Related Experiment Videos
Nursing Morbidity and Mortality: The Clinical Nurse Specialist Role in Improving Patient Outcomes
Kathleen Evanovich Zavotsky1, Melissa Ciccarelli, Vicky Pontieri-Lewis
1Author Affiliations: Assistant Vice President, The Center for Professional Development, Innovation, and Research (Dr Zavotsky); Clinical Nurse Educator, Neuro/Orthopedics (Ms Ciccarelli); Clinical Nurse Specialist, Wound Ostomy and Continence (Ms Pontieri-Lewis); Clinical Nurse Educator, Surgical Critical Care (Ms Royal); and Clinical Nurse Educator, Respiratory Care/Behavioral Health (Ms Russer), Robert Wood Johnson University Hospital, New Brunswick, New Jersey.
Purpose:
The purpose of this article is to discuss the development and implementation of a nursing morbidity and mortality (M&M) monthly conference at an academic medical center. Nursing M&M was developed as a peer review process in which cases where clinical errors or misjudgments that have occurred are reviewed in a nonpunitive setting. The cases are selected based on the National Database for Nursing Quality Indicators and the implications they have for the quality of nursing practice.
Background/Rationale:
Morbidity and mortality conferences are well documented in the physician arena as an avenue to review and discuss adverse events. There is little published in the literature related to nursing using this peer review format and what impact this forum can have on clinical outcomes. Clinical nurse specialists and clinical nurse educators are oftentimes positioned to help implement this type of forum and evaluate the impact that it has for the staff and patients that they work with.
Description:
The clinical nurse specialists/clinical nurse educators at this fourth-time designated Magnet® academic medical center facilitate the monthly M&M and select 4 to 5 cases to present. At the end of each brief presentation, the outcome is determined to be either preventable or unpreventable. Action items for educational needs are also identified.
Outcomes:
Nursing M&M has been well attended over the past year. Since its inception, multiple practice changes have been implemented. Based on the positive feedback from the evaluations, this monthly conference has become standing practice in the institution.
Insights
A new nursing morbidity and mortality (M&M) conference was implemented at an academic medical center. This peer review process has led to significant practice changes and positive outcomes for nursing quality.
Area of Science:
- Nursing Quality Improvement
- Patient Safety
- Healthcare Management
Background:
- Morbidity and mortality (M&M) conferences are established for physicians to review adverse events.
- Limited literature exists on nursing-focused M&M conferences and their impact on clinical outcomes.
- Clinical nurse specialists and educators are key in implementing and evaluating such forums.
Purpose of the Study:
- To describe the development and implementation of a nursing M&M conference at an academic medical center.
- To establish a non-punitive peer review process for clinical errors and misjudgments in nursing practice.
- To utilize cases from the National Database for Nursing Quality Indicators for quality improvement.
Main Methods:
- Monthly nursing M&M conferences facilitated by clinical nurse specialists/educators.
- Selection of 4-5 cases per conference based on quality indicators.
- Determination of case outcomes (preventable/unpreventable) and identification of educational action items.
Main Results:
- Consistent high attendance at the nursing M&M conferences over the past year.
- Implementation of multiple practice changes resulting from case reviews.
- Positive participant feedback leading to the conference becoming a standing institutional practice.
Conclusions:
- The nursing M&M conference is a valuable tool for enhancing nursing practice and patient safety.
- The peer review model effectively identifies areas for improvement and drives practice change.
- Sustained implementation of nursing M&M conferences can lead to measurable improvements in healthcare quality.
Related Concept Videos
01:27Nursing Clinical Information System
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
01:22Nursing Diagnosis
The nursing diagnosis focuses on evidence-based...
01:30National Nursing Organizations II
The AACN emphasizes a healthy work environment through six standards to achieve an optimal patient outcome. The standards are appropriate staffing, meaningful recognition, collaboration, authentic leadership, effective communication, and decision-making. In addition, AACN provides certification programs, webinars, journals, and...
01:29Nursing Interventions II: Selecting and Classifying the Nursing Interventions
01:28Current Trends in Nursing I
01:29Aims Of Nursing