title: Implementation of a pediatric surgical quality improvement (QI)-driven M&M conference.
abstract: OBJECTIVE
  The M&M conference at Nationwide Children's Hospital (NCH) categorized failures as technical error or patient disease, but failure modes were never captured, action items rarely assigned, and follow-up rarely completed. In 2013 a QI-driven M&M conference was developed, supporting implementation of directed actions to improve quality of care.
  
  
  METHODS
  A classification was developed to enhance analysis of complications. Each complication was analyzed for identification of failure modes with subcategorization of root cause, a level of preventability assigned, and action items designated. Failure determinations from 11/2013-10/2014 were reviewed to evaluate the distribution of failure modes and action items.
  
  
  RESULTS
  Two-hundred thirty-seven patients with complications were reviewed. One-hundred thirty patients had complications attributed to patient disease with no individual or system failure identified, whereas 107 patients had identifiable failures. Eighty-five patients had one failure identified, and 22 patients had multiple failures identified. Of the 142 failures identified in 107 patients, 112 (78.9%) were individual failures, and 30 (21.1%) were system failures. One-hundred forty-seven action items were implemented including education initiatives, establishing criteria for interdisciplinary consultation, resolving equipment inadequacies, removing high risk medications from formulary, restructuring physician handoffs, and individual practitioner counseling/training.
  
  
  CONCLUSIONS
  Development of a QI-driven M&M conference allowed us to categorize complications beyond surgical or patient disease categories, ensuring added focus on system solutions and a reliable accountability structure to ensure implementation of assigned interventions intended to address failures. This may lead to improvement in the processes of patient care.
authors.affiliation: Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Barrett
authors.initials: B
authors.lastname: Cromeens
authors.affiliation: Department of Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Brilli
authors.affiliation: Department of Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Kelli
authors.initials: K
authors.lastname: Kurtovic
authors.affiliation: Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Brian
authors.initials: B
authors.lastname: Kenney
authors.affiliation: Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
authors.forename: Benedict
authors.initials: B
authors.lastname: Nwomeh
authors.affiliation: Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA. Electronic address: Gail.Besner@nationwidechildrens.org.
authors.forename: Gail E
authors.initials: GE
authors.lastname: Besner
mesh_terms: D002648:Child; D002675:Child, Preschool; D003226:Congresses as Topic / Q000458:organization & administration*; D005260:Female; D017052:Hospital Mortality; D006776:Hospitals, Pediatric / Q000592:standards*; D006801:Humans; D007223:Infant; D008297:Male; D019300:Medical Errors / Q000517:prevention & control; D010372:Pediatrics / Q000592:standards*; D058996:Quality Improvement; D013043:Specialties, Surgical / Q000592:standards*; D014481:United States
keywords: Morbidity; Mortality; Quality improvement