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Perioperative Team-Based Morbidity and Mortality Conferences: A Systematic Review of the Literature
Aubrey Samost-Williams1, Roni Rosen2, Alexander Hannenberg3
1From the Department of Anesthesia, Critical Care, and Pain Medicine, University of Texas Health Science Center at Houston, Houston, TX.
Objective:
This systematic review aimed to identify key elements of perioperative team-based morbidity and mortality conferences (TBMMs) and their impact on patient safety, education, and quality improvement outcomes.
Background:
Patient safety in the perioperative period is influenced by system, team, and individual behaviors. However, despite this recognition, single-discipline morbidity and mortality conferences remain a mainstay of educational and quality improvement efforts.
Methods:
A structured search was conducted in MEDLINE Complete, Embase, Web of Science, ClinicalTrials.gov, Cochrane CENTRAL, and ProQuest Dissertations and Theses Global in July 2022. Search results were screened, and the articles meeting inclusion criteria were abstracted.
Results:
Seven studies were identified. Key TBMM elements were identified, including activities done before the conference-case selection and case investigation; during the conference-standardized presentation formats and formal moderators; and after the conference-follow-up emails and quality improvement projects. The impacts of TBMMs on educational, safety, and quality improvement outcomes were heterogeneous, and no meta-analysis could be conducted; however, improvement was typically shown in each of these domains where comparisons were made.
Conclusions:
Recommendations for key TBMM elements can be drawn from the reports of successful perioperative TBMMs. Possible benefits of structured TBMMs over single-discipline conferences were identified for further exploration, including opportunities for rich educational contributions for trainees, improved patient safety, and the potential for system-wide quality improvement. Design and implementation of TBMM should address meticulous preparation of cases, standardized presentation format, and effective facilitation to increase the likelihood of realizing the potential benefits.
Insights
This review identifies key elements of perioperative team-based morbidity and mortality conferences (TBMMs) and their impact on patient safety and education. Structured TBMMs show potential benefits over single-discipline conferences for quality improvement.
Area of Science:
- Medical Education
- Patient Safety
- Quality Improvement
Background:
- Perioperative patient safety relies on system, team, and individual factors.
- Traditional single-discipline morbidity and mortality conferences are common but may not fully address complex patient safety issues.
Purpose of the Study:
- To identify essential components of perioperative team-based morbidity and mortality conferences (TBMMs).
- To evaluate the impact of TBMMs on patient safety, medical education, and quality improvement.
Main Methods:
- A systematic literature search was performed across multiple databases in July 2022.
- Included studies were screened, and relevant data were abstracted.
Main Results:
- Seven studies were identified, detailing key TBMM elements: pre-conference case selection/investigation, in-conference standardized formats/moderators, and post-conference follow-up/QI projects.
- While results were heterogeneous, TBMMs demonstrated improvements in educational, safety, and quality improvement outcomes where comparisons were made.
Conclusions:
- Key elements for successful perioperative TBMMs include meticulous preparation, standardized presentations, and effective facilitation.
- Structured TBMMs offer potential advantages over single-discipline conferences, including enhanced trainee education, improved patient safety, and system-wide quality improvement.
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