RT Journal Article
SR Electronic
T1 Trying to Improve Care: The Morbidity and Mortality Conference in a Division of Rheumatology
JF The Journal of Rheumatology
JO J Rheumatol
FD The Journal of Rheumatology
SP 2452
OP 2458
DO 10.3899/jrheum.140203
VO 41
IS 12
A1 Michelle Batthish
A1 Shirley M.L. Tse
A1 Brian M. Feldman
A1 G. Ross Baker
A1 Ronald M. Laxer
YR 2014
UL http://www.jrheum.org/content/41/12/2452.abstract
AB Objective. To describe the frequency and types of reported adverse events and system improvement recommendations in the Morbidity and Mortality Conference (M&MC) within the Division of Rheumatology at The Hospital for Sick Children, Toronto, Ontario, Canada (SickKids). Methods. A 5-year retrospective review of the M&MC within the Division of Rheumatology at SickKids was completed. Descriptive data including the number and types of events reported were collected. Events were categorized using an adaptation of the National Coordinating Council for Medication Error Reporting and Prevention Index. Recommendations were classified according to the Institute for Safe Medication Practices Canada. Results. Between January 2007 and December 2011, 30 regularly scheduled M&MC were held. Eighty-three cases were reviewed. The most common types of reported events were related to “miscommunication” (34.9%), “treatment/test/procedure” (22.9%), “adverse drug reactions” (12.0%), and “medication errors” (8.4%). Category A events (“an event that has the capacity to cause error”) were the most common with 39.8% of the cases, followed by Category C events (“an event occurred that reached the patient, but did not cause harm”) with 28.9%. Eighty-nine recommendations were made. Over half of these were classified as “information” (58.4%), followed by 11 “rules and policies” recommendations (12.4%). Of the 36 action items generated from these recommendations, most are either complete or ongoing. Conclusion. The M&MC within the Division of Rheumatology reviews a variety of events. Increased reporting of adverse events can lead to system improvements, and has the potential to improve and promote safer healthcare.