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- Communication Improvement 1
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- Error Reporting and Analysis
- Logistical Approaches 1
- Quality Improvement Strategies 1
- Specialization of Care 1
- Technologic Approaches 1
Search results for "Morbidity and Mortality Conferences"
- Clinical Misdiagnosis
- Morbidity and Mortality Conferences
Journal Article > Study
Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.
Patient safety in trauma poses unique challenges given the acuity of the patients and the need for rapid assessment in delivering life-saving care. This study analyzed more than 2500 complications discussed at morbidity and mortality (M&M) conferences to characterize their preventability and clinical relevance. Investigators discovered that the complications ripe for quality improvement initiatives included unintended extubations, surgical technical failures, missed injuries, and intravascular catheter-related complications. An invited critique [see link below] reflects on the study's findings and points out the challenges in reporting performance data without needed standardization. A past AHRQ WebM&M commentary discussed the systematic assessment of trauma patients in the context of a missed patient injury.
Cases & Commentaries
- Spotlight Case
- Web M&M
Lisa M. Bellini, MD; February 2004
Housestaff evaluate and admit a severely ill patient with lupus, suspect a viral syndrome, and do not initiate antibiotics. Despite discovery of the correct diagnosis in the morning by the attending, the patient dies.