Anonymity Decreases the Punitive Nature of a Departmental Morbidity and Mortality Conference

被引:8
|
作者
Jansson, Paul S. [1 ,2 ,3 ]
Schuur, Jeremiah D. [2 ,3 ]
Baker, Olesya [2 ]
Hagan, Sean C. [2 ]
Nadel, Eric S. [1 ,2 ,3 ]
Aaronson, Emily L. [1 ,3 ]
机构
[1] Massachusetts Gen Hosp, Dept Emergency Med, Boston, MA 02114 USA
[2] Brigham & Womens Hosp, Dept Emergency Med, 75 Francis St, Boston, MA 02115 USA
[3] Harvard Med Sch, Dept Emergency Med, Boston, MA 02115 USA
关键词
morbidity and mortality conference; anonymity; error; culture of safety; system errors; individual errors; error analysis; graduate medical education; PATIENT SAFETY; REVISED MORBIDITY; CULTURE; FORMAT;
D O I
10.1097/PTS.0000000000000555
中图分类号
R19 [保健组织与事业(卫生事业管理)];
学科分类号
摘要
Objectives We sought to analyze the effect of an anonymous morbidity and mortality (M&M) conference on participants' attitudes toward the educational and punitive nature of the conference. We theorized that an anonymous conference might be more educational, less punitive, and would shift analysis of cases toward systems-based analysis and away from individual cognitive errors. Methods We implemented an anonymous M&M conference at an academic emergency medicine program. Using a pre-post design, we assessed attitudes toward the educational and punitive nature of the conference as well as the perceived focus on systems versus individual errors analyzed during the conference. Means and standard deviations were compared using a paired t test. Results Fifteen conferences were held during the study period and 53 cases were presented. Sixty percent of eligible participants (n = 38) completed both the pretest and posttest assessments. There was no difference in the perceived educational value of the conference (4.42 versus 4.37, P = 0.661), but the conference was perceived to be less punitive (2.08 versus 1.76, P = 0.017). There was no difference between the perceived focus of the conference on systems (2.76 versus 2.76, P = 1.00) versus individual (4.21 versus 4.16, P = 0.644) errors. Most participants (59.5%) preferred that the conference remain anonymous. Conclusions We assessed the effect of anonymity in our departmental M&M conference for a 7-month period and found no difference in the perceived effect of M&M on the educational nature of the conference but found a small improvement in the punitive nature of the conference.
引用
收藏
页码:E86 / E89
页数:4
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