PC1212: "Reflect and learn:" a Structured Quality-driven Approach to Improve Patient Care and Safety in the Pediatric Emergency Department

Purpose/Objectives: The morbidity and mortality conferences (MMC) are traditionally held conferences to review patient encounters, examine medical errors, complications, adverse events, and discuss opportunities for improvement. Although regular MMCs are a requirement of residency training and are widely held in many hospitals throughout the world, no uniform requirements regarding their specific content or format exist. Recent evidence has emerged that standardization of the MMC can serve as a powerful tool to identify system-based opportunities, reduce medical errors and increase patient safety. While several of these strategies have been successfully adapted to some inpatient specialties, there are few studies that examine their impact in pediatric emergency departments.

Design/Methods: We implemented a modified approach to the traditional MMC in a pediatric emergency department to “Reflect and Learn” on patient encounters, identify opportunities for improvement, and propose system-based interventions. We also created a process to track and operationalize system-based interventions to improve patient care and safety. A standardized, evidence-based systems audit tool was utilized for case presentations, error identifications, tracking and follow up. Our interdisciplinary and interprofessional conferences maintained confidentiality to encourage open discussion of patient care without fear of judgment. Identified opportunities were shared with the emergency department and proposed system-based interventions were assigned to appropriate stakeholders and tracked to ensure that the “Reflect and Learn” series resulted in practice and process improvement.

Results: Over a 60-month period, 57 cases were identified and discussed. Identified opportunities were categorized into communication (26%), procedure (20%), diagnostic (18%), poor task prioritization (17%), process (17%) and medication-related errors (2%). All categories identified had system-based interventions proposed during the multidisciplinary discussion. An Emergency Department interprofessional committee was created to review, design, and implement educational interventions. We optimized communication in the format of I-PASS to standardize and document handoffs. A total of 49 system-based interventions (clinical pathways, order sets, education/simulation-based, communication and documentation, policy-based interventions and quality improvement projects) were created to improve the workflow processes of identified opportunities discussed in “Reflect and Learn.”

Conclusion/Discussion: Our study shows that a standardized, systematic, and consistent approach to the traditional MMC can serve as a powerful tool to identify and implement system-based interventions targeted towards enhancing patient safety in the pediatric emergency department. “Reflect and Learn” is an effective model of an inter-professional and multidisciplinary conference for identifying, tracking, and operationalizing interventions to enhance systems-based care in the pediatric emergency department.