Background/purpose: The M&M conference at Nationwide Children's Hospital (NCH) categorized failures as technical error or patient disease, but failure modes were never captured, action items rarely assigned, and follow-up rarely completed. In 2013 a QI-driven M&M conference was developed, supporting implementation of directed actions to improve quality of care.
Methods: A classification was developed to enhance analysis of complications. Each complication was analyzed for identification of failure modes with subcategorization of root cause, a level of preventability assigned, and action items designated. Failure determinations from 11/2013-10/2014 were reviewed to evaluate the distribution of failure modes and action items.
Results: Two-hundred thirty-seven patients with complications were reviewed. One-hundred thirty patients had complications attributed to patient disease with no individual or system failure identified, whereas 107 patients had identifiable failures. Eighty-five patients had one failure identified, and 22 patients had multiple failures identified. Of the 142 failures identified in 107 patients, 112 (78.9%) were individual failures, and 30 (21.1%) were system failures. One-hundred forty-seven action items were implemented including education initiatives, establishing criteria for interdisciplinary consultation, resolving equipment inadequacies, removing high risk medications from formulary, restructuring physician handoffs, and individual practitioner counseling/training.
Conclusions: Development of a QI-driven M&M conference allowed us to categorize complications beyond surgical or patient disease categories, ensuring added focus on system solutions and a reliable accountability structure to ensure implementation of assigned interventions intended to address failures. This may lead to improvement in the processes of patient care.
Keywords: Morbidity; Mortality; Quality improvement.
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