The Morbidity and Mortality Conference (MMC) in Oncology: A patient safety and root cause analysis (RCA)-driven approach at the Cleveland Clinic Taussig Cancer Institute (TCI).

Abstract

191 Background: MMC has been traditionally viewed as an educational tool. However, negative associations with MMC include emphasis on individual error and assigning blame, with little attention to improving patient safety and quality of care. MMC at the TCI has been designed to provide an opportunity to discuss MMC cases in an open, non-judgmental setting. Methods: Since September 2013, a monthly MMC, open to all caregivers, not just physicians, has been held as part of CME certified oncology grand rounds. Two cases are discussed per session and are obtained from nursing, pharmacy, and physician recommendation through the hospital Safety Event Reporting System or direct communication. Fellows investigate and present cases with patient and provider information de-identified to assure the discussion occurs in a blame-free setting. RCA is performed to determine action items. Process and safety improvements are recommended where applicable. Ongoing follow-up and improvement tracking is reported at future MMCs. The MMC governance committee, composed of the TCI quality officer, quality director, fellow representative, and a multi-disciplinary group of providers, meets quarterly to review cases and follow up action items under the guidance of the TCI MMC charter. The MMC governance committee reports to the TCI Quality Steering Committee. Results: Cases reviewed to date include chemotherapy dosing/administration errors (23%), hospital acquired medical complications (31%), communication breakdown between caregivers (15%), and end of life care (31%). An average of 3.5 action items has resulted from each case with 75% addressed within 90 days. Physician attendance is 59% higher and 23% more physicians report that they are very likely to change their practice behaviors from MMC than other grand rounds presentations. Conclusions: A patient safety driven MMC, delivered in an open setting, can be an effective tool to improve quality of care and caregiver communication in a large academic cancer center. High provider attendance and survey feedback reflects engagement in the process and will be essential to sustaining a meaningful and productive MMC.