House staff-led interdisciplinary morbidity and mortality conference promotes systematic improvement. 2017

Christopher J Tignanelli, and Genevieve G R Embree, and Amir Barzin
Department of Surgery, University of North Carolina, Chapel Hill, North Carolina. Electronic address: ctignane@med.umich.edu.

Improvements in patient safety are critical to improving clinical outcomes. We present a resident-led interdisciplinary morbidity and mortality (M&M) conference utilizing postconference task forces to identify unique system issues, classify key contributors to interdisciplinary complications, and implement systems solutions. The conference also served to facilitate resident involvement in quality improvement projects. Members of the UNC Housestaff Council designed and implemented a hospital-wide M&M conference. Cases involving two or more service lines and resulting from systematic failures were selected for presentation by an interdisciplinary group of residents involved in the patient's care. Postconference task forces addressed problems and developed initiatives to improve care. Of the 15 cases presented, 60% were attributable to an error in judgment, 26% to an error in diagnosis, and 13% to an error in technique. Communication (67%), coordination/care utilization (47%), poor process/workflow (40%), and inadequate training (33%) were the main associated contributing factors. Poor communication contributed to all complications resulting from an error in judgment. Inadequate training and poor workflow were the most common contributing factors with an error in technique. Poor utilization of care and inadequate processes were most common with an error in diagnosis. Postconference task forces identified system-based improvement projects in 73% (11 of 15) of cases with 82% (9 of 11) of projects successfully implemented or in process. House staff-led interdisciplinary M&M conference utilizing postconference task forces is an ideal setting to identify unique system issues and implement system-based improvement strategies.

UI MeSH Term Description Entries
D007396 Internship and Residency Programs of EDUCATION, MEDICAL, GRADUATE training to meet the requirements established by accrediting authorities. House Staff,Internship, Dental,Residency, Dental,Residency, Medical,Dental Internship,Dental Internships,Dental Residencies,Dental Residency,Internship,Internship, Medical,Internships, Dental,Medical Residencies,Medical Residency,Residencies, Dental,Residencies, Medical,Residency,Residency and Internship,Internships, Medical,Medical Internship,Medical Internships,Residencies,Staff, House
D009657 North Carolina State bounded on the north by Virginia, on the east and Southeast by the Atlantic Ocean, on the south by Georgia and South Carolina, and on the west by Tennessee.
D003226 Congresses as Topic Works about conferences, conventions or formal meetings usually attended by delegates representing a special field of interest. Conferences,Conference Proceedings as Topic,Conferences and Congresses,Conferences and Proceedings,Congresses and Conferences,Professional Meetings and Conferences,Congresses as Topics,Proceedings and Conferences,Topics, Congresses as
D006748 Hospital Departments Major administrative divisions of the hospital. Departments, Hospital,Department, Hospital,Hospital Department
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D058996 Quality Improvement The attainment or process of attaining a new level of performance or quality. Improvement, Quality,Improvements, Quality,Quality Improvements
D061214 Patient Safety Efforts to reduce risk, to address and reduce incidents and accidents that may negatively impact healthcare consumers. Patient Safeties,Safeties, Patient,Safety, Patient
D019300 Medical Errors Errors or mistakes committed by health professionals which result in harm to the patient. They include errors in diagnosis (DIAGNOSTIC ERRORS), errors in the administration of drugs and other medications (MEDICATION ERRORS), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings. Medical errors are differentiated from MALPRACTICE in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent. Medical Mistakes,Surgical Errors,Critical Incidents, Medical,Critical Medical Incidents,Errors, Medical,Errors, Surgical,Medical Error of Commission,Medical Error of Omission,Medical Errors of Commission,Medical Errors of Omission,Medical Mistake,Mistake, Medical,Mistakes, Medical,Never Event,Surgical Error,Wrong-Patient Surgery,Wrong-Procedure Errors,Wrong-Site Surgery,Commission Medical Error,Commission Medical Errors,Critical Incident, Medical,Critical Medical Incident,Error, Medical,Error, Surgical,Error, Wrong-Procedure,Errors, Wrong-Procedure,Event, Never,Events, Never,Incident, Critical Medical,Incident, Medical Critical,Incidents, Critical Medical,Incidents, Medical Critical,Medical Critical Incident,Medical Critical Incidents,Medical Error,Medical Incident, Critical,Medical Incidents, Critical,Never Events,Omission Medical Error,Omission Medical Errors,Surgeries, Wrong-Patient,Surgeries, Wrong-Site,Surgery, Wrong-Patient,Surgery, Wrong-Site,Wrong Patient Surgery,Wrong Procedure Errors,Wrong Site Surgery,Wrong-Patient Surgeries,Wrong-Procedure Error,Wrong-Site Surgeries
D033183 Interdisciplinary Communication Communication, in the sense of cross-fertilization of ideas, involving two or more academic disciplines (such as the disciplines that comprise the cross-disciplinary field of bioethics, including the health and biological sciences, the humanities, and the social sciences and law). Also includes differences in patterns of language usage in different academic or medical disciplines. Communication Research,Cross-Disciplinary Communication,Multidisciplinary Communication,Communication, Cross-Disciplinary,Communication, Interdisciplinary,Communication, Multidisciplinary,Communications, Cross-Disciplinary,Communications, Interdisciplinary,Communications, Multidisciplinary,Cross Disciplinary Communication,Cross-Disciplinary Communications,Interdisciplinary Communications,Multidisciplinary Communications,Research, Communication

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