Processes for Identifying and Reviewing Adverse Events and Near Misses at an Academic Medical Center.

BACKGROUND

Conferences, processes, and/or meetings in which adverse events and near misses are reviewed within clinical programs at a single academic medical center were identified.

METHODS

Leaders of conferences, processes, or meetings-"process leaders"-in which adverse events and near misses were reviewed were surveyed.

RESULTS

On the basis of responses from all 45 process leaders, processes were classified into (1) Morbidity and Mortality Conferences (MMCs), (2) Quality Assurance (QA) Meetings, and (3) Educational Conferences. Some 22% of the clinical programs used more than one of these three processes to identify and review adverse events and near misses, while 10% had no consistent participation in any of them. Explicit criteria for identifying and selecting cases to be reviewed were used by 58% of MMCs and 69% of QA Meetings. The explicit criteria used by MMCs and QA Meetings varied widely. Many MMCs (54%, 13/24), QA Meetings (54%, 7/13), and Educational Conferences (70%, 7/10) did not review all the adverse events or near misses that were identified, and several MMCs (46%, 6/13), QA Meetings (29%, 2/7), and Educational Conferences (57%, 4/7) had no other process within their clinical program by which to review these remaining cases.

CONCLUSIONS

There was wide variation regarding how clinical programs identify and review adverse events and near misses within the MMCs, QA Meetings, and Educational Conferences, and some programs had no such processes. A well-designed, coordinated process across all clinical areas that incorporates accepted approaches for event analysis may improve the quality and safety of patient care.