A resident-driven mortality case review innovation to teach and drive system-based practice improvements in the...

Traditionally, Morbidity and Mortality Conference (M&MC) are forums where medical errors are discussed. Though M&MC can lead to identification of opportunities for system wide improvements, there is little in the literature to describe the use for this purpose, particularly in residency training programs. This paper describes the use of M&MC case review as a quality improvement activity that teaches systems-based practice and can engage residents in improving systems of care.

Internal medicine residents at a tertiary care academic medical center reviewed 347 consecutive mortalities from March 2104 to September 2017. Residents used case review worksheets to categorize and track causes of mortality. The residents then debriefed with a faculty member. Selected cases were then presented at a larger interdepartmental meeting and action items were implemented. Descriptive statistics and thematic analysis were used to analyze the results.

The residents identified a diagnosis mismatch from admission to death in 54.5 % (n=189) of cases and possible need for improvement in management in 48.0% cases. Three 'management failure' themes were identified including failures to plan, failure to communicate and failure to rescue, consisting of 21.9%, 10.7 %, and 10.1% of cases respectively. Following the reviews, quality improvement initiatives proposed by residents lead to system-based changes.

A resident-driven mortality review curriculum can lead to improvement in systems of care. This type of novel curriculum can teach systems-based practice. The recruitment of teaching faculty with expertise in quality improvement and mortality case analyses is essential for such a project.