Christopher J Tignanelli1, Genevieve G R Embree2, Amir Barzin3. 1. Department of Surgery, University of North Carolina, Chapel Hill, North Carolina. Electronic address: ctignane@med.umich.edu. 2. Preventive Medicine, Department of Family Medicine, University of North Carolina, Chapel Hill, North Carolina; Ambulatory Care Physician, Durham Veterans Affairs Medical Center, Durham, North Carolina. 3. Department of Family Medicine, University of North Carolina, Chapel Hill, North Carolina.
Abstract
BACKGROUND: 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. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
BACKGROUND: 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. MATERIALS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
Authors: Rosa Park; Justin Gyorfi; Kalyan Dewan; Girish Kirimanjeswara; Joseph Y Clark; Matthew G Kaag; Kathleen Lehman; Jay D Raman Journal: Int Urol Nephrol Date: 2018-07-17 Impact factor: 2.370
Authors: Alexandria J Robbins; Nicholas E Ingraham; Adam C Sheka; Kathryn M Pendleton; Rachel Morris; Alexander Rix; Victor Vakayil; Jeffrey G Chipman; Anthony Charles; Christopher J Tignanelli Journal: J Pain Symptom Manage Date: 2020-09-17 Impact factor: 3.612