Morbidity and Mortality Conferences VETS6308 2024 PDF

Morbidity and Mortality Meetings Learning Outcomes Discuss the need for morbidity and mortality meetings Identify and apply effective strategies for ongoing system improvement in the context of the veterinary profession Why is this a unicorn paper? (Troxel, 2015) What are Morbidity and Mortali...

Morbidity and Mortality Meetings Learning Outcomes Discuss the need for morbidity and mortality meetings Identify and apply effective strategies for ongoing system improvement in the context of the veterinary profession Why is this a unicorn paper? (Troxel, 2015) What are Morbidity and Mortality meetings? Ideally: A confidential forum for critical case review, allowing the medical team to analyse what went wrong in a particular case and explore factors contributing to complications (Powell et al., 2011). Provide retrospective, detailed, non-judgmental analysis of case management Common in teaching institutions Why (go to the effort and spend the time to hold these meetings)? Suggestions? Morbidity and mortality meetings provide: “a unique opportunity for caregivers to improve medical and surgical management through case study” (Aboumatar et al 2007) Not all clinics hold these (in fact most do not). What potential barriers do you see? Suggestions? What sort of cases should be discussed? “The criteria for case selection seem similar between human and veterinary programs and include unexpected morbidity, mortality, and educational value.” (Kieffer and Mueller) “Where case selection is necessary, it should be based on the greatest benefit to future patient safety and educational value” (Pang, Rousseau-Blass and Pang) What sort of cases should be discussed? Unexpected complications Near misses Harmless hits OR types of cases e.g. Higher than expected SSI (surgical site infection) rates Multiple cases of phlebitis in patients with intravenous catheters High rate of wound dehiscence What sort of cases should be discussed? Errors e.g. wrong dose/type of medication; wrong site surgery; improper use of equipmnt Accidents e.g. animal falling out of cage, animal escaping, animal injuring itself Recall your lecture on errors and complications and animal welfare in TVP 2. Wallis et al Classification System (Wallis et al., 2019)  “Never ever” events "Never Event" was first introduced in 2001 by Dr Ken Kizer, Surgery or other invasive procedure former CEO of the National Quality Forum (NQF), to describe particularly shocking medical errors that should never occur. performed on the wrong body part The term's use has since expanded to signify adverse events Surgery or other invasive procedure that are unambiguous (clearly identifiable and measurable), performed on the wrong patient serious (resulting in death or significant disability), and usually preventable. Unintended retention of a foreign object in a patient after surgery or other Source: https://psnet.ahrq.gov/primer/never-events procedure Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the health care setting Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration) From: Clinical Excellence Commission. 2016. M&M/CLINICAL REVIEW MEETINGS SHOULD BE HELD ON A REGULAR, MEETINGS SHOULD BE MULTIDISCIPLINARY Guidelines for SCHEDULED BASIS. conducting and reporting Mortality & Morbidity Clinical Review meetings. Sydney: Clinical Excellence Commission. MEETINGS SHOULD BE USED TO THE FOCUS OF THESE MEETINGS SHOULD CRITICALLY ANALYSE THE CIRCUMSTANCES BE ON THE SYSTEMS AND PROCESSES OF SURROUNDING OUTCOMES OF CARE AND CARE AND NOT ON INDIVIDUAL CONTRIBUTING FACTORS. PERFORMANCE. Recommendations arising from individual cases should focus on measures that can prevent similar outcomes or adverse incidents, or that will improve the processes of care provided to this group of patients. These recommendations should not apportion blame to individuals. Actions to implement the recommendations should be initiated and it is the responsibility of the Chair of the meeting to oversee progress in their implementation. Outcomes and decisions of these meetings should be documented in a brief meeting report. Presentation format of M and M meetings (Pang et al 2018)  How (are adverse incidents reported) Usually via the completion of a form which includes information such as: The patient affected Where and when the incident occurred Details of exactly what happened Individuals involved Assessment of the affected animal Details of people informed Any contributing factors https://tinycards.duolingo.com/decks/GuVmPPm5/completing-a-form How…. “The focus of these meetings Fundamentally, these meetings should avoid finger pointing and blame should be on the “The strongest barrier to MMRs appears to remain systems and the focus on individual clinician rather than a more processes of care general, systems approach to errors.” (Travaglia and Debono, 2009) and not on “In principle, M&MCs should provide an open forum individual for the collaborative review of adverse events without performance.” fear of retribution or blame.” (Pang et al, 2018) Psychological Safety The term ‘psychological safety’ is ‘a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes’ Amy Edmondson Harvard Business School Professor This is an important concept for an M and M meeting to function effectively The TED talk is here: https://www.youtube.com/watc h?v=LhoLuui9gX8 https://ya-webdesign.com/imgdownload.html  Meetings should be multidisciplinary What this means will vary with the hospital but, ideally should include nursing staff. May just mean vet and head nurse or include representatives of each department of a large specialist hospital https://www.teammed.com.au/blog-page/76-5-top-tips-for-new-doctors  M&M/clinical review meetings should be held on a regular, scheduled basis. This will also look different depending on the size of the clinic. For a large hospital, monthly meeting would be necessary whereas quarterly or six monthly may be adequate for a 1 – 2 vet practice It is just important that they are scheduled or life will get in the way https://www.wrike.com/blog/top-features-monthly-employee-work-schedule-template/  The outcomes should be followed up It is important that the outcomes of the meeting are followed up, otherwise nothing will change M&M meetings fail if they aren’t perceived to make any difference https://www.vividfish.co.uk/blog/its-all-in-the-follow-up How Current evidence shows that a structured M&MC with a standardised presentation format and root effective are cause analysis, and tracking of outcomes, serves as a valuable educational experience with the these greatest potential to improve patient safety and quality of care. (Pang et al 2018) meetings in M&Ms lead to a 40% decrease in gross mortality over 4 years in one Academic Centre (Antonacci, improving 2009). patient outcomes? Example case Natchez is a 8 year old Staffy presented for hind limb lameness. A ruptured cranial cruciate ligament was diagnosed and a TPLO recommended He was admitted for radiographs and surgery. The anaesthesia request said left TPLO. Natchez was anaesthetised at 5.30PM after delays due https://commons.wikimedia.org/wiki/File:NATCHEZ_300.jp to emergencies  Natchez is clipped and proceeds to surgery When the surgeon opens the joint, she observes that the cranial cruciate ligament is intact. A review of the radiographs and the patient’s record reveals that the wrong leg has been operated on How did this happen? https://todaysveterinarybusiness.com/be-a-cut-above/  What if there is no M&M? Reflective writing/journalling with focus on contributing factors, potential points for intervention and preventative measures Discussion with a trusted specialist Discussion with a trusted mentor Case report CARE with online forums  Summary M&M meetings are a confidential forum to investigate near misses, harmless hits and adverse events. Primary purpose is investigation, identification of all possible contributing factors and a plan to improve future patient safety. Not a tool for performance review or apportioning individual blame. Must be held regularly. Changes MUST be implemented and evaluated. Alternatives include individual reflection/research, discussion with specialists, mentors, trusted colleagues Two great books to read  References and recommended reading Aboumatar H J, Blackledge C G, Dickson C, Heitmiller E, Freischlag J & Pronovost P J. A Descriptive Study of Morbidity and Mortality Conferences and Their Conformity to Medical Incident Analysis Models: Results of the Morbidity and Mortality Conference Improvement Study, Phase 1. American Journal of Medical Quality, Vol. 22, No. 4, (Jul/Aug 2007) Antonacci A C, Lam S, Lavarias V, Homel P & Eavey R A. A Report Card System Using Error Profile Analysis and Concurrent Morbidity and Mortality Review: Surgical Outcome Analysis, Part II. Journal of Surgical Research 153, 95–104 (2009) Churchill K.P., Murphy J. and Smith N. Quality Improvement Focused Morbidity and Mortality Rounds: An Integrative Review. Cureus 2020 Dec 18;12(12):e12146 Clinical Excellence Commission. 2016. Guidelines for conducting and reporting Mortality & Morbidity / Clinical Review meetings. Sydney: Clinical Excellence Commission. References and recommended reading Kieffer P J & Mueller P O E. A profile of morbidity and mortality rounds within resident training programs of the American College of Veterinary Surgeons. Veterinary Surgery. 47:343-349 (2018) Pang D S J, Rousseau-Blass F and Pang J M. Morbidity and Mortality Conferences: A Mini Review and Illustrated Application in Veterinary Medicine. Frontiers in Veterinary Science Vol 5 Article 43 (2018) Powell L, Rozanski E, & Rush J. (2011) Small Animal Emergency and Critical Care: Case Studies in Client Communication, Morbidity and Mortality, Iowa, Blackwell Publishing Ltd. Travaglia J & Debono D. Mortality and morbidity reviews: a comprehensive review of the literature. The Centre for Clinical Governance Research in Health (2009) WALLIS, J., FLETCHER, D., BENTLEY, A. & LUDDERS, J. 2019. Medical errors cause harm in veterinary hospitals. Frontiers in Veterinary Science, 6: https://doi.org/10.3389/fvets.2019.00012.