Using the Mortality and Morbidity Conference to Improve Patient Safety

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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

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What is MM?

• Someone dies
• Something bad happens
• Someone does something wrong
• Assumption
• There was an error
• It was preventable

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Why do we have MM Conference?

• Its tradition!
• Its honorable
• Its good for education
• It looks good for QA

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What is the goal of MM?

• Education A case conference with
• mystery, intrigue, suspense!
• Learn from our mistakes
• Educate new trainees
• Teach accountability

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Traditional MM Conferences

• Accounts for failures
• Teach accountability
• Education the best teaching hour in curriculum

• Sometimes results in shame
• Sometimes, a hazing ritual.
• Education is only part of the potential of MM

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Tradition isnt Everything

• The Traditional MM fails to realize its full
  potential
• There is more to be gained.

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The Enlightened Approach to MMThe DISSIS
Approach

• D Discovery
• I Insight
• S Strategies
• S Solutions
• I Improvement
• S Satisfaction

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The Enlightened MM Model

• Acknowledges complexity
• Identifies human and system factors
• Encourages open discussion
• Actively seeks solutions

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Discovery

• Investigate
• Discuss and Probe
• Allow new facts to surface
• Appreciate complexity of case
• Include cognitive and system factors to be
  discovered

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The Question of Anonymity ?Benefits

• Protective
• Preserves Self-Esteem
• May remove defensive nature

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The Problem with Anonymity

• Limits fact finding and discovery
• Limits insight
• Encourages secrecy
• Adds to shame, fear
• Limits problem-solving

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Exposing the Clinician Who Erred

• Allows conversation
• Provides a more balanced view of the error (for
  audience and clinician)
• Audience can help moderate tendency toward
  maladaptive behavior
• There is some opportunity for absolution

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Insight The Aha! Moment

• Full discovery of facts
• Audience discussion
• Expand audience to cross disciplines and roles
• May provide the best learning opportunity

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Insanity Doing the same thing over and over
again and expecting different results.

• Albert Einstein (attributed)

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Strategies and Solutions

• How can we do better?
• Each case should have
• A lesson for medical decision-making
• A system problem to pursue
• A plan

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Optimizing MM Conference to Drive Improvement

• Use Group Dynamics to solve problem
• Fresh ideas
• Creative solutions
• Forge alliances
• Promote teamwork
• Foster collaborative spirit
• An expert to offer guidance and advice

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Optimizing the MM Conference to Drive Improvement

• Identify System Factors in every case
• Can you design a system that could help another
  person avoid the same error?

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When the problems are really big

• MM can serve as a meeting ground
• Neutral academic setting
• Fascinating case discussion
• Allows heroes to emerge
• new policy
• new agreements

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The Multidisciplinary MM

• Target and assemble the right audience power
  players who can make change
• Collect the cases
• 1 case is interesting
• 2 cases seem like bad luck
• 3 cases make a pattern that cant be ignored
• State the problem
• Ask for a solution!

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Special Cases Better by Design

• Multidisciplinary MMS
• Ectopic
• RLQ pain in women
• Aortic dissections
• Abdominal pain in the elderly
• Look for the problem in YOUR institution

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Improvement

• State whats been done to address issues.
• Existing problems that need fresh solutions
• Recruit your audience to find solutions
• Changes role of the individual from passive,
  enduring punishment to active problem-solver.

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Satisfaction

• There is nothing more painful than the shame of
  failure made public
• There is nothing more invigorating than meeting a
  challenge and solving a tough problem

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MM Can Be

• A rational approach to solving real problems
• Done well it will
• Provide good medical education
• Give insight
• Find creative solutions to real problems.
• Teach clinicians a healthy approach to managing
  medical error.

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Long Term Gain

• Traditional MM teaches accountability, but
  creates shame.
• The Enlightened MM teaches life-long strategy
  for dealing with error, a healthy constructive
  approach to real life practice.
• One approach documents error the other changes
  things for the better.

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Failure is not an option

• Gene Kranz

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Every failure is an opportunity for improvement
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