportunity to incorporate all six ACGME competencies effectively and efficiently into a surgical residency training program.…”

Section: Introductionmentioning

confidence: 99%

The Use of a Multidisciplinary Morbidity and Mortality Conference to Incorporate ACGME General Competencies

Kauffmann

Landman

Shelton

et al. 2011

Journal of Surgical Education

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Background-The Surgical Morbidity and Mortality conference has long been used as an opportunity for both process improvement and resident education. With recent heightened focus on creating environments of safety and on meeting the ACGME General Competencies, novel approaches are required. With the understanding that the provision of medical care is an inherently multi-disciplinary enterprise, we advocate the creation and use of a Multi-disciplinary Morbidity and Mortality conference (MM&M) as a means to establish this culture of safety while teaching the ACGME General Competencies to surgery residents.

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The Experience of Conducting Mortality and Morbidity Reviews in a Pediatric Interventional Radiology Service: A Retrospective Study

Cited by 16 publications

References 14 publications

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

Initial Experience with the Use of Remote Control Monitoring and General Anesthesia during Radiosurgery for Pediatric Patients

The Use of a Multidisciplinary Morbidity and Mortality Conference to Incorporate ACGME General Competencies

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