Morbidity and mortality conferences increase adverse event reporting in IR departments

New research published in the Journal of the American College of Radiology suggests increased adverse event (AE) reporting occurs after the implementation of a monthly morbidity and mortality (M&M) conference compliance review.

“There have been numerous attempts to increase physician reporting,” wrote Mandeep S. Dagli, MD, Hospital of the University of Pennsylvania in Philadelphia, and colleagues. “These include improved physician education regarding the need for reporting, institution of web-based reporting systems to streamline the reporting process, and reminder strategies. These interventions have been met with mixed results and have indicated that to induce sustained change, interventions need to be both effective and continually reinforced over time."

The researchers sought to analyze the impact on major AE reporting after the implementation of a monthly M&M conference compliance review in the interventional radiology department at the Hospital of the University of Pennsylvania. Additionally, the team sought to describe the association of procedure class and preventable errors with major AE occurrence.

Dagli and colleagues established a structured monthly M&M conference review confirming if each complication needed institutional AE reporting—and if so, was it timely? They assessed the M&M conference minutes post-implementation over a five-year period. Lastly, the researchers assessed if the type of interventional radiology procedure had an impact on the risk of an AE. They assessed each AE for its preventability.

The researchers noted there were 46,600 patient encounters, almost three percent were major and minor complications and one percent were reportable AEs. They found that over the period, the percentage of reportable AEs increased from 67 to 98 percent.

The number of months from the implementation of the program “was a significant predictor of the likelihood of AE reporting,” the authors wrote. Additionally, procedure class was “strongly associated” with the risk of a reportable AE. A total of 24 percent of reportable AEs could have been prevented.

“Our 5-year experience suggests that a structured monthly M&M conference review of physician AE reporting can lead to significant improvement in unprompted IR physician self-reporting over time,” the researchers wrote. “Our results also suggest that the incidence of AEs is strongly associated with procedure type and that a significant proportion of AEs in interventional radiology are potentially preventable.”