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标题：An innovative resident-driven mortality case review curriculum to teach and drive system-based practice improvements in the United States
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作者：Nila S.Radhakrishnan ; Margaret C.Lo ; Rohit Bishnoi 等
期刊名称：Journal of Educational Evaluation for Health Professions
电子版ISSN：1975-5937
出版年度：2018
卷号：15
期号：1
页码：1-8
DOI：10.3352/jeehp.2018.15.31
语种：English
出版社：Korea Health Insurance Licensing Examination Institute
摘要：Purpose:Traditionally,the morbidity and mortality conference (M&MC) is a forum where possible medical errors are discussed.Although M&MCs can facilitate identification of opportunities for systemwide improvements,few studies have described their use for this purpose,particularly in residency training programs.This paper describes the use of M&MC case review as a quality improvement activity that teaches system-based practice and can engage residents in improving systems of care.Methods:Internal medicine residents at a tertiary care academic medical center reviewed 347 consecutive mortalities from March 2014 to September 2017.The residents used case review worksheets to categorize and track causes of mortality,and then debriefed with a faculty member.Selected cases were then presented at a larger interdepartmental meeting and action items were implemented.Descriptive statistics and thematic analysis were used to analyze the results.Results:The residents identified a possible diagnostic mismatch at some point from admission to death in 54.5% of cases (n= 189) and a possible need for improved management in 48.0% of cases.Three possible management failure themes were identified,including failure to plan,failure to communicate,and failure to rescue,which accounted for 21.9%,10.7 %,and 10.1% of cases,respectively.Following these reviews,quality improvement initiatives proposed by residents led to system-based changes.Conclusion:A resident-driven mortality review curriculum can lead to improvements in systems of care.This novel type of curriculum can be used to teach system-based practice.The recruitment of teaching faculty with expertise in quality improvement and mortality case analyses is essential for such a project.
关键词：Purpose:Traditionally,the morbidity and mortality conference (M&MC) is a forum where possible medical errors are discussed.Although M&MCs can facilitate identification of opportunities for systemwide improvements,few studies have described their use for this purpose,particularly in residency training programs.This paper describes the use of M&MC case review as a quality improvement activity that teaches system-based practice and can engage residents in improving systems of care.Methods:Internal medicine residents at a tertiary care academic medical center reviewed 347 consecutive mortalities from March 2014 to September 2017.The residents used case review worksheets to categorize and track causes of mortality,and then debriefed with a faculty member.Selected cases were then presented at a larger interdepartmental meeting and action items were implemented.Descriptive statistics and thematic analysis were used to analyze the results.Results:The residents identified a possible diagnostic mismatch at some point from admission to death in 54.5% of cases (n= 189) and a possible need for improved management in 48.0% of cases.Three possible management failure themes were identified,including failure to plan,failure to communicate,and failure to rescue,which accounted for 21.9%,10.7 %,and 10.1% of cases,respectively.Following these reviews,quality improvement initiatives proposed by residents led to system-based changes.Conclusion:A resident-driven mortality review curriculum can lead to improvements in systems of care.This novel type of curriculum can be used to teach system-based practice.The recruitment of teaching faculty with expertise in quality improvement and mortality case analyses is essential for such a project.