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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”. - PowerPoint PPT Presentation
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Using the Mortality and Using the Mortality and Morbidity Conference to Morbidity Conference to Improve Patient SafetyImprove Patient Safety
Karen Cosby MDKaren Cosby MDCook County Hospital/Rush Medical Cook County Hospital/Rush Medical
CollegeCollegeICEP Academic ForumICEP Academic Forum
What is M&M?What is M&M?
Someone diesSomeone dies
Something bad happensSomething bad happens
Someone does something wrongSomeone does something wrong
Assumption:Assumption:– There was an “error”There was an “error”– It was “preventable”It was “preventable”
Why do we have M&M Why do we have M&M Conference?Conference?
It’s tradition!It’s tradition!
It’s honorableIt’s honorable
It’s good for educationIt’s good for education
It looks good for QAIt looks good for QA
What is the goal of M&M?What is the goal of M&M?
Education: A case conference with: Education: A case conference with: – mystery, intrigue, suspense!mystery, intrigue, suspense!
Learn from our mistakesLearn from our mistakes
Educate new traineesEducate new trainees
Teach accountabilityTeach accountability
Traditional M&M ConferencesTraditional M&M Conferences
Accounts for failuresAccounts for failures
Teach accountabilityTeach accountability
Education: the best Education: the best teaching hour in teaching hour in curriculumcurriculum
Sometimes results in Sometimes results in shameshame
Sometimes, a hazing Sometimes, a hazing ritual. ritual.
Education is only part Education is only part of the potential of of the potential of M&MM&M
Tradition isn’t EverythingTradition isn’t Everything
The Traditional M&M fails to realize it’s full The Traditional M&M fails to realize it’s full potentialpotential
There is more to be gained….There is more to be gained….
The Enlightened Approach to M&MThe Enlightened Approach to M&M“The DISSIS Approach”“The DISSIS Approach”
D = DiscoveryD = Discovery
I = InsightI = Insight
S = StrategiesS = Strategies
S = SolutionsS = Solutions
I = ImprovementI = Improvement
S = Satisfaction S = Satisfaction
The Enlightened M&M ModelThe Enlightened M&M Model
Acknowledges Acknowledges complexitycomplexity
Identifies human and Identifies human and system factors system factors
Encourages open Encourages open discussiondiscussion
Actively seeks Actively seeks solutionssolutions
DiscoveryDiscovery
InvestigateInvestigate
Discuss and ProbeDiscuss and Probe
Allow new facts to Allow new facts to surfacesurface
Appreciate complexity Appreciate complexity of caseof case
Include cognitive and Include cognitive and system factors to be system factors to be discovereddiscovered
The Question of Anonymity: ?The Question of Anonymity: ?BenefitsBenefits
ProtectiveProtective
Preserves Self-EsteemPreserves Self-Esteem
May remove defensive natureMay remove defensive nature
The Problem with AnonymityThe Problem with Anonymity
Limits fact finding and discoveryLimits fact finding and discovery
Limits insightLimits insight
Encourages secrecyEncourages secrecy
Adds to shame, fearAdds to shame, fear
Limits problem-solvingLimits problem-solving
Exposing the Clinician Who ErredExposing the Clinician Who Erred
Allows conversationAllows conversation
Provides a more balanced view of the Provides a more balanced view of the error (for audience and clinician)error (for audience and clinician)
Audience can help moderate tendency Audience can help moderate tendency toward maladaptive behaviortoward maladaptive behavior
There is some opportunity for absolution There is some opportunity for absolution
Insight: The “Aha!” MomentInsight: The “Aha!” Moment
Full discovery of factsFull discovery of facts
Audience discussionAudience discussion
Expand audience to Expand audience to cross disciplines and cross disciplines and rolesroles
May provide the best May provide the best learning opportunitylearning opportunity
Insanity: Doing the same thing Insanity: Doing the same thing over and over again and over and over again and
expecting different results. expecting different results.
Albert Einstein (attributed)Albert Einstein (attributed)
Strategies and SolutionsStrategies and Solutions
How can we do better?How can we do better?
Each case should have:Each case should have:– A lesson for medical decision-makingA lesson for medical decision-making– A system problem to pursueA system problem to pursue– A planA plan
Optimizing M&M Conference to Optimizing M&M Conference to Drive ImprovementDrive Improvement
Use Group Dynamics to solve problemUse Group Dynamics to solve problem– Fresh ideasFresh ideas– Creative solutionsCreative solutions– Forge alliancesForge alliances– Promote teamworkPromote teamwork– Foster collaborative spiritFoster collaborative spirit
An “expert” to offer guidance and adviceAn “expert” to offer guidance and advice
Optimizing the M&M Conference to Optimizing the M&M Conference to Drive ImprovementDrive Improvement
Identify System Identify System Factors in every caseFactors in every case
– Can you design a Can you design a system that could help system that could help another person avoid another person avoid the same error?the same error?
When the problems are really big…When the problems are really big…
M&M can serve as a meeting groundM&M can serve as a meeting ground
Neutral academic settingNeutral academic setting
Fascinating case discussionFascinating case discussion
Allows heroes to emerge: Allows heroes to emerge: – new policynew policy– new agreementsnew agreements
The Multidisciplinary M&MThe Multidisciplinary M&M
Target and assemble the right audience: Target and assemble the right audience: power players who can make changepower players who can make change
Collect the cases:Collect the cases:– 1 case is interesting1 case is interesting– 2 cases seem like bad luck2 cases seem like bad luck– 3 cases make a pattern that can’t be ignored3 cases make a pattern that can’t be ignored
State the problemState the problem
Ask for a solution! Ask for a solution!
Special Cases: Better by DesignSpecial Cases: Better by Design
Multidisciplinary M&MS:Multidisciplinary M&MS:Ectopic Ectopic
RLQ pain in womenRLQ pain in women
Aortic dissectionsAortic dissections
Abdominal pain in the elderlyAbdominal pain in the elderly
Look for the problem in YOUR institutionLook for the problem in YOUR institution
ImprovementImprovement
State what’s been done to address issues.State what’s been done to address issues.
Existing problems that need fresh Existing problems that need fresh solutionssolutions
Recruit your audience to find solutionsRecruit your audience to find solutions
Changes role of the individual from Changes role of the individual from passive, enduring punishment to active passive, enduring punishment to active problem-solver. problem-solver.
SatisfactionSatisfaction
There is nothing more painful than the There is nothing more painful than the shame of failure made publicshame of failure made public
There is nothing more invigorating than There is nothing more invigorating than meeting a challenge and solving a tough meeting a challenge and solving a tough problemproblem
M&M Can Be:M&M Can Be:
A rational approach to solving real A rational approach to solving real problemsproblems
Done well it will :Done well it will :– Provide good medical educationProvide good medical education– Give insightGive insight– Find creative solutions to real problems.Find creative solutions to real problems.– Teach clinicians a healthy approach to Teach clinicians a healthy approach to
managing medical error.managing medical error.
Long Term GainLong Term Gain
Traditional M&M teaches accountability, Traditional M&M teaches accountability, but creates shame.but creates shame.
The Enlightened M&M teaches life-long The Enlightened M&M teaches life-long strategy for dealing with error, a healthy strategy for dealing with error, a healthy constructive approach to real life practice.constructive approach to real life practice.
One approach documents error; the other One approach documents error; the other changes things for the better. changes things for the better.
““Failure is not an option”Failure is not an option”
Gene KranzGene Kranz
Every failure is an opportunity Every failure is an opportunity for improvementfor improvement