Preventing patient harm via adverse event review: An APSA survey regarding the role of morbidity and mortality (M&M) conference

J Pediatr Surg. 2019 Sep;54(9):1872-1877. doi: 10.1016/j.jpedsurg.2018.12.008. Epub 2019 Jan 18.

Abstract

Introduction: Peer-review endeavors represent the continual learning environment critical for a culture of patient safety. Morbidity and mortality (M&M) conferences are designed to review adverse events to prevent future similar events. The extent to which pediatric surgeons participate in M&M, and believe M&M improves patient safety, is unknown.

Methods: A cross-sectional survey of the American Pediatric Surgical Association membership was conducted to evaluate participation in and perception of M&M conferences. Closed and open-ended questions were provided to gauge participation and perceptions of M&M effectiveness. Standard frequency analyses and tests of associations between M&M program attributes and surgeons' perceptions of effectiveness were performed.

Results: The response rate was 38% (353/928). Most surgeons (85%) reported that they always participate in M&M, but only 64% believe M&M is effective in changing practice or prevention of future adverse events. Effective M&Ms were more likely to emphasize loop closure, multidisciplinary participation, standardized assessment of events, and connection to quality improvement efforts.

Conclusions: Most pediatric surgeons participate in M&M, but many doubt its effectiveness. We identified attributes of M&M conferences that are perceived to be effective. Further investigation is needed to identify how to optimally utilize peer-review programs to prevent adverse events and improve patient safety.

Level of evidence: V.

Keywords: Morbidity and mortality; Patient safety; Peer review; Postoperative complications; Quality improvement.

MeSH terms

  • Cross-Sectional Studies
  • Humans
  • Morbidity
  • Patient Harm / prevention & control*
  • Patient Safety / standards*
  • Pediatricians* / organization & administration
  • Pediatricians* / statistics & numerical data
  • Quality Improvement
  • Surgeons* / organization & administration
  • Surgeons* / statistics & numerical data