1. Morbidity and Mortality Conference

2. M&M Conference “a forum in which members of a multidisciplinary health care team….engage in objective, non- judgemental review of adverse outcomes and commit to systematic process change.” Reminder: All participants are reminded that this is a privileged and confidential meeting- subject to peer review and medical review protections at University of Colorado Hospital and in the State of Colorado.

3. Overview Review of case Clinical Pearls from Case Review of adverse event Identify contributory factors including systems and cognitive failures Identify ways to reduce likelihood of this happening again Identify how we will know the risk of the event is reduced

4. The Case History of Present Illness

5. Anesthetic Plan

6. Timeline of events during case

7. Timeline for post op period (if applicable)

8. Analysis of case Diagnostic or Therapeutic questions Clinical Pearls

9. What happened? Adverse Event

10. Why did this adverse event happen? 5 why’s tool- to help fill in the tools below RCA/Fishbone Vanderbilt matrix

11. 11 PRACTICE-BASED LEARNING AND IMPROVEMENT (What have we learned, what will we improve) Improvement SYSTEM-BASED PRACTICE (What is the Process? On whom do we depend and who depends on us) PROFESSIONALISM (How must we act) INTERPERSONAL AND COMMUNICATION SKILLS (What must we say) MEDICAL KNOWLEDGE (What must we know) PATIENT CARE (Overall Assessment) Yes/No Assessment PATIENT- CENTERED EQUITABLEEFFICIENTEFFECTIVETIMELYSAFE Aims Competencies Healthcare Matrix: Care of Patient(s) with…. © 2004 Bingham, Quinn Vanderbilt University

12. 12 Linking outcomes of care and the ACGME core competencies, Quinn and Bingham, 2007

13. RCA, Fishbone Patient Factors Individual/St aff Factors Physical, psychological, cognitive, personality Individual/St aff Factors Physical, psychological, cognitive, personality Task Factor Guidelines, Protocols, task design Task Factor Guidelines, Protocols, task design Supplies and Equipment Availability, Functionality, Competence, usability Supplies and Equipment Availability, Functionality, Competence, usability Education/Training Factors Competence, supervision Avail, appropriateness Education/Training Factors Competence, supervision Avail, appropriateness Working Conditions Physical environ, Staffing, hours, time Working Conditions Physical environ, Staffing, hours, time Organizational Priorities, Safety culture Organizational Priorities, Safety culture Communication Verbal, written, nonverbral Communication Verbal, written, nonverbral Team Factors Role congruence, Leadership, culture, Support, Team Factors Role congruence, Leadership, culture, Support, Adverse Event Adverse Event Source-NHS

14. How can we reduce this risk of this happening again?

15. How can we measure the effectiveness of the changes proposed?