SummaryNorthwestern Memorial Hospital holds monthly patient safety meetings, known as Patient Safety Morbidity and Mortality Conferences, that serve as a forum for clinicians and staff from all levels and multiple disciplines to hear about and discuss adverse events that have occurred at the hospital. Led by a moderator and staff panel, the meetings provide an opportunity for participants to not only hear case presentations but also to actively evaluate the root causes of adverse events and suggest work redesign steps geared toward preventing the recurrence of similar events in the future. Staff responsible for the processes involved in the event attend the conference, incorporate these ideas into their improvement work, and are accountable for reporting on implementation. Based on the success of these meetings, additional monthly meetings have been added that focus on nursing- and pharmacy-specific safety issues. The program significantly improved staff perceptions of the organization's safety culture and increased the reporting of adverse events.Moderate: The evidence consists of pre- and post-implementation comparisons of scores on the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture and the number of adverse events reported each year through the hospital's electronic reporting system.
Developing OrganizationsNorthwestern Memorial Hospital
Date First Implemented2004
Problem AddressedAlthough many health care organizations attempt to create a culture of safety, most clinicians and staff continue to fear a punitive response when adverse events occur. Designing initiatives that promote open dialogue about adverse events can help organizations to develop a culture of safety, yet many organizations do not implement such programs.
- Continuing fear of blame: Despite the health care industry's growing focus on promoting a culture of safety, scores on the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture remain low with respect to promoting a "nonpunitive response to error" and rank at the bottom of all domains included in the survey (43, 44, and 44 percent of positive responses in 2007, 2008, and 2009, respectively).1
- Lack of open dialogue about adverse events: Although open dialogue about adverse events can help to promote a culture of safety, relatively few hospitals have programs that encourage multidisciplinary groups of clinicians and staff to discuss and learn from specific adverse events that have occurred.
Description of the Innovative ActivityNorthwestern Memorial Hospital holds monthly patient safety meetings, known as Patient Safety Morbidity and Mortality Conferences, that serve as a forum for clinicians and staff from all levels and multiple disciplines to hear about and discuss adverse events that have occurred at the hospital. Led by a moderator and staff panel, the meetings provide an opportunity for participants to not only hear case presentations, but to actively evaluate the root causes of adverse events and suggest work redesign steps geared toward preventing the recurrence of similar events in the future. Staff responsible for the processes involved in the event attend the conference, incorporate these ideas into their improvement work, and are accountable for reporting on implementation. Key elements of the program include the following:
- Case selection: Each meeting focuses on an actual adverse event that occurred at the hospital within the previous 2 or 3 months that was reported through the hospital's voluntary electronic adverse event reporting system. Topics are selected by the hospital's medical director for quality and patient safety in conjunction with the quality committee that reviews all serious adverse events and near misses. Cases may represent events that occur frequently (even if they do not cause major harm) or rare events that have great clinical significance. (Occasionally, the medical director selects a high-profile event that took place at a different institution but could have occurred at the hospital.) Identifying details about the patients involved are modified or removed before case discussion. Sample conference topics include order and administration of a wrong (sound-alike) drug, transporting the wrong patient to a procedure area, and progression of a patient's stage one pressure ulcer.
- Meeting logistics: One-hour meetings take place each month over lunch in a large hospital conference room. The medical director for quality and patient safety moderates each session, with the support of a three- to five-member panel selected based on the disciplines involved in the event and the panel member’s ability to speak in an informed manner about the care processes addressed by the case. Panel members may or may not have been involved in the case being discussed. Quality department staff approach relevant departments to solicit participation on the panel. All hospital staff receive notification of the monthly programs via e-mail and are invited to participate as members of the audience. Invitees also receive e-mail reminders with the date, time, location, and topic before each session. Participants include physicians; nurses; pharmacists; management staff; radiology technicians; occupational, physical, and respiratory therapists; information systems staff; unit secretaries; transport staff; and other administrative and support staff. Since the program's inception, approximately 60 such meetings have been held and roughly 100 participants now attend the typical session (up from 30 at the start of the program). Physicians generally comprise approximately 20 percent of the audience. Physicians, nurses, pharmacists, and other clinicians earn continuing medical education or continuing education credits for participation.
- Conference content: Each conference follows the following three-part agenda:
- “Good Catch” award: At the start of each meeting, a member of the hospital’s quality improvement department presents a “Good Catch” award to one or two individuals who caught an error or systems breakdown before it reached the patient.
- Update on previous month’s case: The moderator briefly reviews the previous month's case, the root causes of the event, the findings and recommendations made by the panel and audience, and the followup that has occurred to date.
- Case discussion: The moderator reads a brief (five- to six-sentence) description of the case to be discussed during the conference. Panel members, who sit at the front of the room, then talk about the event, review the role of their own discipline in the case, describe usual practice, speculate about what went wrong, and solicit ideas for improvement. After approximately 20 minutes, the moderator turns to the audience for input. Audience members, whose printed conference agendas list the root cause analysis questions outlined by the National Center for Patient Safety at the U.S. Department of Veterans Affairs, are invited to identify root causes of the event and suggest system-level changes to prevent similar events in the future.
- Incorporation of feedback into improvement activities: The quality department organizes an improvement team consisting of staff responsible for the process involved in the event that attends the conference and listens to participants’ feedback. After the meeting, this team takes responsibility for incorporating these insights and ideas into specific process improvements. At the subsequent conference, the team reports on the progress of these improvement activities. Outside of the conference, the team personally approaches the staff affected by the process changes to explain the reason and rationale behind the improvement. Examples of adverse events discussed and solutions devised and implemented include the following:
- Dropped antibiotic therapy: A patient admitted to the hospital through the emergency department (ED) received her first dose of antibiotics in the ED. Upon admission, physicians ordered additional antibiotics as “pharmacist to dose,” meaning that the pharmacist would determine the appropriate dosage based on the patient's weight. Because the medication was ordered as "pharmacist to dose," the hospital's electronic medical record (EMR) required the pharmacist to cancel the order in one location in the system and then reenter it in another location. The pharmacist canceled the order but was distracted and did not reenter it. Consequently, the patient did not get the needed antibiotics, and nursing and physician staff failed to notice the omission for 2 days of the patient's stay. After discussion of this case at a monthly meeting, the improvement team implemented the following suggested solutions:
- Changing the pharmacy portion of the EMR to present information on one screen so that the second step (order reentry) was obvious.
- Reducing vulnerability to this error by eliminating "pharmacist to dose" options for as many medications as possible (reduced to 18 from 29 medications).
- Reinforcing the medication reconciliation process.
- Creating electronic patient handoff tools prepopulated with medication lists to prevent omission of medications for patients admitted from the ED.
- Educating nurses and physicians about the need for a global review and assessment of adequate treatment of patients, with a special focus on medication reconciliation.
- Wrong patient brought to diagnostic testing area: The wrong patient was taken to a treatment room in radiology for diagnostic testing because the patient responded to another person's name when staff called the name in the waiting room. No diagnostic intervention was performed but the event highlighted a vulnerability in the system. After discussing this case at a monthly meeting, the improvement team implemented a verification process whereby a member of the radiology staff calls the patient's name in the waiting room and then asks the individual to confirm and initial his/her name and date of birth on the patient requisition form before any imaging.
- Expansion to discipline-specific safety conferences: Based on the success of these conferences, additional monthly safety conferences have been added, including one focused on nursing-specific issues in 2004 and one focused on pharmacy-specific issues in 2007.
References/Related ArticlesSzekendi MK, Barnard C, Creamer J, et al. Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety. Jt Comm J Qual Patient Saf. 2010 Jan;36(1):3-9. [PubMed]
Contact the InnovatorCynthia Barnard, MBA, MSJS, CPHQ
Director, Quality Strategies
Northwestern Memorial Hospital
211 E. Ontario #1559
Chicago, IL 60611
Phone: (312) 926-4822
Fax: (312) 926-9879
Marilyn K. Szekendi, PhD
Director, Quality Research
University HealthSystem Consortium
155 North Wacker Drive
Chicago, IL 60606
Phone: (312) 775-4301
Innovator DisclosuresMs. Barnard and Dr. Szekendi have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsThe program significantly improved staff perceptions of the organization's safety culture and increased the reporting of adverse events.
Moderate: The evidence consists of pre- and post-implementation comparisons of scores on the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture and the number of adverse events reported each year through the hospital's electronic reporting system.
- Improvement in staff perceptions of organization's safety culture: Since program inception, statistically significant improvements in AHRQ's Hospital Survey on Patient Safety Culture scores have been achieved in multiple domains, as outlined below:
- Among all staff: Between 2004 and 2008, positive scores on the "hospital management support for patient safety" domain increased from 57.7 to 61 percent; positive scores on the "feedback and communication about error" domain increased from 51 to 53 percent, and positive scores on the "nonpunitive response to error" domain increased from 49 to 58 percent.
- Among nursing staff: Between 2004 and 2008, the percentage of nurses responding positively to the phrase "we are actively doing things to improve patient safety" increased from 74 to 90 percent; the percentage responding positively to the phrase "mistakes have led to positive changes here" increased from 60 to 84 percent; and the percentage responding positively to the phrase, "we discuss ways to prevent errors from happening" increased from 60 to 89 percent.
- More reporting of adverse events: Between 2003 and 2009, the number of adverse events reported each year through the hospital's voluntary reporting system increased by 66 percent, suggesting that the improvements in perceptions noted above have made staff less fearful of being blamed and hence more comfortable reporting errors and near misses.
Context of the InnovationNorthwestern Memorial Hospital, a 900-bed academic medical center in Chicago, has 6,000 employees, 1,500 admitting physicians, and 500 house staff. In 2001, the hospital began developing a series of initiatives to improve patient safety, including charging a dedicated group of nurses and pharmacists with focusing on the issue, creating a user-friendly electronic adverse event reporting system, administering the AHRQ Hospital Survey on Patient Safety Culture, and implementing a number of collaborative, interdisciplinary quality improvement projects. After a guest speaker held a case-specific discussion with hospital leaders on patient safety, these leaders decided that engaging clinicians and staff in the discussion of specific cases could enhance the organization’s patient safety culture and lead to care process improvements. Subsequently, the hospital's medical director for quality and patient safety initiated the monthly conferences.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Securing leadership support: The medical director for quality and patient safety approached other hospital leaders about the concept of the monthly conferences, immediately securing their support.
- Soliciting initial participation: The quality department sent an e-mail to all department managers and medical staff quality committee chairs to introduce the program and ask them to choose one person to attend the meetings (either the same person each month or a different person based on the specific case to be discussed). The quality department also e-mailed all hospital staff and medical staff to introduce the conferences.
- Securing approval for continuing medical education and continuing education credits: The quality department sought and received approval for nurses, physicians, pharmacists, social workers, and other participating clinicians to receive continuing medical education and continuing education credits for conference attendance.
- Investigating legal implications: The hospital explored any legal issues associated with holding conferences that discuss specific adverse events. Illinois law provides complete protection for discussions of adverse events held for quality improvement purposes, including exemption from subpoena and legal discovery.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as participants incorporate the meetings into their everyday responsibilities.
- Costs: The program costs relatively little, with the primary expense being the food provided at the monthly sessions.
Funding SourcesNorthwestern Memorial Hospital
Tools and Other ResourcesThe AHRQ Hospital Survey on Patient Safety Culture is available at:
The U.S. Department of Veterans Affairs Web site provides information regarding root cause analysis, including tools for using the five rules of causation and a list of interactive triggering and triage questions; more information is available at: http://www.patientsafety.gov/rca.html.
Getting Started with This Innovation
- Minimize hierarchies: Staff, regardless of position, should be made to feel comfortable reporting adverse events, discussing these events during the conferences, and contributing ideas for process improvements. To achieve this, Northwestern Memorial Hospital invites all staff to the conferences, creates an open and "blame-free" environment during the conference, and solicits and highlights staff input from all levels and disciplines.
- Begin with noninvolved representatives: Northwestern Memorial Hospital began its conferences with panelists not involved in the events. Over time, as the culture of safety improved and comfort levels increased, clinicians and staff involved in the events expressed a greater willingness to serve on the panels.
- Consider quality department resources: Although Northwestern Memorial Hospital did not add staff to manage the patient safety conferences, potential adopters should be aware of the significant time that can be involved in selecting the event, preparing the case, assembling and briefing the panel, and performing administrative tasks related to each conference.
- Ensure appropriate followup action: It is important to have steps in place to ensure meaningful followup on the suggestions provided at each meeting and accountability for implementation of improvement actions.
- Be sensitive to staff concerns: Hospital leaders, clinicians, and staff often question the legal ramifications of holding conferences that discuss specific adverse events. To alleviate these concerns, the quality committee at Northwestern Memorial Hospital sponsors the monthly sessions. To further add to clinician comfort, Northwestern disguises identifying details of the specific cases being discussed.
Sustaining This Innovation
- Provide continuing medical education and continuing education credits: Clinicians will be more likely to remain interested in participating if they receive this added benefit.
- Act on new information: Once root causes of adverse events have been identified, organizations should develop and implement initiatives that correct system flaws to prevent similar events from occurring in the future. This step will demonstrate the organization’s commitment to patient safety to clinicians and staff, and hence encourage future participation in conferences and reporting of adverse events.
- Hold conferences at convenient, fixed time: Set a regular schedule (monthly or quarterly) for conferences so as to prevent them from "slipping through the cracks." Meetings should be set for a convenient time; as noted, Northwestern decided to hold its sessions at noon, when clinicians and staff are likely to break for lunch.
- Measure success: Identify and monitor measures of program success, such as trends in the number of conference participants and adverse events reported, staff perceptions of the organization's safety culture, and qualitative feedback about the program's value.
Szekendi MK, Barnard C, Creamer J, et al. Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety. Jt Comm J Qual Patient Saf. 2010 Jan;36(1):3-9. [PubMed]
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Service Delivery Innovation Profile
Original publication: June 23, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: May 15, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: July 22, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.