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Clinical Pediatrics51(11) 1079 1086 The Author(s) 2012Reprints and permission: sagepub.com/journalsPermissions.navDOI: 10.1177/0009922812461069http://cpj.sagepub.com

Introduction

The morbidity and mortality conference (MMC) has long been a forum for discussing adverse outcomes in the academic medical setting.1 The Accreditation Council for Graduate Medical Education (ACGME) has recognized the educational value of resident participa-tion in systematically analyzing practice and imple-menting changes with the goal of practice improvement.2 The format and methods by which cases are identified, presented, and discussed vary widely among training programs and disciplines across the United States and Canada3,4 and even within our own institution.5

Although much has been published about both tradi-tional and innovative uses of the MMC in internal medi-cine,1,3,6 emergency medicine,7-11 surgery,12-25 and other disciplines as a forum for highlighting the core compe-tencies of ACGMEs and quality improvement,12-14,26-29 there is a paucity of literature about the role of the MMC in pediatrics.4,30 At the Johns Hopkins Childrens Center, the MMC had become very similar to the weekly case

management conference in which interesting and instructive cases were discussed by faculty members with, primarily, residents and medical students in atten-dance. The nature and source of the morbidity and/or mortality were often difficult to ascertain. Without a unifying philosophy, these sessions did not produce effective or lasting solutions.

We hypothesized that by clearly identifying goals for the MMC and empowering those involved to reach these goals, we could create a constructive venue for quality improvement and a vehicle for initiating system change. We restructured the conference to encourage discussions

461069 CPJXXX10.1177/0009922812461069Clinical PediatricsRabizadeh et al

1Cedars-Sinai Medical Center, Los Angeles, CA, USA2Wake Forest School of Medicine, Winston-Salem, NC, USA 3Johns Hopkins School of Medicine, Baltimore, MD, USA4Vanderbilt University, Nashville, TN, USA

Corresponding Author:Shervin Rabizadeh, Cedars-Sinai Medical Center, 8635 W 3rd Street, Suite 1165W, Los Angeles, CA 90077, USA Email: [email protected]

Restructuring the Morbidity and Mortality Conference in a Department of Pediatrics to Serve as a Vehicle for System Changes

Shervin Rabizadeh, MD, MBA1, W. Adam Gower, MD2, Kurlen Payton, MD1, Kathryn Miller, BS3, Kimberly Vera, MD, MSCI4, and Janet R. Serwint, MD3

Abstract

Purpose. Morbidity and mortality conference (MMC) serves an important role in medical care and education. We restructured our Department of Pediatrics MMC to focus on multidisciplinary participation and improved communication among disciplines, quality improvement, and system changes for safer clinical care and enhanced learning from adverse outcomes. Method. The structure and philosophy of the Department of Pediatrics MMC was changed. We present guiding principles for the restructuring process and evaluation results postrestructuring, which examined achievement of conference goals, including quality improvement. Results. The MMC led to system changes within the Department of Pediatrics as well as other parts of the hospital. Satisfaction with these changes was high among conference participants, who felt that the conference achieved its goals of including multiple disciplines and creating system changes. Conclusions. The successful change in the focus of the pediatric MMC conference resulted in significant hospital-wide system changes, quality improvements, enhanced education, and departmental satisfaction.

Keywords

morbidity, mortality, system changes, multidisciplinary

1080 Clinical Pediatrics 51(11)

about avoiding adverse events by focusing less on the roles of individuals in the event and more on the system and team management environment that enabled such events. We anticipated that shifting the focus of discus-sion away from individual management would encour-age increased attendance and participation at the conference while providing a venue for initiating change through open dialogue, with the goal of preventing future morbidity and mortality (M&M). We emphasized the importance of including all disciplines in discussions about enacting system changes. In addition, we felt that this could be an effective way to empower residents to take the lead in identifying areas for quality improvement in the Childrens Center and marshalling the resources necessary for enacting change. The purpose of this article is to (1) describe how our department changed the format and philosophy of our MMC to address systems issues, (2) describe content from the conferences during the first 2 years following this change, and (3) present evaluation data from surveys collected from faculty, residents, and hospital staff about the perceived effectiveness and satis-faction with this new approach.

MethodsNew Conference Format

The Johns Hopkins Department of Pediatrics MMC is an hour-long continuing medical education (CME) approved twice monthly conference. Our revised goals for this conference were to (1) identify events resulting in adverse patient outcomes, (2) create and participate in a forum in which health care providers acknowledge and address reasons for medical errors, (3) modify behavior and judgments by learning from past adverse events, (4) address educational and systematic flaws that led to adverse outcomes, and (5) identify a group to engineer the identified needed changes and quality improvement. The conferences are attended by Department of Pediatrics faculty, fellows, residents, and medical students as well as representatives from other disciplines, including nurs-ing, pharmacy, social work, child life, pediatric surgical subspecialties, and other interested parties. If the case involves other departments, such as surgery or obstetrics and gynecology, invitations are extended to representa-tives from these groups to attend and participate in the discussion. Typically, a case with an adverse event is presented in detail by one of the members of the M&M team (see below) followed by discussions led by faculty members and additional staff (nursing, pharmacy, etc) involved in the case. The conference ends with a sum-mary of the identified system errors as well as a plan for future actions toward quality improvement.

Morbidity and Mortality Team and Case Identification

The M&M team changes annually and is comprised of 6 senior pediatric residents, the 2 pediatric chief resi-dents, and 4 faculty advisors, including the associate residency program director. This team is charged with the task of identifying cases with adverse outcomes that have occurred at the Johns Hopkins Childrens Center. The members of the M&M team are identified at the beginning of the academic year and health care providers are encouraged to share ideas for cases with any member of the team. In addition, team members solicit potential cases from faculty in high-acuity units such as the pediatric emergency department, pediatric intensive care unit, oncology, and the neona-tal intensive care unit. Each M&M team resident is given primary responsibility for developing several case presentations during the year. Preparation for the conference presentation includes review of all perti-nent medical records, in-depth interviewing of the staff members involved with the case, and inviting speakers from the various disciplines to present and participate in the discussion. The team member pri-marily responsible for the case develops a slide pre-sentation on case details and other pertinent issues. At the end of the case presentation, the primary team member summarizes key points addressed during the conference. From this, 1 to 3 action items are gener-ated, and individuals are assigned to follow up on discussed changes. The chief residents are responsible for obtaining updates regarding progress made on the action plans and system changes. The Department of Pediatrics Chair and the Governing Executive Committee are updated, and their involvement is solicited for systems changes that involve depart-ments other than pediatrics.

Case OverviewsBiannually, a conference is devoted to reviewing all the cases presented in the previous 6 months. The cases are summarized, and updates on the progress toward pro-posed system changes are reported. In addition, a sum-mary table, consisting of a brief case presentation, identified system errors, and updates on changes initi-ated by the case are distributed via e-mail to the Department of Pediatrics faculty and residents and members of other disciplines who had attended the conference. The primary types of errors identified by each case were grouped into categories by 2 of the authors (KP and JRS). Any disagreements were settled by group consensus.

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Evaluation Process

A survey was developed to evaluate the change in the MMC format. The 17-question survey included demo-graphics, responses to the proposed goals of the confer-ence, and qualitative comments that addressed reasons why participants attended, whether participants had implemented system changes in their practice, the value of the twice yearly MMC summary, and suggestions for improvement of the conference. The survey was distrib-uted via e-mail during June of 2006 and 2007, at the end of each respective academic year. Data from 2 years of evaluations were included to determine sustainability of changes. Survey questions that addressed the MMC goals used a standard 1 to 5 Likert response scale with 1 = strongly disagree and 5 = strongly agree. Space was provided for additional free text commentary. The sur-vey was sent to all Department of Pediatrics faculty and residents as well as nurses, pharmacists, social workers, and other interested individuals who had attended the MMC. Survey reminders were also sent a total of 3 times over a 6-week period. The surveys were returned to the Senior Academic Program Coordinator in the Department of Pediatrics (KM). Institutional review board approval was obtained, and participants consented by agreeing to complete the survey. Any identifying information was removed prior to data extraction. Qualitative comments were reviewed by 2 of the authors (KM and JRS), and representative examples were selected.

Statistical AnalysisData analysis was performed using the Statistical Program for the Social Sciences, SPSS, version 10 (SPSS Inc, Chicago, IL). Frequencies were calculated, and 2 analysis was performed comparing the 2 aca-demic years.

ResultsDemographicsA total of 18 MMCs were held during the academic year 2005-2006 and 14 during 2006-2007. An additional 2 conferences during each academic year were devoted to the biannual reviews. There were 10 different categories of error types leading to M&M identified from the cases during the 2 academic years (Table 1). The majority were a result of communication problems and issues relating to medications and allergies. In reviewing the survey results, the majority of the respondents were physicians (Table 2). Other disciplines were represented and included nurses, pharmacists, social workers, and other interested individuals or staff who did not more specifically identify themselves. Demographic analysis revealed no significant differences between the 2 aca-demic years; hence data were combined. Almost two-thirds of survey responders attended more than 4 sessions during an individual academic year. Individuals who did not attend regularly cited scheduling conflicts as the primary reason for nonattendance.

Multidisciplinary ApproachGiven the wide range of services involved in the care of patients, one of the successes of this conference was drawing individuals from a variety of services and backgrounds. There was active participation and pre-sentations by individuals from pediatric subspecialties (36), nursing (13), pharmacy (5), surgical subspecialties (4), ophthalmology (3), hospitalist service (3), anesthe-sia (3), infection control (3), hospital safety (3), radiol-ogy (2), pathology (2), obstetrics/gynecology (1), adult emergency medicine (1), nutrition (1), Child Life (1), and legal services (1). Survey respondents agreed that the discussions were held in a nonthreatening manner

Table 1. Types of Primary Errors and Number Per Year Identified in the Conferences

Type of Error 2005-2006 Academic Year 2006-2007 Academic Year

Communication between providers 3 2Communication with family 2 0Equipment failure 1 0Failure/Delayed diagnosis 3 1Infection control 2 1Medication/Allergy 3 2Patient transport 0 1Primary prevention 3 1Resuscitation 1 3Transfer of care 0 3


with productive identification of problems and/or errors leading to M&M as well as suggestions for implement-ing change. In fact, 95% of survey responders felt that the MMC created a forum for different disciplines to address reasons for medical errors.

Case Description and Implemented ChangesExamples of cases discussed and the system changes that occurred as a result of the MMC are presented (Table 3). During the 2005-2006 academic year, one of the most notable system changes involved a new hospi-tal policy wherein positive pregnancy test results (besides those obtained on the obstetrics unit) were deemed critical action values, requiring immediate notification to the patients caretakers with acknowl-edgement and documentation of the notification. The impetus for this system change was secondary to a MMC in which a group to champion the change was identified. This group successfully lobbied for the new policy through various hospital improvement commit-tees. Although this error was identified during the MMC of the Department of Pediatrics, the system change was seen as beneficial for the entire hospital, and an institu-tional policy was amended. Another example of the MMC leading to hospital policy change occurred in the 2006-2007 academic year. An insulin drip was mistak-enly run in place of the ordered nalaxone drip secondary

to physical similarities in the medication bottles. The pediatrics MMC was the impetus for forming a multi-disciplinary group, including physicians, nurses, and pharmacists, that successfully advocated a change in hospital policy. As a result, nalaxone drips are now administered in a 60-cc syringe (no longer in a bottle) via a preprogrammed syringe pump, with the medica-tion name scrolling across the pump screen. The third case example illustrates the effect of the multidisci-plinary approach of the conference in promoting change. A large number of peripheral intravenous (IV) catheter infiltrates were noted in Childrens Center patients via data from the patient safety tracking system, an online tool for all hospital caretakers for reporting safety issues or adverse events in the hospital. The multidisciplinary participation and discussion at the pediatric MMC pro-vided the momentum for Childrens Center policy changes directed at decreasing the number of peripheral IV catheter infiltrates.

Survey ResultsAccording to the majority of individuals who completed the annual surveys, the new MMC format achieved its goals and objectives (Figure 1). A total of 98% of indi-viduals agreed or strongly agreed that this conference allowed a practitioner to modify behavior and judgments by learning from past adverse events, whereas 95% felt that the conference was able to address educational and systemic flaws that led to adverse outcomes. Additionally, 80% agreed or strongly agreed that the discussions were held in a nonthreatening manner, whereas 70% agreed or strongly agreed that a group was identified to move for-ward with needed changes and quality improvement. In all domains, the positive responses were either sustained or improved during the second year of study. Similar to the survey results, comments showed appreciation and strong support for the new MMC format (Figure 2). Respondents also expressed satisfaction with the bian-nual summary. Suggestions for improvement centered on greater participation of all disciplines, inclusion of nonmedical aspects of the cases, and development of a systematic way to identify cases.

DiscussionWe have successfully implemented a new system for the Department of Pediatrics MMC and, in doing so, created a conference focused on education and quality improvement. Our results indicate that we had active participation from individuals with multidisciplinary backgrounds engaged in nonthreatening discussions about major patient-related M&M. Furthermore, system

Table 2. Demographics of Survey Participants

N Percentage

Attended 1 M&M conference

81/94 86%

Of those who attended 81 Discipline Physician 72 89% Faculty 23 32% Fellow 6 8% Resident 43 60% Other disciplinea 9 11%Male gender 25 31%Number of sessions

attended

1-3 29 36% 4-6 33 41% 7 19 23%Received biannual summary 59 73%

Abbreviation: M&M, morbidity and mortality.aIncludes nursing, social work, pharmacist, bereavement coordinator, child life worker.


changes were proposed during the conference, and processes for implementing those changes were initi-ated. The conference led to hospital-wide system changes as exemplified by the new policy for positive pregnancy test notification on nonobstetrics units and change in the delivery apparatus of nalaxone drips to avoid medication error. In addition, certain departmen-tal policies were changed, such as appropriate use of peripheral IV access to reduce catheter infiltrates. The annual survey demonstrated that participants felt that the conference was effective in identifying relevant system issues related to patient safety, fostering dis-cussion of these issues and suggested changes, identi-fying groups of individuals to address the potential changes, and successfully implementing them. Scheduling conflicts, not a perceived lack of value of the process, was the primary reason for nonattendance, again supporting the overall satisfaction with the new format of the conference.

The importance of didactic and case management conferences cannot be overstated, but in changing the MMC, we were able to transform an existing educa-tional vehicle in pediatrics that has benefited not only the knowledge base of caretakers but also led to system improvements translating to better and safer care. As evident in the survey results, the nonthreatening, multi-disciplinary approach to the MMC was a well-received adjunct to more traditional resident education and CME.

Changing the culture of a conference such as the MMC is never a static process and requires evolution with ongoing adaptation. One of the most important aspects of the change in the MMC within our depart-ment is the ability for future growth with ongoing adjustments. To build on our success in terms of atten-dance, multidisciplinary participation, problem identifi-cation, and impetus for policy changes, the MMC will need to evolve based on participant feedback. We seek to make this a dynamic process that responds to the

Table 3. Examples of MMC Cases Extracted From the Yearly Summary Table

Presenting Symptoms Issue Morbidity/Mortality System Changes

16-Year-old girl transferred in from outside hospital with seizures, hypertension, and vision changes and presumed to have venous sinus thrombosis

Pregnancy test obtained on admission not noted to be positive for 5 hours, postresult availability. After noting result, patient diagnosed with eclampsia and underwent emergent Cesarian section

Delayed diagnosis of eclampsia because caretakers were unaware of pregnancy test results

Newborn died in NICU secondary to respiratory failure

Patient fully recovered

Hospital-wide policy changed that positive pregnancy test results (besides those obtained on obstetrics floor patients) made critical action value requiring immediate notification to patients caretakers

15-Year- old girl with history of lupus admitted with pancreatitis and course complicated by significant pain and hyperglycemia

Patient was treated with PCA and naloxone drip for her pain as well as temporarily on an insulin drip, which was eventually transitioned to SC regimen for hyperglycemia. During hospital course, she developed hypoglycemia refractory to all interventions (ie, stopping insulin). Required transfer to PICU

Though it had been discontinued, insulin was mistakenly hung instead of naloxone, leading to the refractory hypoglycemia. Insulin and naloxone drips were contained in identical bottles. Furthermore, the bottle had correctly been labeled as insulin but the IV tubing leading to the patient was marked as naloxone leading to the medication error. The patient did well after the error was discovered

Hospital-wide policy changed that naloxone would be administered in a 60-cc syringe (no longer bottle) via a syringe pump that will be programmed to have the medication name scroll across the pump screen

A high number of peripheral IV catheter infiltrates were noted after routine review of data in patient safety net (an online tool for all hospital caretakers to report any safety issues or adverse events)

In all, 36 IV infiltrate events were recorded, of which 24 caused significant morbidity and required additional treatment. The majority of the 24 were receiving peripheral parenteral nutrition via the infiltrating IV

High number of peripheral IV infiltrates, with two-thirds having associated morbidity

Childrens Center policy changed that peripheral parenteral nutrition will not be allowed unless approved by pediatric gastroenterology, nutrition, and pharmacy after reviewing the need and contents of the IV nutrition. Also the PICC line service will get list of all admissions listed by diagnosis and touch base with charge nurses on a daily basis, so as to be aware of patients who may need longer-term IV access

Abbreviations: MMC, morbidity and mortality conference; NICU, neonatal intensive care unit; PICU, pediatric ICU; OB, obstetrics; PCA, patient-controlled anesthe-sia; SC, subcutaneous; IV, intravenous; PICC, peripherally inserted central catheter.


Figure 2. Representative comments made by conference participants in the annual survey

Figure 1. Survey results


changing conditions in both the patient care and medical education environments. Our hope is that this will elicit a more comprehensive cultural change in medical think-ing, especially in pediatrics, where the most difficult casesthe ones in which harm has occurred to the patientwill be discussed in a confidential, nonthreat-ening manner with identification and initiation of system-based changes that will make for safer patient care.

We recognize the limitations of evaluation using a postsurvey study method. Our ability to quantify the impact of the change in the conference format is limited because no baseline survey data were collected prior to the implementation of this change. Additionally, no objective data were collected to quantify whether pro-posed changes led to increased patient safety or a decrease in adverse events. Furthermore, the survey was susceptible to responder bias.

Despite these limitations, survey results and com-ments suggest that we have successfully reformatted the MMC in our pediatrics department. The new conference format has promoted a nonthreatening environment for multidisciplinary discussions of adverse events and, most important, the nidus for promoting system changes that can have significant effect across the entire medical center. This is best exemplified by the following com-ment from an anonymous MMC participant: A vast improvement over prior years during which [in previous years] we would talk about cases in which the ball was dropped, shake our heads forlornly and walk out of the room. Keep up the good work! We hope to further improve the MMC and maintain its new position as an important vehicle for identification of errors, learning from errors, and promoting system changes.

Acknowledgments

We would like to acknowledge Dr George Dover and Dr Julia McMillan for their support of the change in the MMC format and their review of the manuscript. We would also like to acknowledge Drs David Bundy, Elizabeth Hunt, Peter Rowe, and Allen Walker who served as faculty advisors for the M&M team. In addition, we would like to recognize the amaz-ing work of the residents on the committee without whom these changes would not be possible: Drs Naseem Amrasingham, Margaret Brewinski, Joshua Dishon, Doran Fink, Raquel Hernandez, Michael Nemergut, and Patrick Wilson (2005-2006); Drs Aaron Chambers, Joan Dunlop, Michelle Dunn, Rachel Johnson, Michael McCrory, and David Shook (2006-2007).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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