Perioperative team-based morbidity and mortality conferences: a systematic review of the literature.

Aubrey Samost-Williams; Roni Rosen; Alexander Hannenberg; Melis Lydston; Garrett M Nash; Mary Brindle

Review

Perioperative team-based morbidity and mortality conferences: a systematic review of the literature.

October 11, 2023

Samost-Williams A, Rosen R, Hannenberg A, et al. Ann Surg Open. 2023;4(3):e321.

View more articles from the same authors.

Morbidity and mortality conferences offer important opportunities for healthcare teams to discuss adverse events, learn from errors, and improve patient safety. This systematic review examined beneficial aspects of perioperative team-based morbidity and mortality (TBMM) conferences. The authors found that TBMM conferences generally led to improvements in patient safety, quality improvement, and educational outcomes and that certain factors (case preparation, standardized presentation format, effective facilitation) increase TBMM benefits.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Perspectives on perioperative team-based morbidity and mortality conferences: a mixed-methods study.

November 29, 2023

Redeployment of health care workers in the COVID-19 pandemic: a qualitative study of health system leaders' strategies.

May 19, 2021

Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years: a multinational survey.

November 17, 2021

A systems approach to analyzing and preventing hospital adverse events.

June 24, 2020

10 years in, why time out still matters.

June 11, 2014

Non-technical skills in surgery during the COVID-19 pandemic: an observational study.

March 9, 2022

Transforming team performance through reimplementation of the surgical safety checklist.

December 6, 2023

Simulation safety first: an imperative.

February 20, 2019

Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers.

May 9, 2018

We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations.

March 17, 2021

Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis.

November 24, 2021

International perspectives on modifications to the surgical safety checklist.

June 21, 2023

CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity.

October 18, 2023

Remote assessment of real-world surgical safety checklist performance using the OR Black Box: a multi-institutional evaluation.

March 20, 2024

Medication safety in a psychiatric hospital.

March 21, 2007

Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study.

August 19, 2020

National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.

December 7, 2016

Association of postoperative readmissions with surgical quality using a Delphi consensus process to identify relevant diagnosis codes.

May 16, 2018

Factors associated with hospital admission after outpatient surgery in the Veterans Health Administration.

February 28, 2018

Patient safety strategies: are we on the same team?

October 3, 2012

Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral problems.

August 1, 2012

Automatable algorithms to identify nonmedical opioid use using electronic data: a systematic review.

November 8, 2017

Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals.

January 11, 2023

Predictors of treatment error for children with uncomplicated malaria seen as outpatients in Blantyre district, Malawi.

September 13, 2006

The impact of post-fall huddles on repeat fall rates and perceptions of safety culture: a quasi-experimental evaluation of a patient safety demonstration project

October 16, 2019

A theory-driven, longitudinal evaluation of the impact of team training on safety culture in 24 hospitals.

April 3, 2013

Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: prospective study in 20 UK hospitals.

August 26, 2015

Learning from the design, development and implementation of the Medication Safety Thermometer.

February 8, 2017

A framework for patient safety: a defense nuclear industry-based high-reliability model.

May 1, 2013

Is oral chemotherapy prescription safe for patients? A cross-sectional survey.

May 7, 2014

How hospitals select their patient safety priorities: an exploratory study of four Veterans Health Administration hospitals.

September 25, 2019

A systematic review of patient safety measures in adult primary care.

May 18, 2016

Does teamwork improve performance in the operating room? A multilevel evaluation.

March 3, 2010

Potentially inappropriate prescribing in elderly veterans: are we using the wrong drug, wrong dose, or wrong duration?

August 24, 2005

Experiences of transgender and gender nonbinary patients in the emergency department and recommendations for health care policy, education, and practice.

July 21, 2021

Racial disparities in diagnostic delay among women with breast cancer.

August 18, 2021

Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion.

December 2, 2020

Increasing naloxone prescribing in the emergency department through education and electronic medical record work-aids.

April 21, 2021

Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence.

April 12, 2023

Guidelines for the prevention of intravascular catheter-related infections.

May 25, 2011

Relationship between medication event rates and the Leapfrog computerized physician order entry evaluation tool.

May 15, 2013

Impact of vendor computerized physician order entry in community hospitals.

February 22, 2012

Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before.

November 20, 2013

The impact of internal service quality on preventable adverse events in hospitals.

March 27, 2019

Evaluating the impact of auto-calculation settings on opioid prescribing at an academic medical center.

May 8, 2019

Primary care physician communication at hospital discharge reduces medication discrepancies.

December 18, 2013

Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery.

April 3, 2005

When doing wrong feels so right: normalization of deviance.

March 25, 2015

"SWARMing" to improve patient care: a novel approach to root cause analysis.

November 4, 2015

HIM functions in healthcare quality and patient safety.

August 10, 2011

Readiness of US general surgery residents for independent practice.

October 4, 2017

Surgeons' disclosures of clinical adverse events.

July 27, 2016

How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital?

April 1, 2009

Development of trigger tools for surveillance of adverse events in ambulatory surgery.

November 10, 2010

Did duty hour reform lead to better outcomes among the highest risk patients?

November 4, 2009

Applying trigger tools to detect adverse events associated with outpatient surgery.

March 16, 2011

Teaching hospital five-year mortality trends in the wake of duty hour reforms.

August 7, 2013

Can teamwork promote safety in organizations?

February 26, 2020

Physicians' views of interventions to reduce medical errors: does evidence of effectiveness matter?

April 21, 2005

Views of practicing physicians and the public on medical errors.

March 27, 2005

Venous thromboembolism after trauma: a never event?

October 10, 2012

A randomized trial of a multifactorial strategy to prevent serious fall injuries.

July 29, 2020

Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review.

January 12, 2022

Improving shared situation awareness for high-risk therapies in hospitalized children.

January 19, 2022

Chief resident for quality improvement and patient safety: a description.

July 2, 2014

Crisis checklists for the operating room: development and pilot testing.

January 30, 2005

Health care-associated invasive MRSA infections, 2005-2008.

August 18, 2010

Simulation-based trial of surgical-crisis checklists.

January 30, 2013

Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.

July 25, 2012

Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study.

July 11, 2018

Quality of life after maternal near miss: a systematic review.

June 2, 2021

Factors influencing providers' willingness to deprescribe medications.

December 1, 2021

The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: scale development and psychometric evaluation.

February 7, 2024

Rates of surgical consultations after emergency department admission in Black and White Medicare patients.

October 26, 2022

Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process.

September 20, 2023

Evaluating the implementation of Project Re-Engineered Discharge (RED) in five Veterans Health Administration (VHA) hospitals.

October 17, 2018

Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug event triggers designed for the outpatient setting.

June 24, 2015

Detecting adverse events in surgery: comparing events detected by the Veterans Health Administration Surgical Quality Improvement Program and the Patient Safety Indicators.

June 4, 2014

Using estimated true safety event rates versus flagged safety event rates: does it change hospital profiling and payment?

May 21, 2014

Validity of selected patient safety indicators: opportunities and concerns.

October 27, 2010

Hospital safety climate and safety outcomes: is there a relationship in the VA?

March 10, 2010

Prolonged hospital stay and the resident duty hour rules of 2003.

January 13, 2010

Comparing safety climate in naval aviation and hospitals: implications for improving patient safety.

April 21, 2010

Identifying organizational cultures that promote patient safety.

November 18, 2009

Comparing safety climate between two populations of hospitals in the United States.

October 14, 2009

Designing an abstraction instrument: lessons from efforts to validate the AHRQ Patient Safety Indicators.

January 12, 2011

Consensus building for development of outpatient adverse drug event triggers.

June 15, 2011

The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries.

April 27, 2011

Team-training in healthcare: a narrative synthesis of the literature.

March 12, 2014

Development and testing of tools to detect ambulatory surgical adverse events.

June 5, 2013

Improving patient care through leadership engagement with frontline staff: a Department of Veterans Affairs case study.

July 31, 2013

Examining the impact of the AHRQ Patient Safety Indicators (PSIs) on the Veterans Health Administration: the case of readmissions.

October 17, 2012

Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their contribution to postoperative outcomes.

March 6, 2019

Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine.

May 3, 2017

Improving admission medication reconciliation with pharmacists or pharmacy technicians in the emergency department: a randomised controlled trial.

November 8, 2017

Identifying risks and opportunities in outpatient surgical patient safety: a qualitative analysis of Veterans Health Administration staff perceptions.

January 31, 2018

Effects of resident duty hour reform on surgical and procedural patient safety indicators among hospitalized Veterans Health Administration and Medicare patients.

July 1, 2009

Relationship of hospital organizational culture to patient safety climate in the Veterans Health Administration.

March 25, 2009

Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey.

September 26, 2007

Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform.

September 12, 2007

Related Resources

Safety and Human Performance in the Operating Room and Other Extreme Environments.

March 27, 2024

Remote assessment of real-world surgical safety checklist performance using the OR Black Box: a multi-institutional evaluation.

March 20, 2024

Creating a just culture in the perioperative setting.

March 13, 2024

The ritualisation of the surgical safety checklist and its decoupling from patient safety goals.

March 13, 2024

Time for prefilled syringes - everywhere.

March 13, 2024

WebM&M Cases

Airway Obstruction during Anterior Cervical Spine Surgery

February 28, 2024

WebM&M Cases

When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy

February 28, 2024

Peer support and second victim programs for anesthesia professionals involved in stressful or traumatic clinical events.

February 21, 2024

Three quarters of preventable patient harm stems from situation awareness breakdowns: recognizing and addressing the core issue.

February 21, 2024

Handbook of Perioperative and Procedural Patient Safety.

February 7, 2024

Taking up the challenge to improve name and role recognition in the operating room.

February 7, 2024

Psychological safety and hierarchy in operating room debriefing: reflexive thematic analysis.

January 31, 2024

WebM&M Cases

Syringe Swap During Regional Block: A Case of Medication Error and Recovery.

January 31, 2024

Surgical safety does not happen by accident: learning from perioperative near miss case studies.

January 24, 2024

Patient Safety Primers

Retained Surgical Items: Definition and Epidemiology.

January 4, 2024

Research from webAIRS incident reporting system.

November 29, 2023

Facilitators and barriers to the implementation of surgical safety checklist (SSC): an integrative review.

November 15, 2023

Anesthesia workspaces for safe medication practices: design guidelines.

November 15, 2023

Technology, Education and Safety

November 15, 2023

Beyond the surgical safety checklist: using intraoperative handoff to facilitate team situation awareness in the OR.

October 25, 2023

CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity.

October 18, 2023

Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions.

October 11, 2023

Surgeons' leadership style and team behavior in the hybrid operating room: prospective cohort study.

October 4, 2023

Standardization and visualization of the surgical time-out.

October 4, 2023

Fire safety in the operating room.

October 1, 2023

Barriers and facilitators associated with the implementation of surgical safety checklists: a qualitative systematic review.

September 27, 2023

Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists.

August 23, 2023

Implementation of barcode medication administration (BMCA) technology on infusion pumps in the operating rooms.

August 9, 2023

Guidelines on Human Factors in Critical Situations 2023.

August 9, 2023

The things we carry: the scope and impact of second victim syndrome.

August 2, 2023

See More About The Topic

Perioperative team-based morbidity and mortality conferences: a systematic review of the literature.

Retained Surgical Items: Definition and Epidemiology.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Perioperative team-based morbidity and mortality conferences: a systematic review of the literature.

Retained Surgical Items: Definition and Epidemiology.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site