Improving quality of care and patient safety through morbidity and mortality conferences.

The objective was to evaluate the analysis of adverse events and the decisions for quality improvement decided during morbidity and mortality conferences (MMCs). We conducted a prospective observational study of MMCs conducted in a teaching hospital between November 2007 and May 2008. Two observers attended the conferences and collected data on the structure of MMCs, the discussion between attendees, and the decisions or actions for quality improvement. Twenty-four MMCs were studied including 146 cases. A majority of the senior physicians present (87.7%) took part in debating the cases; the participation of residents was lower (32.6%) and varied between departments (p < .001). Few paramedical professionals and other attendees participated in the debate. Shortcomings were sought in 91% of cases, but a structured method was used in less than 10% of cases. An analysis of underlying factors contributing to these shortcomings was observed in 75% of cases, with 4% considered structured and thorough. Eighty-five decisions or actions to improve quality of care or patient safety were listed, with 28 of them (33%) planned for implementation. Discussion of adverse events appears to lack a structured method and although a large number of decisions for quality improvement were declared, fewer actions were planned with a timeline.

Morbidity and mortality conferences: their place in quality assessments.

PURPOSE: This article aims to analyze morbidity and mortality conferences (M&MCs) in a university-affiliated hospital, notably their format and progression since the 1990s. DESIGN/METHODOLOGY/APPROACH: A cross-sectional study was conducted and M&MC characteristics were collected using three methods: a questionnaire to all department heads to identify past M&MCs; semi-structured interviews with each M&MC leader; and when available, meeting reports were analyzed. FINDINGS: Of 189 questionnaires sent to department heads, 105 were completed and returned (55.6 per cent). A total of 27 M&MCs were identified; five times more than in 1994. The M&MC format varied greatly between departments. In surgical units, cases per conference tended to be higher than in intensive care or medical units and paramedical staff were invited less often. Compared with 1998, head nurses (70.4 vs 27.3 percent, p = 0.03) and paramedical staff (63.0 vs 18.2 percent, p = 0.03) attendance increased significantly. Physicians considered M&MCs important for improving service quality, patient safety and enhancing team cohesion. RESEARCH LIMITATIONS/IMPLICATIONS: Patient outcomes were not assessed. PRACTICAL IMPLICATIONS: Although undefined formats allowed leaders to conduct M&MCs according to their objectives, how these conferences are conducted should impact healthcare quality and safety. ORIGINALITY/VALUE: Results indicate that M&MCs have evolved over the past 20 years, showing them to be valuable quality and safety improvement methods.

Infectious disease specialist telephone consultations requested by general practitioners.

BACKGROUND: Infectious diseases (ID) make up a substantial part of a general practitioner's (GP's) workload. GPs frequently solicit ID specialists requesting advice on managing their patients with ID. The objectives of this study were to examine GP reasons for soliciting ID consultations and to assess the GPs' and specialists' opinions of the ID consultation service. METHODS: This was a prospective study of consecutive solicited ID consultations requested by GPs from the ID specialists of a 2200-bed university-affiliated hospital, conducted between October 2008 and March 2009. Data related to GP characteristics, their reasons for requesting the consultation, the recommendations given by the specialists, and the specialists' perceptions of the exchange were collected. GPs were asked to report their adherence to recommendations and their perceptions of the consultations. RESULTS: A mean of 57 telephone consultations per month were requested by GPs during the study period. ID specialist recommendations were related to antibiotic treatment (66.2%), diagnostic or monitoring tests (46.5%), and a subsequent formal consultation or hospitalization (29.6%). The reasons reported for GPs requesting an ID consultation were related to patient management (96.5%), rapidity of access (86.3%), and quality of care improvement (84.2%). GPs were satisfied with the telephone consultations in 97.9% of cases and ID specialists in 94.7%. CONCLUSIONS: Telephone consultations with ID specialists were widely appreciated by GPs, probably due to the accessibility of these specialists. Further study is needed to assess the effects of these telephone consultations on quality of care.

Effects of age, gender and time on receptor expression and anti-Aspergillus functions of human phagocytes.

Phagocytes play a central role in immune defense. Their dysfunction predisposes to infections. This study determined the expression level of nine receptors involved in Aspergillus immune response as well as the values of phagocytosis and production of radical oxygen species after Aspergillus stimulation, in a healthy adult population. The expression values of the CD11b, CD11c, CD14, CD18, CD35, CD181, CD182, CD282 and CD284 receptors on peripheral human monocytes and granulocytes was established. A heterogenous expression of the CD282 on granulocytes was observed as CD181, CD182 and CD284 on monocytes. Similarly, we observed considerable variation in the expression of these receptors over time. Only CD282 on granulocytes varied with sex. No variation with age was observed. Adherence of Aspergillus conidia to phagocytes was dependent of individual, sex, age and time. A better characterization of these innate immunity parameters is necessary to develop in the future an immunologic surveillance strategy for transplant recipients.

Automated drug dispensing system reduces medication errors in an intensive care setting.

OBJECTIVES: We aimed to assess the impact of an automated dispensing system on the incidence of medication errors related to picking, preparation, and administration of drugs in a medical intensive care unit. We also evaluated the clinical significance of such errors and user satisfaction. DESIGN: Preintervention and postintervention study involving a control and an intervention medical intensive care unit. SETTING: Two medical intensive care units in the same department of a 2,000-bed university hospital. PATIENTS: Adult medical intensive care patients. INTERVENTIONS: After a 2-month observation period, we implemented an automated dispensing system in one of the units (study unit) chosen randomly, with the other unit being the control. MEASUREMENTS AND MAIN RESULTS: The overall error rate was expressed as a percentage of total opportunities for error. The severity of errors was classified according to National Coordinating Council for Medication Error Reporting and Prevention categories by an expert committee. User satisfaction was assessed through self-administered questionnaires completed by nurses. A total of 1,476 medications for 115 patients were observed. After automated dispensing system implementation, we observed a reduced percentage of total opportunities for error in the study compared to the control unit (13.5% and 18.6%, respectively; p<.05); however, no significant difference was observed before automated dispensing system implementation (20.4% and 19.3%, respectively; not significant). Before-and-after comparisons in the study unit also showed a significantly reduced percentage of total opportunities for error (20.4% and 13.5%; p<.01). An analysis of detailed opportunities for error showed a significant impact of the automated dispensing system in reducing preparation errors (p<.05). Most errors caused no harm (National Coordinating Council for Medication Error Reporting and Prevention category C). The automated dispensing system did not reduce errors causing harm. Finally, the mean for working conditions improved from 1.0±0.8 to 2.5±0.8 on the four-point Likert scale. CONCLUSIONS: The implementation of an automated dispensing system reduced overall medication errors related to picking, preparation, and administration of drugs in the intensive care unit. Furthermore, most nurses favored the new drug dispensation organization.

[Value of morbidity and mortality review conferences for physician education and improvement of care quality and safety: a literature review]. / Intérêt des revues de mortalité et de morbidité pour la formation des médecins et l'amélioration de la qualité et de la sécurité des soins : revue de la littérature.

BACKGROUND: In France, national incentives promote the development of morbidity and mortality conferences (M&MC) in hospitals. OBJECTIVE: A systematic literature review was performed to investigate the effectiveness of M&MC as well as how they were conducted and how participants experienced them. DATABASES: The review was carried out by searching the MEDLINE and PASCAL databases and included articles in English and French. The following keywords were used: mortality, morbidity, conference, rounds, review, meetings, committee. STUDY SELECTION: Two independent reviewers selected all original studies describing or evaluating M&MC and published from 1st January 2002 through 31st December 2008. RESULTS: We analyzed 17 articles, of which 11 reported structured interviews, 3 analyzed M&MC minutes, 2 monitored indicators, and 1 described observations of M&MC. They showed good physician participation and a wide variety of types of meeting organization. Attendance by paramedical staff, the number of cases covered per meeting, and case selection criteria affected their content. Studies of the efficacy of M&MC were rare and concerned specific topics (digestive endoscopy and childbirth). STUDY LIMITATIONS: Both the methods and the objectives of studies analyzing M&MC are heterogeneous. CONCLUSION: The published studies viewed M&MC as a valuable tool for physician education and quality assurance, but the factors associated with their effectiveness require further study.

[Management of type 2 diabetes patients in community health care centers in Grenoble]. / Prise en charge des patients diabétiques de type 2 par les centres de sané associatifs de la ville de Grenoble.

Community health care centers in Grenoble aim to provide quality primary health care, including prevention, to populations living in disadvantaged urban areas. The objective of the study was to assess the quality of follow-up provided by physicians in health care centers in Grenoble to patients with diabetes mellitus. A cross-sectional study was conducted for an observation period of one week in june 2007. All type 2 diabetes patients seen in community health care centers during this given week were included in the study's sample (n=121). During the consultation, the physician collected the data on diabetes follow-up recorded in the patient's medical record over the last year. The data were compared with the recommendations and guidance published by the French National Authority for Health in 2006. The result of a hemoglobin A1c test dated less that three months-old was present in 80% of patients' medical records. Serum creatinine concentration, blood lipids, and microalbuminuria levels were obtained and confirmed with annual tests, and were present and recorded in the last year in 95%, 91%, and 77% of cases, respectively. The patient's weight, recorded within the last year, was noted in all cases. An ophthalmology consultation had been provided within the year for 57% of patients and 55% had received an electrocardiogram. Compliance with French National Authority for Health recommendations for the follow-up of diabetics in the community health care centers was satisfactory. Thus, it seems relevant to analyze their organizational methods.