New cutting-edge technologies, the unique needs of patients, a constantly increasing volume of care, and the need for versatility among healthcare professionals require our healthcare system to develop a vicarious and multimodal organizational network.
While awaiting the development of such a network, the growing complexity of healthcare activities, combined with strains on human resources, increases the risk of adverse events.
Identifying and understanding these events through systemic analysis in order to learn from them (and prevent their recurrence) is fundamental.
Morbidity and Mortality Meetings (MMM) or Experience Feedback Committees (CREX) are dedicated forums for sharing experiences and analyzing events that may include accidents, incidents, or near misses, sometimes referred to as "close misses" in English. The analysis also provides an opportunity to revisit key solutions such as teamwork. CREX (Critical Feedback and Experience) reports result from a multidisciplinary approach to analyzing a specific event, leading to improvement measures. These committees, which generally meet monthly, are intended to complement the Morbidity and Mortality Reviews (MMRs) by addressing identified precursors upstream of the incident.
Use these meeting times to develop a culture of best practices
According to the French National Authority for Health (HAS), a Morbidity and Mortality Review is a “collective, retrospective, and systemic analysis of cases marked by the occurrence of a death, a complication, or an event that could have caused harm to the patient, and whose objective is the implementation and monitoring of actions to improve patient care and the safety of care.”*
In concrete terms, it is a comprehensive analysis that allows for a diagnosis of a team's functioning and enables the implementation of a program to improve practices. It allows us to move beyond reflection solely focused on one or more individuals.
The French National Authority for Health (HAS) emphasizes the importance of "seeking the causes, not who is at fault." This approach involves understanding what happened during the adverse event without blaming healthcare professionals. Therefore, the facilitator must maintain strict neutrality in the opinions heard and avoid acting as a judge. Analyzing adverse events helps improve the quality and safety of care and is not about blaming healthcare professionals or finding someone to blame. Following this analysis, lessons can be learned about existing strengths and vulnerabilities to inform actions aimed at improving the quality and safety of care. For a successful Morbidity and Mortality Review (MMR), it is essential to offer an approach based on objective analysis and grounded in a fair and positive culture. An ethical commitment from the facilitator and other participants is necessary. Respect for the confidentiality of participants' statements and the cases studied is paramount. The criteria for good conduct for a successful morbidity and mortality meeting are: listening to other participants, respecting professional secrecy, respecting the confidentiality of participants' statements, respecting the confidentiality of the cases studied, no blaming, no judgments. src="https://cdn.prod.website-files.com/61f1c5bbc327ec3679e7457c/62778d24ee72c11d0e8c1e3f_Capture%20d%E2%80%99e%CC%81cran%202022-05-08%20a%CC%80%2011.22.30.png" width="auto" height="auto" loading="lazy">
Key Stages in CREX - RMM
Traditionally, these exchange sessions follow different key stages:
- Reconstructing the Event Chronology:
The care process is broken down into successive chronological stages.
When the fact Did it happen? Who are the actors involved (anonymously)? What actions (or omissions) were performed by these actors? How were the actions carried out (what means were used)?
- Investigation of the causes of the event:
Many factors can explain why adverse events occur: the number of actors involved with the patient, their interactions, task interruptions, stress or fatigue management…
Thus, prior to the error, it is necessary to understand the malfunctions and identify all the causes (immediate and underlying) that contributed to the occurrence of the event. These only become apparent during a thorough analysis of the causes.
- Analysis of safety barriers:
Safety barriers correspond to all the human, technical, or organizational means that make it possible to prevent the occurrence of an adverse event, to recover from it when it occurs, or to mitigate the severity of its consequences.
- Action plan and follow-up:
Following this in-depth analysis of the adverse event, corrective actions and the methods for their implementation must be chosen.
In the analysis process, our experts believe it is also very valuable to share successes or the elements that made it possible to recover from a situation that was off to a bad start. Sharing successes also has the advantage of focusing on what works rather than what doesn't. The corollary to this questioning is to then safeguard the elements of success: briefing, checklist, clear distribution of roles…
Simple things can help you analyze your experiences: favor questions that begin with how rather than questions that begin with why. The risk of questions that begin with why is that they lead to a sterile search for causes, hindering the improvement of care activities, while questions that begin with how allow healthcare facilities to pinpoint organizational functioning.
SafeTeam and the organization of a morbidity and mortality meeting
The analysis of a medical incident cannot be improvised.
To improve patient safety in your facility and adopt a modern risk management approach, it is essential to evolve your meetings to make them multidisciplinary and informative. With this in mind, the SafeTeam Academy has designed a training program on organizing and conducting a Morbidity and Mortality Review (MMR) meeting. In this program, participants will lead or participate in a MMR following a medication error. They will be assessed on their skills in safety culture and will systematically analyze their activity. At the end of the module, they will attend a presentation explaining the key steps of these patient safety meetings. If you too would like to contribute to improving the reliability of care within your facilities, SafeTeam Academy training courses are for you! For more information, write to the following address: contact@safeteam.academy.
