scholarly journals Learning From Errors: Curriculum Guide for the Morbidity and Mortality Conference With a Focus on Patient Safety Concepts

MedEdPORTAL ◽  
2016 ◽  
Vol 12 (1) ◽  
Author(s):  
Christine Garcia ◽  
Nirvani Goolsarran
Keyword(s):  
Patient Safety ◽  
Morbidity And Mortality ◽  
Learning From Errors ◽  
Curriculum Guide ◽  
Morbidity And Mortality Conference ◽  
Mortality Conference

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

2021 ◽  
Author(s):  
Nicolas Michel ◽  
Bernard Bui-xuan ◽  
Lionel Bapteste ◽  
Thomas Rimmele ◽  
Marc Lilot ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Simulation Training ◽  
Training Programme ◽  
Morbidity And Mortality ◽  
In Situ Simulation ◽  
Active Feedback ◽  
Morbidity And Mortality Conference ◽  
Mortality Conference

Abstract 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.

scholarly journals Leveraging a Redesigned Morbidity and Mortality Conference That Incorporates the Clinical and Educational Missions of Improving Quality and Patient Safety

2016 ◽  
Vol 91 (9) ◽  
pp. 1239-1243 ◽  
Author(s):  
Darlene B. Tad-y ◽  
Read G. Pierce ◽  
Jonathan M. Pell ◽  
Lindsie Stephan ◽  
Patrick P. Kneeland ◽  
...  
Keyword(s):  
Patient Safety ◽  
Morbidity And Mortality ◽  
Morbidity And Mortality Conference ◽  
Quality And Patient Safety ◽  
Mortality Conference

scholarly journals The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety

2016 ◽  
Vol 17 (1) ◽  
pp. 67-72 ◽  
Author(s):  
Bernhard Frey ◽  
Carsten Doell ◽  
Dietrich Klauwer ◽  
Vincenzo Cannizzaro ◽  
Vera Bernet ◽  
...  
Keyword(s):  
Patient Safety ◽  
Intensive Care ◽  
Pediatric Intensive Care ◽  
Morbidity And Mortality ◽  
Morbidity And Mortality Conference ◽  
Mortality Conference

Assessing educational validity of the Morbidity and Mortality Conference: A pilot study

2003 ◽  
Vol 60 (2) ◽  
pp. 204-209 ◽  
Author(s):  
Donald A Risucci ◽  
Thomas Sullivan ◽  
Stephen DiRusso ◽  
John A Savino
Keyword(s):  
Pilot Study ◽  
Morbidity And Mortality ◽  
Morbidity And Mortality Conference ◽  
Mortality Conference

Trying to Improve Care: The Morbidity and Mortality Conference in a Division of Rheumatology

2014 ◽  
Vol 41 (12) ◽  
pp. 2452-2458 ◽  
Author(s):  
Michelle Batthish ◽  
Shirley M.L. Tse ◽  
Brian M. Feldman ◽  
G. Ross Baker ◽  
Ronald M. Laxer
Keyword(s):  
Adverse Events ◽  
Test Procedure ◽  
Morbidity And Mortality ◽  
Error Reporting ◽  
Descriptive Data ◽  
Medication Error Reporting ◽  
Morbidity And Mortality Conference ◽  
System Improvement ◽  
Sick Children ◽  
Mortality Conference

Objective.To describe the frequency and types of reported adverse events and system improvement recommendations in the Morbidity and Mortality Conference (M&MC) within the Division of Rheumatology at The Hospital for Sick Children, Toronto, Ontario, Canada (SickKids).Methods.A 5-year retrospective review of the M&MC within the Division of Rheumatology at SickKids was completed. Descriptive data including the number and types of events reported were collected. Events were categorized using an adaptation of the National Coordinating Council for Medication Error Reporting and Prevention Index. Recommendations were classified according to the Institute for Safe Medication Practices Canada.Results.Between January 2007 and December 2011, 30 regularly scheduled M&MC were held. Eighty-three cases were reviewed. The most common types of reported events were related to “miscommunication” (34.9%), “treatment/test/procedure” (22.9%), “adverse drug reactions” (12.0%), and “medication errors” (8.4%). Category A events (“an event that has the capacity to cause error”) were the most common with 39.8% of the cases, followed by Category C events (“an event occurred that reached the patient, but did not cause harm”) with 28.9%. Eighty-nine recommendations were made. Over half of these were classified as “information” (58.4%), followed by 11 “rules and policies” recommendations (12.4%). Of the 36 action items generated from these recommendations, most are either complete or ongoing.Conclusion.The M&MC within the Division of Rheumatology reviews a variety of events. Increased reporting of adverse events can lead to system improvements, and has the potential to improve and promote safer healthcare.

Web-enabled morbidity and mortality conference improves specific competency yield

2006 ◽  
Vol 130 (2) ◽  
pp. 287
Author(s):  
D.S. Kwon ◽  
A. Yoshida ◽  
I. Rubinfeld ◽  
A. Shepard ◽  
J. Butler
Keyword(s):  
Morbidity And Mortality ◽  
Morbidity And Mortality Conference ◽  
Specific Competency ◽  
Mortality Conference

Lessons Learned From the Surgical Morbidity and Mortality Conference

2019 ◽  
Vol 76 (1) ◽  
pp. 174-181 ◽  
Author(s):  
Kaio S. Ferreira ◽  
Kenneth Lynch ◽  
Beth A. Ryder ◽  
Michael Connolly ◽  
Thomas Miner ◽  
...  
Keyword(s):  
Lessons Learned ◽  
Morbidity And Mortality ◽  
Surgical Morbidity ◽  
Morbidity And Mortality Conference ◽  
Mortality Conference
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