Characterization and evaluation of a pharmacy morbidity, mortality, and improvement case conference for drug safety optimization: An 8‐year experience

Abstract

AbstractIntroductionTraditional morbidity and mortality conferences focus on clinical decision‐making rather than process improvement (PI) and patient safety. A local pharmacy morbidity, mortality, and improvement (MMI) program evolved didactic clinical case presentations into an action‐oriented, resident‐led, case‐based PI learning experience to enhance the institutional patient safety culture.ObjectivesThe purpose of this report is to describe a pharmacy‐led MMI program including the overall MMI process, characterization of drug errors evaluated, and review of drug use process optimizations.MethodsA narrative review of the MMI process was performed including retrospective characterization of errors and PIs identified from patient safety events presented between June 2013 and August 2021. Errors were classified per the American Society of Health‐System Pharmacists (ASHP) Guidelines on Preventing Medication Errors in Hospitals and the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Medication Error Index. PI strategies were qualitatively and quantitatively described.ResultsImplementation and evolution of MMI over 8 years resulted in consistent error classification, PI interventions across the drug use process, and numerous patient safety continuing education (CE) offerings. Ninety‐seven (80.3%) events completed all MMI components. The majority of events occurred in the emergency department/intensive care unit (42 [43%]) or medical‐surgical floor (36 [37%]). A median of two (interquartile range [IQR] 1‐3) steps in the drug use process contributed to the event. ASHP level 4 (32 [33%]) and NCC MERP category D (22 [21%]) were the most common classifications; NCC MERP error without harm (51 [53%]) had the highest incidence. A total of 163 PI initiatives were identified (median 2 [IQR 1‐2] per case) with 76 (78%) including high‐impact areas such as high‐alert drugs and transitions of care. A total of 606.5 CE hours were awarded.ConclusionThe pharmacy‐led MMI program is an effective and innovative opportunity to enhance patient safety and improve the drug use process.