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Abstract
Morbidity and mortality conferences (MMCs) have evolved beyond their traditional educational role to become instrumental in enhancing patient safety. System-based MMCs offer a unique perspective on patient safety by dissecting systemic factors contributing to adverse events. This paper reviews the impact of MMC in managing postoperative bleeding after gastric and pancreatic cancer surgery, within the constraints of limited resources. The study conducted at the National Institute of Oncology in Rabat, Morocco, analysed 18 MMC of haemorrhage following gastric and pancreatic surgeries and allowed to identify two patterns of cumulative factors contributing to adverse events. The first one relates to organisational issues and the second to postoperative management. Fifteen recommendations of improvement emerged from MMC addressing elements of these patterns with an implementation rate of 53.3%.
- Healthcare quality improvement
- Morbidity and mortality rounds
- Patient safety
- Quality improvement
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
System-based morbidity and mortality conferences (MMCs) represent a new approach to analysing systemic causes of adverse events and enhance patient safety.
WHAT THIS STUDY ADDS
This study delves into the role MMC hold on examining a specific surgical complication surgery, by examining the process and diverse failure patterns in a resource-constrained context.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
system-based MMC may be instruments for analysing specific surgical complications and support ongoing process improvement and a cultural shift towards safer surgical environments.
Introduction
Morbidity and mortality conferences (MMCs) have been a long-standing tradition in the medical profession for over a century, initially intended as an educational platform for medical professionals and surgical residents by reviewing surgical complications and learning from errors. Since the publication of the landmark report To Err Is Human,1 MMCs have taken on a new role as a tool for improving quality and patient safety. By detecting and evaluating adverse events because of system performance, MMCs have added a new dimension to their well-established educational value.1 2
The recent concept of system-based MMC represents a paradigm shift in how we think about MMC. By analysing systemic mechanisms that lead to adverse events and understanding causation beyond individual errors, system-based MMCs offer a new perspective on patient safety. The rationale behind this idea is simple: healthcare environments are complex organisations with inherent weaknesses. Errors will inevitably occur when failures in local working conditions align. Recent studies3 4 have shown that by using a standardised method to identify potential system failures, addressing specific systems-based problems, instituting timely interventions and conducting regular follow-up, MMC can drive significant improvements in systems as well as patient safety and care. Moreover, by enabling open discussion without individual blame, MMC can promote a cultural change in healthcare.5
Previous studies assessed MMC in a general setting and included various heterogeneous medical situations, and none about a specific surgical complication.6 7 This study addresses this gap by examining 18 MMC of postoperative bleeding after gastric and pancreatic cancer surgery, aiming to assess the process of MMC and analysing different patterns of failures in the context of limited resources.
Methods
Study design and setting
This study was a retrospective analysis performed between January 2020 and January 2022 in the digestive surgical oncology department at the National Institute of Oncology (NIO) in Rabat, Morocco. The manuscript is written in accordance with the Standards for Quality Improvement Reporting Excellence Guidelines.8 Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.
The NIO, an academic anticancer centre affiliated with Ibn Sina University Center, Mohammed V University of Rabat, offers comprehensive cancer care, including surgery, radiology, medical oncology and more. The institute offers cancer care pathways including endoscopy, radiology, medical oncology, radiotherapy, surgery, intensive care, genetics and pathology. Diagnosis and therapeutic arteriography are unavailable at the hospital. At the time of the study, the digestive surgical oncology department had a capacity of seventeen beds. The team included 5 surgeons, 10 nurses, between 7 and 12 residents and 4 administrative personnel. Since 2019, the team has implemented weekly MMC to discuss all severe postoperative complications defined as postoperative morbidity >3a according to the Clavien-Dindo grading system.9
Case selection
We included in this study all the MMCs discussing a postoperative severe intraperitoneal bleeding, within 30 days of a curative surgery for gastric or pancreatic cancers, in adult patients (>18 years).
Exclusion criteria were bleeding after supramesocolic surgery and/or bleeding exteriorised from the digestive tract: haematemesis, rectal bleeding.
MMC process description
To ensure that critical contributory factors are considered during MMC, the team developed a standardised template for case analysis and presentation, adapted from the ‘Association of Litigation And Risk Management’ ALARM framework.10 The first version of the tool was reported in a previous study11 and included 50 questions covering the 7 ALARM categories: ‘patient’, ‘tasks’, ‘individual staff’, ‘team’, ‘work environment’ and ‘management’ and ‘institutional context’.
In April 2021, several workshops were held to improve the reporting tool, since it was considered long and time-consuming to use by residents. The 50 questions were merged to adapt to our institutional context, and the number of questions was reduced to 30. The two categories ‘organisational and management factors’ and ‘institutional context factors’ were also merged under ‘management and institutional context’, as suggested by Vincent et al.10 12
For the purpose of this study, the research team transformed all data from the cases discussed before April 2021 to correspond to the new template.
The current template is a spreadsheet created using Google Sheet web application (online supplemental file 1). It contains three pages. The first page provides a chronological sequence of events, including preoperative diagnosis and workup, surgical procedures, and postoperative course data. The second page identifies the adverse events and contextualises care-related issues in the preoperative, operative or postoperative period.
Supplemental material
The third page is designed to report and categorise contributing factors. It contains 30 items covering the 7 categories of the ALARM framework. Each contributing factor is substantiated with a textual explanation.
Once an adverse event within the scope of inclusion criteria is identified from the discharged patients’ list, the case is assigned to the surgical resident who was on call at the time of the complication, assuming he would have a better insight into the postoperative course. The resident prepares a non-interpretative chronological sequence of events, including all the relevant documentation from the patient’s medical and paramedical care. If needed, interviews with physicians, nurses, the patient and his family are done. Then, the resident performs a preliminary analysis of contributing and recovering factors. For each factor activated, a detailed description is added on the grid.
During the MMC, the resident presents the case using the template described above. A senior surgeon moderates the meeting, with the objective of encouraging discussion and reflection in a ‘blame-free’ environment. After the presentation, the multidisciplinary team discusses the case and agrees on contributing factors and improvement measures by consensus. All modifications are recorded during the meeting in the same document used for the presentation. All the modified presentations were stored in a shared folder, after removing all the information that may allow patients’ identification.
The resident who presented the case had to prepare and submit an actionable plan and present it during the next meeting. Once the team approved the improvement measure, it was implemented and shared via the department local website.
MMC analysis
All consecutive MMCs discussing the adverse events of this study were included. The research team studied each MMC to extract all identified contributory factors and improvement measures. Answers incriminating a contributing factor are referred to as ‘triggered contributory factor’.
To identify patterns of contribution to harm and/or failure to prevent harm, we performed an aggregation analysis of single cases to obtain a distribution (percentage) of triggered contributory factors and their respective ALARM categories. This process of aggregation also concerned improvement measures, allowing to report their implementation rate.
Results
Patients’ characteristics
From January 2020 to December 2022, 88 gastrectomies and 33 pancreatectomies were performed at NIO. In 25 cases (20.6%), intraperitoneal bleeding within 30 days from surgery occurred, following 18 gastrectomies and 7 pancreatectomies. Key patient characteristics are outlined in table 1. The primary symptom was bleeding through the abdominal drain, with 48% of patients having haemodynamic instability. CT scan angiography was performed on five patients, and none showed signs of bleeding. Emergency laparotomy identified the bleeding source in 64% of cases.
Characteristics of patients, disease and treatment of cases presenting postoperative bleeding
11 patients (44%) experienced bleeding recurrences, leading to 9 redo surgeries and 2 interventional radiology procedures. The overall mortality rate in bleeding cases was 36%.
MMCs’ analysis
Problems identified
Among the 25 cases, 18 were discussed in MMC (72 %). In total, the team identified 106 problems, with a median of 5 problems identified per patient (quartiles: 4–7.5). The most frequent problems were identified in the ‘patient’ category 23.6%, followed by ‘team’ 18.8%; ‘tasks’ 17.9% and ‘healthcare staff ‘15% (table 2).
Percentage of frequent identified problems among different categories
The most commonly activated ALARM category was ‘teams’ 94.4%, where the most frequent issues identified were related to the team structure, specifically understaffing with a highlight on the absence of a referent surgeon for the gastric surgery programme which entails a lack of a standardised surgical technique and perioperative care.
The second frequent failure related to communication with other departments, namely the radiology regarding difficulties in interpretation of CT scans, and the anaesthesiology department, where a miscommunication resulted in a misjudgement of urgency in four cases.
The second most frequently activated category was ‘tasks’ (14 meetings, 77.7%) where the lack or misuse of protocols was flagged in 8 cases. The lack of protocol for managing haemorrhage after supra mesocolic surgery was a triggered factor in five of these cases.
‘Healthcare staff’ category was activated in 66% of cases. This related essentially to the physical and mental state of the staff due to fatigue and heavy workload, especially during COVID-19 pandemic.
‘Patient’ category was activated in 61.1% of cases, accounting for case complexity and medical comorbidities of the patients.
‘Work environment’ category was triggered in 50% of MMC and the lack of equipment, mainly the unavailability of arteriography, was identified as a contributing factor in five cases.
The ‘management’ category was activated in 50% of cases. It includes out of hospital factors namely COVID-19 pandemic but more importantly, repeated difficulties in obtaining arteriography in a context of previously reported failures. Figure 1 describes the intrication of factors identified in different categories.
The intrication of systemic contributing factors identified in different categories through morbidity and mortality reviews.
Table 3 presents the rates of activation of each category and the most triggered factors. Percentages and details of all identified contributing factors for each case are shown in online supplemental files 2 and 3.
Supplemental material
Supplemental material
Number at percentages of activated categories and most contributing factors identified during morbidity and mortality conferences
Patterns of failure
Conclusively, two patterns of failures leading to adverse events can be described: the first one is related to an organisational aspect, where the absence of a structured programme supervised by a referent surgeon for gastric and pancreatic surgery translates in a lack of a standardised surgical technique and preoperative assessment.
The second pattern relates to postoperative management. An alarming combination of substantial work demands, coupled with a lack or deficiency in adhering to established protocols, led to an underestimation of the situation and delayed diagnosis and treatment. Furthermore, ineffective communication with radiology and anaesthesia contributed to diagnostic delay and misinterpretation of urgency.
Recommendations analysis
15 improvement recommendations emerged from the MMC, primarily addressing ‘team’ and ‘task’ categories. In the ‘tasks’ category, recommendations included protocol development for managing postoperative bleeding and gastrectomy-related complications. In the ‘team’ category, MMC mainly recommended the assignment of a gastric surgery referent (table 4).
Issued recommendations and implementation status
The implementation rate for these recommendations was 53.3%. Based on the identified contributing factors, various interventions were conducted both on departmental and organisational levels. Restructuring the surgical team included appointing a gastric surgery referent. Protocols for managing program-specific complications such as postoperative haemorrhage and postgastrectomy duodenal and pancreatic fistula were designed in collaboration with surgeons, surgical residents and nurses and implemented. Regular communication with the administration is initiated to facilitate radiologic interventions.
Discussion
Summary of the main results
This study explores system-based MMC’s role in enhancing patient safety through an analysis of postoperative bleeding following supra mesocolic cancer surgery. The findings highlight specific and systemic dysfunctions within an organisation, focusing on ‘team’ and ‘task’ categories of the ALARM framework. Two distinct patterns of cumulative factors contributing to adverse events are discussed, the first one relates to organisational issues and the second to post-operative management. To our knowledge, there is no previous report describing the impact of MMC in the context of a specific surgical complication. Such analysis may help shed light on system vulnerabilities contributing to a specific clinical situation, as well as the implemented improvement initiatives.
Strengths of the study
This study adhered to thorough and standardised procedures for case selection, format of discussion and implementation of quality improvement initiatives, aligning with recommendations for restructuring MMC.13 14 Furthermore, the standardised framework inspired by the ALARM reporting tool and meetings model used in our MMC allowed for a better formulation and description of contributing factors, an explicit identification of problems and elaboration of targeted recommendations for improvement.
The aggregated form chosen for this study focused on a specific, serious and recurrent complication. This model of analysis is sporadically reported in the literature11 15 16 and may give valuable insight into trends of seemingly disparate adverse events and expose common underlying patterns and process failures.17 18
The multidisciplinary approach, including concerned parties involved in the surgical care pathway, allowed a wider perspective in the identification of failures and suggestion of corrective measures leading to organisation changes that support continuous improvement and promote future reporting of failures.19
Comparison with literature
Intraperitoneal bleeding following supramesocolic surgery is a well-known, life-threatening complication, the prevalence of which varies depending on the surgical type. Previous studies have reported prevalence rates ranging from 2.3% to 5.7% for pancreatectomies20 21 and 1.9% to 33% for gastrectomies, with associated mortality rates as high as 33.3% and 22%, respectively.22 23 In our study, we observed notably higher prevalence and mortality rates, with haemorrhage occurring in 20.6% of cases and a mortality rate of 36% among patients undergoing pancreatic and gastric surgeries combined. This divergence from existing literature underscores the urgency of understanding contributing factors and potential causes to this deviation while striving to enhance patient outcomes.
Through the rigorous analysis of MMC, we discerned two significant patterns of factors that potentially explain this gap. The first pattern revolves around organisational and structural aspects. All cases identified were discussed in a multidisciplinary meeting and were carried out or supervised by senior surgeons. However, cases were not centralised and no surgeon could achieve the minimum required number to define specialisation. Furthermore, this led to non-standardised surgical techniques and perioperative care.
In order to tackle this persistent problem, we have taken specific steps, such as designating a referent surgeon centralising all cases of gastric surgery in order to generate a volume large enough to achieve specialisation. He also had to produce written protocols standardising surgical technique, perioperative care and rehabilitation. Finally, he had to establish a prospective database that includes all gastric cancer patients to allow ongoing monitoring of oncological results, morbidity and mortality.
The second pattern relates to delayed diagnosis and therapeutic management, primarily attributed to lapses in effective communication. Communication breakdowns, especially with the radiology department concerning interpretation or delays in executing imaging exams, and with the anaesthesia department resulting in the underestimation of clinical urgency, were identified as crucial factors contributing to therapeutic delays. These findings align with existing literature, which underscores the role of communication in adverse events.24 25 Furthermore, periods of heavy workload and understaffing, exacerbated by the COVID-19 pandemic, were also identified as contributing factors of therapeutic and diagnostic delays. To mitigate these issues, we introduced targeted measures for improvement. These measures included the establishment of a protocol for managing supra mesocolic haemorrhage, the systematic analysis of urgent radiologic exams by senior surgeons, and the availability of operative details in medical files.
We also encountered challenges related to the accessibility of critical resources, such as diagnostic and therapeutic angiography.22 In the context of limited resources, addressing these challenges necessitates ongoing discussions with the administration. The goal is to find viable solutions to ensure prompt access to these vital resources, minimising delays in patient care. While this problem is still not solved, the implemented protocol for managing postoperative bleeding took into consideration this problem, to ease the decision-making process in case of emergency.
A persistent challenge in the MMC process is ensuring the consistent implementation of improvement initiatives. To tackle this, we adopted strategies advocated by Nussenbaum and Chole18 emphasising the issuance of specific and detailed recommendations, complete with clear plans and timelines. Responsibility for monitoring and implementing these improvements was assigned to dedicated individuals. This approach resulted in a commendable implementation rate of 53.3%.
While we primarily focused on addressing issues within the ‘team’ and ‘task’ categories due to their direct relevance to our interventions, contributing factors related to the ‘work environment’ and ‘management’ were also examined. However, limited resources and administrative complexities hindered the implementation of improvement measures in these areas. Notwithstanding, a dedicated lead person was assigned to oversee each prioritised recommendation within a defined time limit.
Additionally, MMCs serve as invaluable platforms for ongoing monitoring of protocol adherence and for further enhancements when necessary. The collective efforts of the healthcare team, driven by a commitment to patient safety, may contribute to significant improvements in our healthcare system. Further studies can shed light on MMC’s potential to monitor and maintain systematic improvement and evaluate the clinical impact of MMCs as a tool to improve patients’ outcomes.
Limitations
The study has several limitations that should be considered. First, the study design was retrospective, which was partly dictated by the aggregated form used for the study. Second, the analysis did not include patients’ and/or their family’s perspective, which could have enriched the analysis and allowed for a better perspective and identification of issues that may have been missed by the healthcare team. Third, we did not evaluate the impact of MMC on clinical results. Although this is seldom reported in literature, it is possible that this is due to the inherently extended period required to assess such impact. Finally, while some may argue that such evaluations should be done by external independent experts to ensure objectivity and limit induced biases, we believe that MMC should be held by the local healthcare team who better knows its context, culture and limits, as well as the dynamics of the team and its interaction with the working environment.
Conclusions
System-based MMCs, as exemplified in this study, hold promise as tools for addressing specific surgical complications and enhancing patient safety. They facilitate the identification of dysfunctions and support the implementation of tailored improvement strategies. MMCs contribute to a cultural shift towards safer surgical environments and foster continuous process improvement.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study being retrospective and observational, approval by the Ethics Committee of Biomedical research was not necessary according to the local legislation (Law 28.13, article 2).
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors AH collected data. OL analysed data and wrote and revised the manuscript. MAM designed the study and revised the manuscript. AB participated in the study design. AS critically reviewed the manuscript. ZB, BAA, AG and RM reviewed the manuscript. All authors agreed on the final version of the article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.