56 The Impact of a Nurse Morbidity and Mortality Meeting

Abstract

Abstract Introduction Physicians have long held Morbidity and Mortality (M&M) conferences to discuss complications and deaths. The format for these conferences lays out the case, discusses care performed, and generates discussion on areas of opportunity. Physician M&M usually focuses on teaching and the presenter may not be the caregiver. There is not much literature on the use of this teaching methodology in nursing. Due to the strong culture of safety on the unit, it was determined that using a similar format for nursing on the Burn Unit could prove beneficial for discussion of complications, deaths, errors, and good catches. Methods Nurse M&M is held monthly for one hour. The nurses are given the opportunity to present the individual case or give personal testimony as to the situation from their point of view. The cases are all presented in the same format. The initial slides cover background, history of present illness, and where the report came from. Next is all of the pertinent review from the electronic charting system and any discussions had with those involved in the case. The presenter then opens up the floor for discussion. If there was a variation in practice, the policy or procedure that relates to the error is reviewed. Topics for Nurse M&M are gathered through many different venues. The hospital uses an online reporting system for electronic submission of adverse events, variations in care, and good catches. The entire multidisciplinary team have all individually reported something they wanted discussed at Nurse M&M. If clarification is needed on a case, the question is punted back to the appropriate decision maker and followed up to the staff. Results Nurse M&M is the most highly attended, non-mandatory, meeting held on the unit. The nursing staff was surveyed to determine their perceptions on how the addition of Nurse M&M had effected them. The results were overwhelmingly positive. All nurses surveyed rated the statement, “I feel that Nurse M&M has had a positive outcome on the unit’s collective practice”, as agree or strongly agree. Over time, the notes taken have evolved into a basic table of what was discussed and if there were action items created off of a case. The staff have come to the point where they will self-report events before they are entered into the online system. Conclusions In conclusion, the Burn Unit nursing staff are highly engaged Nurse M&M. The staff are open to discussing errors in a way that fosters educational growth and critical thinking development. Even if the case being discussed is because of a personal error, more often than not, the person responsible will discuss why they made the decision they did and facilitate the discussion with their peers as to what could have been done differently. The bedside nurses’ commitment to being present, engaged, and open minded are strong signs of the healthy work environment present on the unit.