Persistent URL of this record https://hdl.handle.net/1887/3276158
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Taking Morbidity and Mortality Conferences to a Next Level: The Resilience Engineering Concept
conferences using advancing insights in safety science.
Summary background data: Mortality and Morbidity conferences (M&M)
are the golden practice for case-based learning. While learning from complications
is useful, M&M does not meet expectations for system-wide
improvement. Resilience engineering principles may be used to improve
M&M.
Methods: After a review of the shortcomings of traditional M&M, resilience
engineering principles are explored as a new way to evaluate performance.
This led to the development of a new M&M format that also reviews
successful outcomes, rather than only complications. This ‘‘quality assessment
meeting’’ (QAM) is presented and the first experiences are evaluated
using local observations and a survey.
Results: During the QAM teams evaluate all discharged patients, addressing
team...Show moreObjective: To explore possibilities to improve morbidity and mortality
conferences using advancing insights in safety science.
Summary background data: Mortality and Morbidity conferences (M&M)
are the golden practice for case-based learning. While learning from complications
is useful, M&M does not meet expectations for system-wide
improvement. Resilience engineering principles may be used to improve
M&M.
Methods: After a review of the shortcomings of traditional M&M, resilience
engineering principles are explored as a new way to evaluate performance.
This led to the development of a new M&M format that also reviews
successful outcomes, rather than only complications. This ‘‘quality assessment
meeting’’ (QAM) is presented and the first experiences are evaluated
using local observations and a survey.
Results: During the QAM teams evaluate all discharged patients, addressing
team resilience in terms of surgeons’ ability to respond to irregularities and to
monitor and learn from experiences. The meeting was feasible to implement
and well received by the surgical team. Observations reveal that reflection on
both complicated and uncomplicated cases strengthened team morale but also
triggered reflection on the entire clinical course. The QAM serves as a tool to
identify how adapting behavior led to success despite challenging conditions,
so that this resilient performance can be supported.
Conclusions: The resilience engineering concept can be used to adjust
M&M, in which learning is focused not only on complications but also on
how successful outcomes were achieved despite ever-present challenges. This
reveals the actual ratio between successful and unsuccessful outcomes,
allowing to learn from both to reinforce safety-enhancing behavior.
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- All authors
- Verhagen, M.J.; Vos, M.S. de; Hamming, J.F.
- Date
- 2020
- Journal
- Annals of Surgery