Search results for "Hospitals"

Morbidity and mortality rounds have evolved to incorporate patient safety concepts. This review examined how morbidity and mortality rounds have been designed and used. The authors recommend tactics such as engaging a range of professional groups and presenting errors as opportunities for learning to contribute to system improvement.

Morbidity and mortality (M&M) conferences were traditionally promoted as a strategy to learn from adverse events. This review explores the history of M&M conferences in medicine, including their use in identifying medical errors and their educational benefits. The author explains why M&M conferences that are multidisciplinary in nature and embody a blame-free approach to learning are likely to be more successful for the learner and for the organization supporting the program.

Morbidity and mortality (M&M) conferences were developed to enable clinicians to discuss and learn from adverse events. This review explores examples of M&M programs that emphasize quality improvement and a culture of safety and determined common themes, including defining the purpose and goals of the M&M conference, identifying appropriate cases, and establishing follow-up responsibilities.

Morbidity and mortality conferences are a longstanding patient safety activity. This pre–post study assessed the impact of implementing a structured method to enhance morbidity and mortality rounds. Investigators found that discussion of cognitive biases and systems issues increased following the intervention, and they recommend wider dissemination of their morbidity and mortality rounds model.

Mortality and morbidity (M&M) conferences are an established learning strategy. This commentary outlines how a hospital designed a new M&M model, implemented it system-wide, and tracked related clinical and educational improvements over a 2-year period.

Morbidity and mortality conferences are a time-tested educational strategy for patient safety. This study demonstrates that using a structured tool to facilitate systems-based learning resulted in increased resident engagement in quality improvement practices. The results demonstrate the benefits of widespread implementation of system-based morbidity and mortality conferences.

Morbidity and mortality (M&M) conferences are a classic patient safety education and feedback strategy. This study found that elements of M&M conferences, including thorough investigation of failures, predicted whether an improvement initiative was implemented. This work suggests that M&M conferences can be optimally designed to foster subsequent improvement efforts.

Traditional morbidity and mortality conferences were designed to focus on educational opportunities to learn from medical errors. In this study, introducing a structured systems-oriented morbidity and mortality conference in a pediatric intensive care unit led to higher attendance rates and more proposed local quality improvement interventions.

Mortality and morbidity (M&M) conferences are established mechanisms to investigate care failures. Describing weaknesses of the traditional M&M conference model, this commentary advocates for a proactive risk management approach that considers the preventability of error and increases the focus on analysis, feedback, and continued learning as critical elements of improvement work.

Cognitive gaps and shortcuts, or heuristics, can result in diagnostic mistakes. This commentary explores decision making in health care and suggests incorporating education about cognitive heuristics into morbidity and mortality rounds to inform improvement efforts and enhance care safety.

This survey of emergency medicine residency program directors revealed wide variability in the structure and emphasis of morbidity and mortality (M&M) conferences, a key component of patient safety training for graduate medical education. Not all conferences supported a blame-free approach to errors or included follow-up to errors, suggesting that M&M conferences could be better designed to support safety culture.

Interdisciplinary morbidity and mortality conferences were an effective way to identify system failures contributing to medical errors, in this report from a children's hospital in Switzerland. The study analyzed 48 morbidity and mortality conferences over a 5-year period and gives examples of the 34 system improvements that were put into place as a result.

Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them. This commentary discusses how the Mayo Clinic reduced never events by using a mortality-review process to identify opportunities for improvement and developing and disseminating safe practices through the organization.

Early efforts to characterize patient safety included the review of individual cases of patient deaths; mortality reviews remain a core aspect of hospital safety efforts. This study describes the implementation of an electronic tool which directly queries clinicians about specific cases of inpatient deaths. The authors determined that the tool was feasible to implement, and clinicians reported delays in accessing or responding to tests, communication barriers, and health care–associated infections as contributors to preventable inpatient mortality. When comparing clinician responses to administrative data, there was little agreement about the presence of complications, with neither source consistently identifying more complications. This work suggests that directly engaging with clinicians about inpatient mortality yields useful patient safety data beyond what chart review can provide and underscores the need to improve existing clinical documentation to support safety efforts.

This study describes the implementation of a systems-focused morbidity and mortality conference at a Veterans Health Administration medical center designed to augment patient care and promote interdisciplinary teamwork and transparency, while addressing residency requirements. The intervention demonstrated lasting improvements in systems issues, consistent with prior data using this learning format.

In this study, applying standardized chart reviews for incidents discussed during morbidity and mortality conferences in a pediatric intensive care unit uncovered many previously unrecognized safety events. Conversely, the conferences revealed near misses and diagnostic errors that were not obvious in chart documentation.

Similar to prior research in internal medicine and surgical programs, this survey study found that structure and processes of morbidity and mortality (M&M) conferences in pediatric intensive care units varied widely. Moreover, there was substantial disagreement between respondents, making it unclear whether the M&M conferences actually conform to key elements of medical incident analysis.

This qualitative study used morbidity and mortality conferences and medication safety scorecards to explore the relative impact of codified knowledge (quantitative and standardized information) and tacit knowledge (experiential) in improving safety at the organizational level.

This commentary describes how design and implementation of an institutional mortality review system evolved over 10 years. The reporting program offers insights about how to promote and enhance organizational learning.

This case series study describes 10 medication errors related to cancer treatment that were investigated using an approach incorporating root cause analysis and a morbidity and mortality conference. This process resulted in the proposal of multiple corrective actions, suggesting that it identifies actionable safety concerns.