Mortality Conference Research Articles

11145 Considering the Full Picture: Addressing Bias in Gynecology Morbidity & Mortality Conference

11145 Considering the Full Picture: Addressing Bias in Gynecology Morbidity & Mortality Conference

Using Mortality and Morbidity Conferences in Advanced Practice Nurse Education to Enhance Student Self-Efficacy.

The integration of morbidity and mortality (M and M) conferences into advanced practice nurse (APN) nursing curricula is a novel approach aimed at enhancing education, reflective learning, and continuous improvement. M and M conferences have traditionally been a standard practice for medical specialties, yet a gap exists in their utilization within APN education. A quasiexperimental pilot study with 20 student registered nurse anesthetists was conducted at a large urban academic center. The General Self-Efficacy Scale was utilized to evaluate student self-efficacy and confidence in managing adverse events. Significant improvement in self-efficacy scores (p = .003) postintervention indicated the educational benefits of M and M conferences. All participants reported increased confidence in navigating unexpected events. The M and M conference is a valuable tool within APN education for cultivating self-efficacy and confidence in navigating adverse events. [J Nurs Educ. 2024;63(X):XXX-XXX.].

Beyond Morbidity and Mortality Conference: How Do We Learn From Special Cases?

Physicians experience scary cases in the course of usual medical practice. Cases of near misses, legal and ethical dilemmas, or unique clinical challenges are great sources of education. However, there is no format for presentation and dissemination of cases that do not meet criteria for morbidity and mortality (M&M) conferences. The Scary Cases Conference is an innovative educational forum for scrutiny and analysis of these challenging clinical cases. Scary Cases differs from traditional Morbidity and Mortality conferences as it explores outcomes beyond the scope of medical or surgical errors. From 2011 to 2021: 11 regional and 10 national "Otolaryngology Scary Cases" conferences and mini-seminars were held. The cases presented were analyzed for case specialty, area of management deemed troublesome, and compared to M&M conference criteria. 187 cases were presented. 62% percent of cases included traditional medical problems, whereas 21% involved legal issues, and 17% focused on ethical dilemmas. For the cases with medical problems, 31% involved airway obstruction, 17% nerve injuries, and 17% malignancy. 49% of cases would have met criteria for presentation at traditional M&M conferences. Of all the "scary cases," 25% were near misses and 26% represented ethical or legal dilemmas which would not be classified as morbitidy, mortality, or near miss. The Scary Cases provides a forum conducive to learning amongst peers and experts. It allows medical and surgical specialties to share the cases deemed most impactful. The M&M conference would only include half of such cases, but could be expanded beyond the traditional scope in the future.

Quality assessment conferences in surgery

Surgical complications are preventable in up to 50% of cases, actually are various tools to avoid them, one of these are morbidity and mortality conferences. However, there are no guides that define their structure for them to be effective. Objective; Analyze the impact of a new modality of surgical conferences in a sector of benign biliary pathology, called quality evaluation conferences. Methodology: Descriptive observational study where the overall improvement of the sector, the decrease in complications and the quality of patient care are compared. For 6 months, a weekly quality evaluation conference was carried out. It had 5 stages; 1. Analysis of all discharged patients. 2. Review of adverse events. 3. Review of the list and order of patients in the surgical plan. 4. Reproduction of recorded surgeries and review of scientific articles. 5. Review of own scientific works in development. after implementing the conferences, there was a decrease in the number and severity of complications, as well as an improvement in the correct and timely surgical indication. Conclusion; Quality evaluation workshops as an evolution of morbidity and mortality workshops are a novel tool that, when well implemented, can help improve quality standards and in turn be used as a learning option in training centers.

Organization of abdominal emergency surgical care across healthcare services in Senegal: a cross-sectional nationwide survey

IntroductionStudying surgical services and the workforce in sub-Saharan Africa is crucial for enhancing access to quality surgical care in the region. Despite many recommendations to produce evidence based on reliable data on this subject to guide policymakers, there is still a knowledge gap on this topic. The aim of this nationwide survey was to describe the organization of abdominal emergency surgical care across healthcare services in Senegal.MethodologyThis was a cross-sectional nationwide survey. The study period was between October 1st, 2023, and January 20th, 2024. The target population included all registered healthcare facilities in Senegal offering emergency surgical services. A structured questionnaire was designed to gather infrastructure-related data, surgical activities, and human resources.ResultsAll 33 identified healthcare facilities responded to the survey (100%). Emergency abdominal surgery services were available for 96.7% of the surveyed structures. The teams were mainly composed of surgeons and residents (45.2%) or surgeons and medical trainees (48.8%). The average bed capacity of the services was 21.9, with a standard deviation of 13.9. The absence of a dedicated hospitalization section for patients requiring special monitoring was found in 69.6% of the facilities. Operating rooms dedicated to emergency abdominal digestive surgery were present in 54.6% of the services. On average, the services performed 17.6 scheduled surgical interventions with a standard deviation of 11.5 and 29.7 emergency surgical interventions with a standard deviation of 16.8 per month. Morbidity and mortality conferences were not routinely held in the majority of departments (only 27.3%). Professional development programmes were present only in 24.2% of departments. Most of the departments did not have adequate human resources (69.6%). A total of 70 surgeons were identified, resulting in a national ratio of 0.39 general surgeons per 100,000 inhabitants. The strategies employed to address staff shortages included additional working hour by staff (54.5%), temporary workers (30.3%) or the use of trainee doctors or nurses (12.1%).ConclusionThis research shows that significant deficiencies are present in the essential physical and human resources needed to conduct fundamental life-saving surgical procedures. These findings suggest potential areas for improvement in the delivery of emergency surgical care in the region.

Surgeon Perception and Attitude Towards the Moral Imperative of Institutionally Addressing Second-Victim Syndrome in Surgery.

Second victim syndrome (SVS) is described as when health care providers encounter significant moral distress after traumatic patient care events. Although broadly recognized in medicine, this remains underrecognized in surgery and no systemic approaches exist to mitigate potential harms of SVS amongst surgeons. When SVS is left unaddressed, surgeons not only suffer personal psychological harm but their ability to care for future patients can also be compromised. The aim was to examine surgeons' perceptions and attitudes regarding mitigation of SVS. This study was conducted at a tertiary-care university hospital using a mixed-methods approach coupling quantitative and qualitative assessments including a 13-item survey, follow-up focus group, and semi-structured interviews The Wilcoxon signed-rank test was used for quantitative analysis and content analysis used to report qualitative findings. Surgeons believe SVS is a universal experience amongst surgeons that healthcare institutions have a moral obligation to address. Surgeons further believe that any effective mitigation strategy must receive legal protection similar to morbidity and mortality (M&M) conferences. The culture, tenor, and tone of review processes after surgical complications can either reduce or exacerbate the burden of SVS. Successful interventions must be easily accessible, voluntary, and culturally acceptable. Furthermore, surgeons may suffer greater SVS compared with non-procedural physicians as adverse events can be inevitable in operation and may potentially be a high frequency outcome depending on patient population. Surgeons agreed that healthcare organizations have a moral imperative to assist surgeons in navigating the psychosocial impacts of SVS after adverse surgical outcomes. The success of mitigation strategies was viewed as ethically relevant to patients and surgeons and dependent on the culture, tenor, and tone of the process.

Preventability of injury-related morbidity & mortality at four hospitals in Cameroon: A systematic approach to trauma quality improvement.

Adverse events reviews are a fundamental component of trauma quality improvement (QI) that facilitate the correction of systemic issues in care. Although injury-related mortality in Cameroon is substantial, to our knowledge, opportunities for QI have not been formally assessed. Thus, a formal review of adverse events in Cameroonian trauma patients was implemented as a first step toward identifying targets for systems modification. A QI committee composed of multidisciplinary experts at four hospitals in Cameroon was formed to review adverse events including deaths among trauma patients from 2019 to 2021. Events were discussed at newly established morbidity and mortality conferences and committee meetings to identify contributing factors and overall preventability. During 50 meetings, 95 adverse events were reviewed, including 58 deaths (61%). Other adverse events were delays in diagnosis/treatment (22%) and surgical site infections (17%). Overall, 34 deaths (59%) were classified as preventable, 21% potentially preventable, and 21% not preventable. Over half (52%) of the 46 preventable or potentially preventable deaths occurred in the emergency department (ED); while brain injury (57%), respiratory failure (41%), and hemorrhage (39%) were the most frequent physiologic factors associated with mortality. Contributory factors identified include lack of a structured approach to patient management, absence of continuous training for personnel, and locally adapted protocols. Basic improvements in evaluation and management of life-threatening issues in the ED can significantly reduce the high rate of preventable trauma-related deaths across Cameroon. Formal trauma QI methods can be utilized in low-resource environments to determine mortality root causes and identify intervention targets.

Treatment Terminations During Radiation Therapy: A 10-Year Experience

Patients undergoing radiation therapy may terminate treatment for any number of reasons. The incidence of treatment termination (TT) during radiation therapy has not been studied. Herein we present a cohort of TT at a large multi-center radiation oncology department over 10 years. TTs between 1/2013 and 1/2023 were prospectively analyzed as part of an ongoing departmental quality and safety program. TT was defined as any premature discontinuation of therapy after initiating radiation planning. The rate of TT was calculated as a percentage of all patients starting radiation planning. All cases were presented at monthly morbidity and mortality (MM) conferences with a root cause reviewed (RCA). A total of 1,448 TTs were identified out of 31,199 planned courses of care (4.6%). Six hundred eighty-six (47.4%) involved patients treated with curative intent, while 753 (52.0%) with palliative intent, and 9 (0.6%) for benign disease. The rate of TT decreased from 8.49% in 2013 to 3.02% in 2022 with rates decreasing yearly. The most common disease sites for TT were CNS (21.7%), H&N (19.3%), Thorax (17.5%), and Bone (14.2%). The most common causes of TT were hospice and/or patient expiration (35.9%), patient choice unrelated to toxicity (35.2%), and clinician choice unrelated to toxicity (11.5%). This 10-year prospective review of TTs identified a year-over-year decrease in TTs as a percentage of planned patients. This decrease may be associated with the addition of RCA for TTs and discussion monthly at MM rounds, coupled with departmental upstream quality initiatives implemented over time. Understanding the reasons behind TTs may help to decrease preventable TTs. While some TTs may be unavoidable, open discourse and quality improvement changes effectively reduce TT incidents over time.

Effectiveness of the uChicago Health Inequity Classification System on surgical morbidity and mortality conference: A pilot study

BackgroundAcross surgery, marginalized individuals experience worse postoperative outcomes. These disparities stem from the interplay between multiple factors. MethodsWe introduced a novel framework to assess the role of barriers to access and bias in surgical complications (the uChicago Health Inequity Classification System, CHI-CS) in the setting of morbidity and mortality conference and assessed impact through pre and post implementation surveys. ResultsAccess and bias were related to surgical complications in 14 ​% of cases. 97 ​% reported enhanced M&M presentations with the grading system, and 47 ​% reported a change in decision-making or practice style. Although post-implementation response rate was low, there were improvements in self-reported confidence and comfort in recognizing and discussing these issues. ConclusionsImplementation of the CHI-CS framework to discuss bias and access to care positively impacted the way providers view, discuss, and process health inequities.

From Reporting to Improving: How Root Cause Analysis in Teams Shape Patient Safety Culture.

Given the increasing focus on patient safety in healthcare systems worldwide, understanding the impact of Continuous Quality Improvement Programs (QIPs) is crucial. QIPs, including Morbidity and Mortality Conferences (MMCs) and Experience Feedback Committees (EFCs), have been identified as effective strategies for enhancing patient safety culture. These programs engage healthcare professionals in the identification and analysis of adverse events to foster a culture of safety (ie the product of individual and group value, attitudes, and perceptions about quality and safety). This study aimed to determine whether patient safety culture differed regarding care provider participation in MMCs and EFCs activities. A cross-sectional web-only survey was conducted in 2022 using the Hospital Survey on Patient Safety Culture (HSOPS) among 4780 employees at an 1836-bed, university-affiliated hospital in France. We quantified the mean differences in the 12 HSOPS dimension scores according to MMCs and EFCs participation, using Cohen d effect size. We performed a multivariate analysis of variance to examine differences in dimension scores after adjusting for background characteristics. Of 4780 eligible employees, 1457 (30.5%) participated in the study. Among the respondents, 571 (39.2%) participated in MMCs or EFCs activities. Participants engaged in MMCs or EFCs reported significantly higher scores in six out of twelve HSOPS dimensions, particularly in "Nonpunitive response to error", "Feedback and communication about error", and "Organizational learning" (Overall effect size = 0.14, 95% confidence interval = 0.11 to 0.17, P<0.001). Notably, involvement in both MMCs and EFCs was associated with higher improvements in patient safety culture compared to non-participation or singular involvement in either program. However, certain dimensions such as "Staffing", "Hospital management support", and "Hospital handoffs and transition" showed no significant association with MMCs or EFCs participation, highlighting broader systemic challenges. The study confirms the positive association between participation in MMCs or EFCs and an enhanced culture of patient safety, emphasizing the importance of such programs in fostering an environment conducive to learning, communication, and nonpunitive responses to errors. While MMCs or EFCs are effective in promoting certain aspects of patient safety culture, addressing broader systemic challenges remains crucial for comprehensive improvements in patient safety.

Rethinking the Gastroenterology Morbidity and Mortality Conference: Insights From a Scoping Review

Rethinking the Gastroenterology Morbidity and Mortality Conference: Insights From a Scoping Review

Teaching Diversity, Equity, and Inclusion and Health Disparities in Radiology Through a Morbidity and Mortality Conference Framework

Teaching Diversity, Equity, and Inclusion and Health Disparities in Radiology Through a Morbidity and Mortality Conference Framework

Morbidity and Mortality Conferences in Internal Medicine Specialty Training in Japan: A Nationwide Cross-sectional Study.

Objective This study evaluated the implementation status of morbidity and mortality conferences in internal medicine specialty training programs in Japan. Methods This cross-sectional study surveyed hospitals in Japan with certified internal medicine specialty training programs. Program directors or equivalently responsible physicians managing certified internal medicine training programs were invited to participate in this study (n=619). Materials Data were collected using an online questionnaire that included questions about the number of morbidity and mortality conferences, types of cases covered, collaboration of the patient safety section and other health professions, and whether or not the conferences were conducted by a subspecialty department-led or program-based. Results Responses were received from 123 hospitals (19.8% response rate), of which 59 (48%) had some form of internal medicine morbidity and mortality conference in place. The average number per year was 9.63 (standard deviation: 18.12). Hospitals with morbidity and mortality conferences in subspecialty departments held significantly more conferences than X (please define X). Furthermore, the involvement of the patient safety department tended to be associated with holding more conferences. Autopsy rates were significantly higher in hospitals with program-based internal medicine morbidity and mortality conferences than subspecialty-led. Conclusion Internal medicine specialty training hospitals had more morbidity and mortality conferences than previously reported. Program-based morbidity and mortality conferences in internal medicine are associated with higher autopsy rates and may lead to an organizational reporting culture and lifelong learning attitudes that support patient safety. Collaboration with organizational management sections, such as patient safety, would be effective in implementing these conferences in internal medicine training programs.

427 Optimization of Morbidity and Mortality Conference: Results of a Multi-center Pilot at Neurosurgical Training Programs

INTRODUCTION: Neurosurgical morbidity and mortality (M&amp;M) conference is essential to resident education and to quality control. Training programs use different methods for executing the conference, with variability in presentation format, case inclusion criteria, adjudication of findings, and follow-up strategy. Optimal format for this conference is debated. METHODS: Ten ACGME-accredited neurosurgical training programs participated in a 3-month pilot to optimize M&amp;M conference. A standardized format was implemented, using a broadly inclusive strategy for case selection, with morbidities selected by residents. Each neurosurgical complication was defined, in group discussion, according to type of error: indication; technique; procedure; judgment; nature of disease. Follow-up intervention was drafted for each case. Surveys were distributed to trainees and attending neurosurgeons before and after the pilot to assess the new format compared to historical standard. RESULTS: A total of 302 surveys were returned from attending and resident physicians. Seventy-four % of respondents found the new format to be an improvement (“slightly improved” or “much improved”) and Eight-five % expressed preference for the new standardized format. Fifty-two % of resident respondents believed engagement at the conference was increased. Twenty-six % responded that significant process improvements resulted from the standardized format. CONCLUSIONS: This 3-month pilot to optimize neurosurgical M&amp;M conference, undertaken at ten neurosurgery training programs, received favorable reviews by survey. Respondents endorsed high levels of faculty &amp; resident engagement. Case categorization by error was favorably reviewed. Significant process improvements were only noted by a minority of respondents, however, perhaps related to the short duration of the pilot. Overall these results suggest that future amplification of a standardized M&amp;M format across neurosurgical training programs could yield high satisfaction and enhanced resident engagement. Additional attention focused on process improvement will be critical.

Interprofessional Collaborative Practice in Professional and Residency Athletic Training Programs: A Report from the Association of Athletic Training Education Research Network

Context Interprofessional collaborative practice (IPCP) is a required component of athletic training education, yet more needs to be learned about how professional and residency programs integrate IPCP into their curricula. Objective Identify current strategies used in the integration, assessment, and quality of IPCP clinical experiences in athletic training programs. Design Cross-sectional survey. Patients or Other Participants Forty-two of the 288 (14.6% response rate) invited individuals participated. All reported being faculty members affiliated with a professional or residency athletic training program. Data Collection and Analysis The IPCP implementation and assessment was e-mailed to all accredited professional and residency program directors to evaluate: (1) institutional or organizational support for and integration of IPCP; (2) faculty, learner, or preceptor preparation for IPCP engagement; and (3) tools for assessment and quality of IPCP experiences. Survey instrumentation was validated through peer and expert review. Descriptive statistics were calculated for quantitative data, and open coding was used to analyze open-ended questions. Results Respondents reported favorable support from their institution or organization (administrative, financial, and organizational structure) to integrate IPCP experiences. The most common methods for IPCP implementation included clinical simulations (n = 22, 22.9%), grand rounds (n = 13, 13.5%), morbidity and mortality conferences (n = 3, 3.1%), journal clubs (n = 6, 6.3%), direct patient care (n = 14, 14.9%), and intentional clinical education experiences (n = 28, 29.2%). Respondents reported formal IPCP training for faculty (n = 7, 16.7%) and learners (n = 23, 54.8%) but not for preceptors (n = 25, 73.5%). While programs assess their learners’ IPCP experiences (n = 25, 59.5%), the quality of those experiences is not formally captured (n = 19, 45.2%). Conclusion(s) Interprofessional collaborative practice experiences within athletic training education continue to evolve. As such, in this study, we highlight the need for formalized training in IPCP for faculty, learners, and preceptors. Additionally, program faculty should consider implementing quality assessments of IPCP experiences to assess the quality and degree to which learners experience interprofessional collaboration.

Reframing the Morbidity and Mortality Conference: The Impact of a Just Culture.

Morbidity and mortality (M&M) conferences are prevalent in all fields of medicine. Historically, they arose out a desire to improve medical care. Nevertheless, the goals of M&M conferences are often poorly defined, at odds with one another, and do not support a just culture. We differentiate among the various possible goals of an M&M and review the literature for strategies that have been shown to achieve these goals. Based on the literature, we outline an ideal M&M structure within the context of just culture: The process starts with robust adverse event and near miss reporting, followed by careful case selection, excluding cases solely attributable to individual error. Prior to the M&M, the case should be openly discussed with involved members and should be reviewed using a selected framework. The goal of the M&M should be selected and clearly defined, and the presentation format and rules of conduct should all conform to the selected presentation goal. The audience should ideally be multidisciplinary and multispecialty. The M&M should conclude with concrete tasks and assigned follow-up. The entire process should be conducted in a peer review protected format within an environment promoting psychological safety. We conclude with future directions for M&Ms.

Enhancing patient safety: a system-based analysis of morbidity and mortality conferences in managing postoperative bleeding following gastric and pancreatic cancer surgery

Morbidity and mortality conferences (MMCs) have evolved beyond their traditional educational role to become instrumental in enhancing patient safety. System-based MMCs offer a unique perspective on patient safety by dissecting...

A case of late-onset bleeding from an intercostal artery pseudoaneurysm after hemostasis using soft coagulation

BackgroundThe use of soft coagulation is becoming common in thoracic surgery. Soft coagulation provides rapid hemostasis from small vessels during surgery by dehydrating tissue and denaturing proteins, without burning the tissue.Case presentationA 68-year-old man, with a history of right lower lobectomy 3 years prior, underwent a partial resection of the right upper lobe for a pulmonary nodule suspicious for secondary lung cancer. During the surgery, dissection of the adhesion caused a bleeding from the 6th intercostal artery, and hemostasis was achieved using soft coagulation (some degree of tissue carbonization was noticed at later mortality and morbidity conference). He experienced hemoptysis at postoperative day 18 and was transferred to our hospital. Contrast-enhanced CT scan revealed bleeding from the pseudoaneurysm of the 6th intercostal artery. Embolization was performed by angiography to stop the bleeding.ConclusionsWe experienced a case of late-onset bleeding from a pseudoaneurysm related to soft coagulation hemostasis. Lessons learned from this patient are that additional hemostasis, such as ligation, would be considered for small arteries after hemostasis has been achieved by soft coagulation, especially when some degree of tissue carbonization is suspected.

Real-Time Reporting of Complications in Hospitalized Surgical Patients by Surgical Team Members Using a Smartphone Application

The surgical morbidity and mortality (M&M) conference is a vital part of a resident's surgical education, but methods to collect and store M&M data are often rudimentary and unreliable. The authors propose a Health Insurance Portability and Accountability Act (HIPAA)-compliant, electronic health record (EHR)-connected application and database to report and store complication data. The app is linked to the patient's EHR, and as a result, basic data on each surgical case-including diagnosis, surgery type, and surgeon-are automatically uploaded to the app. In addition, all data are stored in a secure SQL database-with communications between the app and the database end-to-end encrypted for HIPAA compliance. The full surgical team has access to the app, democratizing complications reporting and allowing for reporting in both the inpatient and outpatient settings. This complication information can then be automatically pulled from the app with a premade presentation for the M&M conference. The data can also be accessed by a Power BI dashboard, allowing for easy quality improvement analyses. When implemented, the app improved data collection for the M&M conference while providing a database for institutional quality improvement use. The authors also identified additional utility of the app, including ensuring appropriate revenue capture. The general appearance of the app and the dashboard can be found in the article. The app developed in this project significantly improves on more common methods for M&M conference complication reporting-transforming M&M data into a valuable resource for resident education and quality improvement.

An Electronic Health Record-integrated Web Application Augments a QI-directed Morbidity & Mortality Conference and Improves Quality of Care

BackgroundIn 2014, we developed a QI-directed Morbidity and Mortality (M&M) Conference, prioritizing discussion of individual and system failures, as well as development of action items to prevent failure recurrence. However, due to a reliance on individual electronic documents to store M&M data, our ability to assess trends in failures and action item implementation was hindered. To address this issue, in 2019, we created a secure electronic health record (EHR)-integrated web application (web app) to store M&M data. Study designIn this study, we assessed the impact of our web app on efficient review and tracking of M&M data, including system failure occurrence and closure of action items. Additionally, in 2021, it was discovered that a backlog of action items existed. To address this issue, we implemented a QI initiative to reduce the backlog, and used the web app to compare action item closure over time. ResultsUse of the web app dramatically improved review of M&M data. During the study period, there was a 67.0% reduction in the occurrence of the most common system failures. Additionally, our QI initiative resulted in a 97.7% reduction in the duration of time to complete a single action item and a 61.1% increase in the on-time closure rate for action items. ConclusionsIntegration of a web app into a QI-directed M&M Conference enhanced our ability to track system level failures and action item closure over time. Using this web app, we demonstrated that our M&M Conference achieved its intended goal of improving the quality of patient care. Level of EvidenceIV.