Background/Purpose:

The morbidity and mortality conference (M&MC) is one of academic medicine’s most visible fora for discussion of adverse events and errors; however it is unclear whether the M&MC is effective in its role to help reduce these events and thereby improve healthcare.  In some contexts, the M&MC has been shown to be an effective forum for addressing patient safety and quality improvement competencies.  However, there is marked variability in the process and standards for the M&MC.  Little is known regarding the extent to which adverse events and errors are actually discussed in the M&MC. To describe the frequency of reported events as well as system improvement recommendations in the M&MC within the Division of Rheumatology at the Hospital for Sick Children (SickKids).

Methods:

A five-year retrospective review of the M&MC minutes within the Division of Rheumatology at SickKids was completed.  Descriptive data including the number of cases, attendance and types and location of reported events were collected.  All events were categorized using an adaptation of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index.  Recommendations were classified in the categories used by the Institute for Safe Medication Practices (ISMP) Canada.

Results:

Between January 2007 and December 2011, a total of 30 regularly scheduled M&MCs were held.  The mean attendance was 19 individuals per session.  Eighty-one cases were reviewed (mean 2.7 cases/session) with 2 reported deaths and 4 planned transfers to the intensive care unit.  The most common type of events were related to “miscommunication” (35.8% of cases) followed by events related to a treatment/test/procedure (23.5%).  There were fewer events related to medications such as adverse drug reactions (12.3%), medication administration errors (8.7%).  Most events occurred in the in-patient setting (40%) followed by the Medical Day Care Unit (26%).  Category A events (“an event that has the capacity to cause error”) were the most common (46.9%).  The next most common events were Category C events (“an event occurred that reached the patient but did not cause harm”) followed by Category E events (“an event occurred that may have contributed to or resulted in temporary harm and required intervention”) with 24.7% and 19.8% of the cases, respectively. A total of 89 recommendations were made over the 5 year period. Just over half of these were classified as “information” according to ISMP Canada (58.4%).  This was followed by 11 “rules and policies” recommendations (12.4%) and 8 “reminders, check lists and double check systems” recommendations (9%). There were 36 action items generated from these recommendations; 36% have been completed while 27.8% are ongoing. 

Conclusion:

The M&MC within the Division of Rheumatology reviews a varied number of adverse events.  Increased reporting and study of adverse events and errors can lead to system improvements and safer health care.  Further research is needed to develop innovative models of the M&MC, which focus on patient safety and systems improvement.  This could lead to the creation of a standard review process which has greater potential to improve quality of care.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/trying-to-improve-care-a-review-of-the-morbidity-and-mortality-conference-in-the-division-of-rheumotology/