UT Southwestern Medical Center, Dallas, TX, USA.
Clin Pediatr (Phila). 2024 Mar;63(3):325-333. doi: 10.1177/00099228231172486. Epub 2023 May 6.
Children are vulnerable to medical errors. Adverse events are leveraged as educational tools in Morbidity and Mortality (M&M) Conference. Traditionally, M&M has brought angst when discussing adverse events. Our goal was to transition M&M to an educational environment highlighting system failures. A survey was created to capture data on satisfaction, education, and system process improvement. Feedback from the surveys led to several changes, including fostering a multidisciplinary forum, prioritizing educational topics, and emphasizing process improvement. In 5 years, satisfaction with M&M Conference has increased by 29%, with an increase by 50% when asked if process improvement issues were addressed adequately, and 100% of faculty incorporate what they learn from M&M into their practice. By developing a hands-on approach to M&M, we have improved satisfaction and focused on education and system process improvement. This design could be used throughout the medical community to improve discussion of adverse events which should improve patient safety.
儿童易受医疗差错影响。不良事件在发病率和死亡率（M&M）会议上被用作教育工具。传统上，在讨论不良事件时，M&M 会议会引起焦虑。我们的目标是将 M&M 会议转变为一个强调系统故障的教育环境。创建了一份调查来收集关于满意度、教育和系统流程改进的数据。调查反馈带来了一些变化，包括培养多学科论坛、优先考虑教育主题以及强调流程改进。在 5 年内，M&M 会议的满意度提高了 29%，当被问及是否充分解决了流程改进问题时，满意度增加了 50%，并且 100%的教师将他们从 M&M 中学到的知识应用到他们的实践中。通过对 M&M 会议采取实际操作的方法，我们提高了满意度，并专注于教育和系统流程改进。这种设计可以在整个医疗社区中使用，以改善对不良事件的讨论，从而提高患者安全性。
