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An 80-year-old woman who intentionally overdosed at home on propranolol hydrochloride (Inderal) and tricyclic antidepressants was brought to the emergency department via ambulance. Upon her arrival, she was immediately intubated, treated for her overdose per protocol, and admitted to the intensive care unit (ICU). Her hospitalization was notable for development of an infiltrate in the lower lobe of the left lung on day 2 after extubation. She was able to follow simple commands but had frequent episodes of agitation and decreased mentation. Her speech was garbled and indecipherable.
On the evening of hospital day 9 at approximately 11 PM, a sleep study was begun. At that time, the registered nurse caring for the patient noted in the chart that the patient was "consistently desaturating with oxygen saturations at 77% to 85%." Documented vital signs continued to deteriorate slowly during the next hour, and at midnight the nurse noted in the chart that the patient "appears obtunded." The physician was paged but did not respond. At 12:45 AM, the charge nurse was notified. At approximately 2:30 AM, the physician returned the page and ordered a blood sample to be obtained for arterial blood gas analysis. Because the results of the analysis appeared to indicate venous blood, they were assumed to be an error that had occurred because a venous blood sample had been obtained rather than an arterial one. A second attempt to obtain an arterial blood sample was unsuccessful because the patient’s pulse was "faint and weak." At 3:50 AM, the patient "appear[ed] more agonal" and was treated with a fraction of inspired oxygen of 100% and manual ventilation via a manual resuscitation bag. At 4 AM, a code blue was called. The patient died at 4:45 AM.
In the preceding scenario, it may appear that errors in clinical judgment occurred. But the question remains whether the outcome for this particular patient was simply a consequence of her underlying condition. It is also possible that poor documentation did not provide an accurate description of what occurred. Whatever the reason for the eventual outcome, prevention of such an outcome in similar cases in the future is paramount. The emphasis after the event should be on improving quality by examining and correcting any errors in clinical judgment.
The report published in 2000 by the Institute of Medicine titled To Err Is Human: Building a Safer System1 created a public outcry. The societal impact and financial/human loss as a result of preventable medical errors was staggering. Operating rooms, ICUs, and emergency departments were cited as the highest probable offenders. Although medical professionals and healthcare systems are not infallible, correction of preventable events would improve quality of care.
| Errors must be analyzed and used to identify patient safety issues and drive quality improvement initiatives.
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Pierluissi et al2 defined adverse events as an "unintentional, definable injury that was the result of medical management and not a disease process." Kaiser3 simplified the definition of medical errors to "an adverse event or near miss that is preventable in light of the current state of medical knowledge." Adverse events and errors must be analyzed and then used as a mechanism to identify potential issues related to patients’ safety and to promote quality improvement initiatives. Recognition of adverse events and errors as faulty systems and processes rather than as individual carelessness is the first step in resolution of these problems. Blaming individuals victimizes them twice: once when the system failed them and again when the system accused them.
| Blaming individuals for errors victimizes them twice: once when the system failed them and again when the system accused them.
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One strategy for avoiding future adverse events and medical errors while intensifying quality improvement efforts is the use of morbidity and mortality (M & M) conferences. The conferences have been used for decades, initiated by surgeons reviewing cases in an attempt to learn from and prevent future surgical complications in a venue that was free of blame or ridicule.2,4,5 In these forums, adverse events and errors are analyzed in an open but structured environment by a group of peers, led by a moderator to maintain a non-threatening atmosphere. Medical staff, including those involved in the event, assess the circumstances that created the cascade of events resulting in error. The purpose is to focus on systems and procedures and not just on the isolated event.3 Appropriate changes are then instituted, allowing responsible parties to be accountable while being part of the solution and not labeled as part of the problem.6
Nurses can incorporate M & M conferences into clinical practice as an educational and quality improvement tool to evaluate how the system of care affects the quality of care.7 An unveiled look at the system of care promotes best practice. In this article, we detail the implementation of an M & M conference that enabled recognition of system failures and allowed appropriate change to promote clinical excellence while focusing on improvement of the system and not individual blame.
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Literature Review |
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In the classroom setting, traditional teaching methods include didactic and passive approaches to learning. In order to accommodate the changing healthcare environment, nursing education is moving toward more active teaching strategies that develop critical thinking and problem-solving skills before students enter the real world of clinical practice.8 One strategy being used is case-based instruction, in which student nurses are presented with actual case reviews and must apply developing clinical and science-based strategies to deal with complex scenarios involving patients. A natural evolution of case-based instruction would be for nurses to continue to build critical thinking and problem-solving skills in the work environment with the use of case review as occurs in an M & M conference. Harbison and Regehr4 think that M & M conferences are one of most powerful teaching tools available because the conferences are reality based.
| Morbidity and mortality conferences have a positive effect when errors are being confronted and corrected, especially when the conferences are focused on system problems and not on individual errors.
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For many years, M & M conferences have been mostly used in teaching hospitals and residency programs. However, the medical version of case-based instruction could easily be adapted to nursing practice. Although M & M conferences are excellent teaching forums,2,9,10 a lack of format and structure can lead to an environment of defensiveness, blame, and inappropriate presentation of events. This situation, in itself, can sabotage the effectiveness and acceptance of the program.
A positive by-product of a well-conducted M & M conference is quality improvement. When the conference format includes review of systems issues with evidence-based solutions accompanied by consequent changes to the system, quality improvement occurs naturally.5,7 Some authors10 do not agree that M & M conferences can be used as a quality improvement tool. The conferences may result in documentation inadvertently being made available to the public and may lead to negative personal behaviors as a defense mechanism. All authors,3,5,9,10 however, agree that the most important feature of an M & M conference is to remain focused on systems problems and not on individual errors. How then can it be said that quality improvement does not occur when systems problems have been addressed and corrected?
The format and structure of M & M conferences have been criticized for lacking the supportive environment required because of the frank discussion required.4,9,10 A suggested resolution has been the promotion of a strong moderator to facilitate the conference. The role of the moderator is to maintain the flow of the conference, abolish finger-pointing attempts, preserve confidentiality of patients and staff, and provoke appropriate questions and discussion.3,5,10 Orlander et al10 presented a framework for guiding the development of an M & M conference program. Their model offered guiding principles, case selection criteria, and moderator choice in an attempt to refocus medical professionals on critical thinking and self-analysis.
In summary, an M & M conference is an appropriate and valuable educational forum. When conducted to evaluate systems problems by using an evidence-based approach, an M & M conference will naturally contribute to quality improvement efforts in the institution and promote clinical excellence and best practice. In order for an M & M conference to be effective, however, a supportive framework must be maintained to prevent a productive time for evaluation from becoming a negatively charged blaming session.
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Project Evolution |
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Before initiating the program, the risk manager was consulted about legal protection of staff members, medical records, and patients’ confidentiality. Guidelines were drafted (Figure 1
), and a case submission form was created (Figure 2). The FOCUS PDCA quality improvement model (Figure 3) was adopted to use within the M & M conference framework to ensure a system focus and to provide a consistent format of evaluation/outcome measurement for each reviewed case. A rapid response of 2 to 4 weeks for review was adopted to address adverse events and errors in a timely fashion. The forum selected for introduction of the M & M conference was the ICU Clinical Nurse Practice Forum, which met monthly.
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). Performance improvement activity reports were completed for each of the identified problems, and teams for problem analysis were formed by using key personnel.
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Evaluation of the M & M Conference |
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As a result of the M & M conference, 5 projects were undertaken. After the documentation from the case was reviewed, the first project was to improve the staff nurses’ charting techniques. A series of seminars were begun with a nurse attorney as facilitator, beginning in the ICU and continuing throughout the institution to discuss effective versus ineffective documentation. Examples were presented, and legal implications were discussed. Questions were posed for nurses to assess their own charting skills. The ICU staff used the information from the seminars to evaluate the paper-and-pencil flow sheets used to document patients’ care and to revise the forms to simplify documentation while addressing possible legal pitfalls.
The second project was a result of staff nurses’ identification of possible barriers to advocacy for patients. One barrier was communication between nurses and physicians. The nurses acknowledged that acting as strong advocates for their patients would require understanding appropriate and professional ways to assert themselves with physicians. To address the issue, the facility established a class on nurse-physician relationships and communication skills in the new employee orientation program. This educational offering is taught by a nurse and physician team and was eventually extended throughout the facility. One concern, however, was a lack of response to the course from physicians. A continued barrier to the success of this process is that physicians are contracted with the hospital and can only be encouraged to participate. We suggest that the "chain of command" be clearly available for staff for just such instances and that the issue of physicians’ nonresponse be handled by the hospital committee that addresses quality issues of physicians’ practice.
A third issue that had to be resolved was improvement of clinical skills at all levels. In order to address this problem, a clinical mentorship program was established. Experienced nurses were interviewed for the position as clinical mentor to junior nurses. Although those chosen must have had experience as a preceptor, the role of a mentor differs from that of a preceptor. The target audience was staff nurses with less than 5 years of experience who had completed their orientation with a preceptor. The goal of this intervention was to groom the mentors for future leadership positions and move them up the clinical ladder while also developing critical thinking and problem-solving skills among the more junior bedside nurses. The goals of the overall program were to take patients’ care to a higher level and to increase retention of nurses by providing a supportive clinical environment for all nursing staff.
The nurse whose charting was reviewed in the case presentation was a registry nurse with many years of experience who had been hired per diem from a contracted agency. The fourth issue identified at the M & M conference was that registry nurses demonstrated their competency at the registry agency but not at the institution in which they were working. The competency guidelines were provided by the institution, but the competency was established at the employing registry agency. The observation method used by the institution to ensure that temporary staff were truly safe was lacking in structure. Nurse leaders began to work with the nurse staffing office to revise competency assessment of temporary staff. Also, a stronger recruitment campaign was instituted to attract permanent staff to fill vacancies occupied by temporary personnel.
The last issue addressed as a result of the M & M conference was the staffing issue. Staff members available on the night of the event were predominantly staff nurses with less clinical experience and temporary nursing staff. The untoward event occurred during the practice of perpetuating the tradition of initiating newly registered nurses on the night shift and rewarding the more experienced nurses with a position on the day shift. The management of the ICU began addressing levels of nursing experience and staffing mixes to ensure a balance of experience among staff members on all shifts.
The cost of implementing an M & M program is minimal compared with the financial and societal costs of repeated preventable errors. The majority of the improvement in quality that occurred after the first case review was in the form of education. The cost to the organization was mostly in man-hours and could be considerable depending on the issues addressed. However, physical plant layout, technological advances, equipment changes, and other more costly endeavors may become an issue for future case reviews in an M & M program.
Rapid and strong responses in addressing adverse events and errors are necessary to prevent distortion of the chronology of the event. However, responding too rapidly might prevent a thorough examination of all the systems issues involved. A lesson learned from this experience was that the first M & M conference may have been initiated too rapidly. Time was not allowed to establish the concrete baseline data needed to measure outcomes accurately. Positive outcomes included staff members’ enthusiasm and improvement of respect and communication between staff and management. However, no outcome measurement tool was identified before the interventions began. In the enthusiasm generated by the process, this vital step was overlooked. We recommend that a short survey tool addressing the effectiveness and usefulness of the M & M conference be developed before the start of the process and be completed by each nurse. Time should be taken during each conference to identify clearly measurable outcomes for patients that can guide the evaluation of the quality improvement effort.
| Morbidity and mortality conferences can be used to confront and correct practice errors while improving professional relationships, respect for evidence-based practice, and the quality of patients’ care.
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The M & M conference becomes a nonthreatening learning tool for all involved personnel. As a result of the conferences, collaboration among staff nurses, management, and physicians may improve over time. If handled according to the guidelines, M & M conferences should improve professional relationships, increase awareness of the legalities of documentation, and increase levels of respect for evidence-based practice and quality improvement initiatives. In work environments where the culture remains one of mistrust and poor communication, a nurse might consult the AACN standards for establishing and sustaining healthy work environments.11
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Summary |
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An annual survey tool addressing the perceived strengths and weaknesses of a facility combined with a unit-based tool to measure satisfaction within nurses’ specific practice environments would be a useful measure of the effectiveness of the M & M program in the ICU. A second method to evaluate effectiveness would be a project board that addresses the identified issues and improvements made. An additional method of evaluation would be to have team members present the progress of the project at staff meetings on an ongoing basis. These strategies would keep the staff abreast of improvements at the systems level, encourage involvement in unit activities, improve unit conformity, and inspire a sense of teamwork.
To err is human, but it is also wise to do our best to prevent the same mistake from occurring a second time. M & M conferences will not solve all systems problems in an organization. The conferences are just another assessment/evaluation tool that, if used correctly, might make substantial differences in the quality of care patients receive, patients’ outcomes, satisfaction among staff members, and most importantly, patients’ safety.
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ACKNOWLEDGMENT |
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