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J Rheumatol. 2014 Dec;41(12):2452-8. doi: 10.3899/jrheum.140203. Epub 2014 Nov 1.

Trying to improve care: the Morbidity and Mortality Conference in a division of rheumatology.

Author information

1
From the Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton; Division of Rheumatology, Department of Pediatrics, Department of Medicine, The Hospital for Sick Children; Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.M. Batthish, MD, Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University; S.M.L. Tse, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto; B.M. Feldman, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto; G.R. Baker, PhD, Institute of Health Policy, Management and Evaluation, University of Toronto; R.M. Laxer, MD, Division of Rheumatology, Departments of Pediatrics and Medicine, The Hospital for Sick Children, University of Toronto. batthim@mcmaster.ca.
2
From the Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton; Division of Rheumatology, Department of Pediatrics, Department of Medicine, The Hospital for Sick Children; Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.M. Batthish, MD, Division of Rheumatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University; S.M.L. Tse, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto; B.M. Feldman, MD, Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Dalla Lana School of Public Health, University of Toronto; G.R. Baker, PhD, Institute of Health Policy, Management and Evaluation, University of Toronto; R.M. Laxer, MD, Division of Rheumatology, Departments of Pediatrics and Medicine, The Hospital for Sick Children, University of Toronto.

Abstract

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.

KEYWORDS:

MORBIDITY; MORTALITY; RHEUMATIC DISEASES

PMID:
25362651
DOI:
10.3899/jrheum.140203
[Indexed for MEDLINE]

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