Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
Directorate of Quality and Patient Safety, Leiden University Medical Center, Leiden, the Netherlands.
Ann Surg. 2020 Nov;272(5):678-683. doi: 10.1097/SLA.0000000000004447.
To explore possibilities to improve morbidity and mortality conferences using advancing insights in safety science.
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.
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.
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.
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.
利用安全科学的最新进展，探索改善发病率和死亡率会议的可能性。
死亡率和发病率会议（M&M）是基于病例学习的黄金实践。虽然从并发症中学习是有用的，但 M&M 不符合系统改进的期望。韧性工程原则可用于改进 M&M。
在回顾了传统 M&M 的缺点之后，探讨了韧性工程原则作为一种新的绩效评估方法。这导致了一种新的 M&M 格式的发展，该格式还审查了成功的结果，而不仅仅是并发症。介绍了这种“质量评估会议”（QAM），并使用当地观察和调查评估了最初的经验。
在 QAM 中，团队评估所有出院患者，根据外科医生应对不规则情况的能力以及监测和从经验中学习的能力，评估团队的韧性。该会议的实施是可行的，并且得到了外科团队的好评。观察结果表明，对复杂和非复杂病例的反思不仅增强了团队士气，而且引发了对整个临床过程的反思。QAM 可作为一种工具，用于确定如何在存在挑战的情况下通过调整行为来取得成功，从而支持这种有弹性的表现。
韧性工程概念可用于调整 M&M，在该调整中，学习不仅集中在并发症上，还集中在尽管存在各种挑战，但如何实现成功结果上。这揭示了成功和不成功结果的实际比例，从而可以从两者中学习，加强安全增强行为。
