Presentation Authors: Justin Ahn*, Bruce Dalkin, Hunter Wessells, Mathew Sorensen, Seattle, WA
Introduction: Present day morbidity and mortality conferences have several limitations. They are typically conducted in a large public forum amongst peers and superiors, they can be an intimidating environment for the clinician responsible, extensive presenter preparation is frequently required, and only complications meeting a certain severity (death, readmission, etc.) are discussed. Safety experts in other high-risk professions seriously value learning from near-miss and unsafe events which arguably happen exponentially more frequently than serious complications (Figure 1). We introduced a new conference format separate from our department&[prime]s morbidity and mortality conference to address these limitations.
Methods: We implemented a new resident-run quality improvement conference where near-miss clinical events and personal medical errors could be disclosed in a safe environment. This 1-hour conference, held quarterly, only permits residents to attend with the exception of one trusted faculty member to serve as a moderator. Residents were only asked to each present one case in a 2-minute synopsis or less (no PowerPoint slides required) with an additional 3 minutes for group discussion per case. Presenters would disclose what happened, what he or she learned, and what could have been done differently. Group discussion served to support the reporter, analyze the case, and propose solutions for prevention. Residents were administered surveys after the first session.
Results: The conference was very well received with 8 of 8 (100%) surveyed residents highly recommending that the conference continue and recur at bimonthly intervals. Cases presented ranged in severity from near-inadvertent ureteral stent placement on the wrong side to forgetting about patient follow up. None of these cases would have been discussed at our morbidity and mortality conference based on their criteria. Residents felt that the conference was more educational than expected, was a safer environment for disclosing personal error, and sparked numerous quality improvement project ideas.
Conclusions: Disclosing personal medical errors can be difficult and near miss clinical complications in our field are likely under reported and analyzed. We propose a new, more resident centered quality improvement conference to better prevent recurrent clinical error.