University Sussex Hospital NHS Foundation Trust, Worthing, UK.
Brighton and Sussex Medical School, Brighton, UK.
Int J Risk Saf Med. 2023;34(2):145-154. doi: 10.3233/JRS-210077.
Morbidity and Mortality meetings (M&Ms) are a fundamental element of surgical practice. However, there has been little investigation into best practices, to maximise education and improvement outcomes.
Create a new, evidence-based M&M methodology, that facilitates standardised analysis of errors in a non-judgemental fashion, and highlights areas for improvement.
A Quality Improvement (QI) methodology was used. This project encompassed a literature review and two sequential QI cycles. A literature review and initial survey highlighted best practice and identified areas for improvement. From this information, a new standardised format was created, which centred around a new modified Fishbone framework, incorporating the London Protocol methodology. The project then sequentially tested new formats, with feedback collected for every new format.
The literature review and surveys guided improvement of the M&M. The need for standardisation was highlighted. The new PowerPoint template and modified Fishbone ensured presentations and analysis were consistent and systematic. Participants reported that M&Ms were more engaging, interactive and structured, ensuring improved discussion of errors. The modified Fishbone framework reinforced a blame-free, system-focused analysis.
M&Ms are a critical aspect of patient safety. This project utilised simple QI tools to encourage collaborative reflection, learning and improvement.
发病率和死亡率会议（M&Ms）是外科实践的基本要素。然而，对于如何最大限度地提高教育和改善效果的最佳实践，研究甚少。
创建一种新的基于证据的 M&M 方法，以非评判的方式促进对错误的标准化分析，并突出改进的领域。
使用了质量改进（QI）方法。该项目包括文献回顾和两个连续的 QI 循环。文献回顾和初步调查突出了最佳实践，并确定了改进的领域。根据这些信息，创建了一个新的标准化格式，该格式以新的改良鱼骨框架为中心，纳入了伦敦议定书方法。该项目随后连续测试了新的格式，并为每个新格式收集反馈。
文献回顾和调查指导了 M&M 的改进。需要标准化。新的 PowerPoint 模板和改良的鱼骨框架确保了演示和分析的一致性和系统性。参与者报告说，M&Ms 更具吸引力、互动性和结构性，确保了对错误的更深入讨论。改良的鱼骨框架强化了无责、以系统为中心的分析。
M&Ms 是患者安全的关键方面。该项目利用简单的 QI 工具鼓励协作反思、学习和改进。
