Key result
System-based morbidity and mortality conferences achieve a ~53% implementation rate for actionable clinical recommendations.
Why the study?
System-based morbidity and mortality conferences offer a unique perspective on patient safety by dissecting systemic factors contributing to adverse events, particularly within the constraints of limited resources.
Does a system-based Morbidity and Mortality Conference (MMC) using an adapted ALARM framework identify systemic contributing factors and facilitate the implementation of safety improvements in adult patients with severe postoperative intraperitoneal bleeding following gastric and pancreatic cancer surgery?
Observational (n=25)
No
Does a system-based Morbidity and Mortality Conference (MMC) using an adapted ALARM framework identify systemic contributing factors and facilitate the implementation of safety improvements in adult patients with severe postoperative intraperitoneal bleeding following gastric and pancreatic cancer surgery?
System-based morbidity and mortality conferences utilizing the ALARM framework effectively identified organizational and postoperative management failures contributing to post-surgical hemorrhage, resulting in a 53.3% implementation rate of targeted quality improvement protocols in a resource-limited oncology setting.
May support system-based M&Ms for safety reviews in surgical oncology; leaves open impact on outcomes and generalizability.
Morbidity and mortality conferences (MMCs) have evolved beyond their traditional educational role to become instrumental in enhancing patient safety. System-based MMCs offer a unique perspective on patient safety by dissecting systemic factors contributing to adverse events. This paper reviews the impact of MMC in managing postoperative bleeding after gastric and pancreatic cancer surgery, within the constraints of limited resources. The study conducted at the National Institute of Oncology in Rabat, Morocco, analysed 18 MMC of haemorrhage following gastric and pancreatic surgeries and allowed to identify two patterns of cumulative factors contributing to adverse events. The first one relates to organisational issues and the second to postoperative management. Fifteen recommendations of improvement emerged from MMC addressing elements of these patterns with an implementation rate of 53.3%.
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Lahnaoui et al. (2024) conducted an observational in Postoperative intraperitoneal bleeding following gastric and pancreatic cancer surgery (n=25). System-based morbidity and mortality conferences (MMCs) using the ALARM framework was evaluated on Implementation rate of improvement recommendations emerging from morbidity and mortality conferences. System-based morbidity and mortality conferences analyzing 18 postoperative bleeding cases identified 106 systemic problems and generated 15 improvement recommendations with a 53.3% implementation rate.
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