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How to manage a mortality/morbidity meeting (MMM)?

How to manage a mortality/morbidity meeting (MMM)?. T. Pottecher thierry.pottecher@chru-strasbourg.fr. What is this?. Morbidity/mortality meeting is: Analysis of all deaths Analysis of some unexpected issues. How to do it?.

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How to manage a mortality/morbidity meeting (MMM)?

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  1. How to manage a mortality/morbidity meeting (MMM)? T. Pottecher thierry.pottecher@chru-strasbourg.fr

  2. What is this? • Morbidity/mortality meeting is: • Analysis of all deaths • Analysis of some unexpected issues

  3. How to do it? Meeting with all physicians, but other professionnels ( nurses, physiotherapist, …) involved are concerned

  4. Who is concerned ? Inviting other physicians (from elsewhere) is seldom performed In routine practice, MMM is an efficient tool for improvement of practices

  5. MMM is not… • Self defence or self satisfaction, • Court in which the physician in charge of unexpected event may feel guilty, • Meeting in which real problems will not be discussed.

  6. Backwards…. • Used in US (since 1920) as a pedagogic tool • Initiated in surgery • Progressive extension to other specialities and countries • French experiences only seldom • Initiated by teams (surgery, anesthesiology, intensive care,….) • Now recommended by HAS (V2) (French High Health Autority)

  7. Theory Practice

  8. How to organize? • Written document explaining : • Occurrence and meeting duration • Interest for attendants(EPP Value) • How cases are choosen • Who are expected attendants • Written report • Improvements expected

  9. Main objective? • Examin, with criticism, how the patient was cared • Was the unexpected event avoidable? • Together, try to explain why the unexpected event has occured

  10. Expected result? Define what must be done to avoid a new case with this unexpected issue. Improvement actions must be decided and planned Define who is in charge, objectives and landmarks of improvements

  11. Questions to answer in case of unexpectedevent (1) What did really occur? Define dommage and consequence Analysis of event’s chain leading to unexpected event?

  12. Questions to answer in case of unexpectedevent (2) • Obvious causes? • Is the event related to medical product or to unadaptedprocess? • Is there any human factor in the event: • Did professional do what they are supposed to do? • Did professionnel knew what they had to do? • Could a better supervision avoid this event?

  13. Questions to answer in case of unexpected event(3) • Hidden causes? • Organization, responsabilities …reallyexplained? • Was communication between care givers efficient? • Washealth care team composition adapted to workload? • Equipments …..adapted? • Lack of security culture?

  14. Questions to answer in case of unexpected event(4) • Preventivemeasures : • Is the prevention system efficient? • What conclusion to avoidthisevent?

  15. Deming’s wheel… Do : decide to explore unexpected events Analyse : Unexpected issues are analysed; Improve : Care givers will improve their organization and pratices to reduce the risk of unexepcted event Plane : Organize care to avoid this event and decide of landmarks which will be measured

  16. Theory Practice

  17. Organization of MMM in a universitary unit of anesthesiology

  18. Réunion morbi-mortalité Toxicité des anesthésiques locaux Information Docteur M. BARON Mercredi 4 novembre 2009 à 16 h salle de réunion d’anesthésie – Hôpital de Hautepierre

  19. Report

  20. Réunion morbi-mortalité ouverte aux anesthésistes, aux IADE et aux IBODE Information Evènement indésirable lors d'une transfusion sanguine Animateurs : J. Hansmann, H. Mohammed Jeudi 22 avril 2010 à 14 h 30 Colloque du niveau 4 – Hôpital de Hautepierre

  21. To improve discussion

  22. Réunion morbi-mortalité Syndrome d'apnées du sommeil Docteurs A. CHARTON et C. PERICARD Mardi 29 juin 2010 à 16 h 00 salle de réunion d’anesthésie – Hôpital de Hautepierre

  23. SAOS connu SAOS suspecté (SAS >15) CPAP disponible Pas de CPAP Risque postop + Risque postop - Newprocedure SSPI durée habituelle SSPI durée habituelle SSPI prolongée de 3 h complication complication RAS RAS complication Selon chirurgie: Ambul,service, soins continus Selon chirurgie: Ambul,service, soins continus Surveillance continue ou SSPI (24h)

  24. Réunion morbi-mortalité Information Surdosage en morphine chez un enfant Docteur C. JEANPIERRE Mercredi 8 décembre 2010 à 16 h 00 salle de réunion d’Anesthésie – Hôpital de Hautepierre

  25. Réunion morbi-mortalité Erreurs médicamenteuses Animateurs : M. Tucella, C. Péricard, F. Barthel Jeudi 9 juin 2011 à 17 h 00 salle de réunion d’Anesthésie – Hôpital de Hautepierre

  26. To conclude, • Initially feared by physicians • Personnal conflicts • Medicolegal consequencies • Today, well accepted • No conflicts between physicians • Practical consequencies evident for anyone

  27. Try it…It’s like russian bathsyou w’ll quickly adopt it…

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