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Using the Mortality and Morbidity Conference to Improve Patient Safety

Using the Mortality and Morbidity Conference to Improve Patient Safety. Karen Cosby MD Cook County Hospital/Rush Medical College ICEP Academic Forum. What is M&M?. Someone dies Something bad happens Someone does something wrong Assumption: There was an “error” It was “preventable”.

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Using the Mortality and Morbidity Conference to Improve Patient Safety

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  1. Using the Mortality and Morbidity Conference to Improve Patient Safety Karen Cosby MD Cook County Hospital/Rush Medical College ICEP Academic Forum

  2. What is M&M? • Someone dies • Something bad happens • Someone does something wrong • Assumption: • There was an “error” • It was “preventable”

  3. Why do we have M&M Conference? • It’s tradition! • It’s honorable • It’s good for education • It looks good for QA

  4. What is the goal of M&M? • Education: A case conference with: • mystery, intrigue, suspense! • Learn from our mistakes • Educate new trainees • Teach accountability

  5. Accounts for failures Teach accountability Education: the best teaching hour in curriculum Sometimes results in shame Sometimes, a hazing ritual. Education is only part of the potential of M&M Traditional M&M Conferences

  6. Tradition isn’t Everything • The Traditional M&M fails to realize it’s full potential • There is more to be gained….

  7. The Enlightened Approach to M&M“The DISSIS Approach” • D = Discovery • I = Insight • S = Strategies • S = Solutions • I = Improvement • S = Satisfaction

  8. The Enlightened M&M Model • Acknowledges complexity • Identifies human and system factors • Encourages open discussion • Actively seeks solutions

  9. Discovery • Investigate • Discuss and Probe • Allow new facts to surface • Appreciate complexity of case • Include cognitive and system factors to be discovered

  10. The Question of Anonymity: ?Benefits • Protective • Preserves Self-Esteem • May remove defensive nature

  11. The Problem with Anonymity • Limits fact finding and discovery • Limits insight • Encourages secrecy • Adds to shame, fear • Limits problem-solving

  12. Exposing the Clinician Who Erred • Allows conversation • Provides a more balanced view of the error (for audience and clinician) • Audience can help moderate tendency toward maladaptive behavior • There is some opportunity for absolution

  13. Insight: The “Aha!” Moment • Full discovery of facts • Audience discussion • Expand audience to cross disciplines and roles • May provide the best learning opportunity

  14. Insanity: Doing the same thing over and over again and expecting different results. Albert Einstein (attributed)

  15. Strategies and Solutions • How can we do better? • Each case should have: • A lesson for medical decision-making • A system problem to pursue • A plan

  16. Optimizing M&M Conference to Drive Improvement • Use Group Dynamics to solve problem • Fresh ideas • Creative solutions • Forge alliances • Promote teamwork • Foster collaborative spirit • An “expert” to offer guidance and advice

  17. Optimizing the M&M Conference to Drive Improvement • Identify System Factors in every case • Can you design a system that could help another person avoid the same error?

  18. When the problems are really big… • M&M can serve as a meeting ground • Neutral academic setting • Fascinating case discussion • Allows heroes to emerge: • new policy • new agreements

  19. The Multidisciplinary M&M • Target and assemble the right audience: power players who can make change • Collect the cases: • 1 case is interesting • 2 cases seem like bad luck • 3 cases make a pattern that can’t be ignored • State the problem • Ask for a solution!

  20. Special Cases: Better by Design • Multidisciplinary M&MS: • Ectopic • RLQ pain in women • Aortic dissections • Abdominal pain in the elderly • Look for the problem in YOUR institution

  21. Improvement • State what’s been done to address issues. • Existing problems that need fresh solutions • Recruit your audience to find solutions • Changes role of the individual from passive, enduring punishment to active problem-solver.

  22. Satisfaction • There is nothing more painful than the shame of failure made public • There is nothing more invigorating than meeting a challenge and solving a tough problem

  23. M&M Can Be: • A rational approach to solving real problems • Done well it will : • Provide good medical education • Give insight • Find creative solutions to real problems. • Teach clinicians a healthy approach to managing medical error.

  24. Long Term Gain • Traditional M&M teaches accountability, but creates shame. • The Enlightened M&M teaches life-long strategy for dealing with error, a healthy constructive approach to real life practice. • One approach documents error; the other changes things for the better.

  25. “Failure is not an option” Gene Kranz

  26. Every failure is an opportunity for improvement

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