Mock Mortality and Morbidity Conferences Demonstrate Importance Of Automated Recordkeeping for Incident and Root Cause Analyses

Jeffrey B. Cooper, PhD; David Gaba, MD

Two mock mortality and morbidity (M&M) conferences were the basis for a lively, controversial discussion about electronic record keeping, use of video recording in operating rooms, and new approaches to using such conferences as a patient safety tool. Organized and led by Drs. Jeffrey Cooper and David Gaba, APSF Executive Committee members, the afternoon session on Friday, October 12, 2001, catalyzed further discussion both during the conference and at the Executive Committee and Board of Directors Meetings held the following day. The APSF Board later approved a statement endorsing and advocating the use of electronic record keeping. An edited video of the session is being prepared and will soon be available on the APSF website.

M&M Panelists (left to right): Sorin Brull, MD, Jeff Cooper, PhD, and Robert Caplan, MD.

The idea for the conference arose from several interests. The APSF Executive Committee decided to build on last year’s successful conference on automated data capture (see APSF Newsletter, 2001;15(4):50-58). The theme of this year’s session was to learn how to use electronically gathered perioperative data to conduct systematic investigations of critical events. The intent was to provoke discussion and debate and to help set the APSF’s future strategy on these topics. As an additional benefit, the M&M conferences would give APSF’s industry colleagues a view into a quality assurance and educational process used widely in medicine, but not open to lay audiences. All of these objectives were met.

The session began with a traditional M&M conference, based on an actual case, modified to fit the learning objectives of the session. Dr. Sorin J. Brull, Chair of the APSF Committee on Scientific Evaluation, led the first conference. Taking on the character of a hard-nosed moderator, he cajoled, battered, and grilled Dr. Casey Blitt, who played the role of the anesthesiologist presenting his own case. The audience joined the fray, putting Dr. Blitt on the spot for his less than detailed, although unusually legible, handwritten record.

Dr. Cooper debriefed the audience members on their perceptions of the conference. Did the clinicians present think it was typical of such conferences? (It was typical for some but not for others. Some felt that their conferences were more in the spirit of open discussion rather than blame assignment.) Was it effective? (The conference was not very effective, since the event was never clearly defined.) Was the record sufficient to learn what happened during the event? (Only one person defended the handwritten “manual” record as being sufficient.)

In preparation for the discussion which followed, Dr. Steve Lussos, an anesthesiologist at Inova Fairfax Hospital in Virginia and an expert in the use of electronic records, introduced the audience to the look of electronic anesthesia records, noting their benefit in legibility and data capture.

Dr. Robert Caplan, of the APSF Executive Committee, then described a more systematic approach to investigating adverse events and the conduct of M&M conferences. He gave a framework for investigating events that included generating a time line, and developing both physiologic and system theories of injury (root cause analysis). This type of analysis focuses on the system, not the individual, and repeatedly asks why and how certain things occurred. Such analyses explore common elements that may be applicable to other potential system failures and allow development of strategies to prevent similar future events. The take home messages included the following:

  • Use explicit frameworks and tools: temporal reconstruction, physiologic theory, system theory (root cause).
  • Develop prevention strategies by moving the emphasis from case specifics to common elements of causality.

Dr. Caplan suggested the M&Ms would be best served by redirecting and refocusing questions (e.g., asking why a question was raised?), working from a prepared event time line, developing a theory of injury, and exploring root causes. All of these steps are aimed at understanding how and why an event occurred and, more importantly, devising system based prevention plans.

A second M&M conference was presented, based on the same case. The patient’s history and events immediately preceding the critical moments were presented systematically. In this session, an electronic medical record was available, which was more detailed than the handwritten record of the first case and gave clear evidence that the vital signs had changed to a much greater degree than was manually recorded. In contrast to the first record, the audience identified a substantial increase in pulmonary artery pressure, coincident with a decrease in exhaled CO2. The evidence for venous air embolism (VAE) was now substantive. However, the underlying cause was still not evident.

What followed was more unusual, provocative, and revealing about the actual events in this (partly fabricated) case. A video was shown of the actual procedure as though it were routine for an M&M of the future. The incredibly realistic reenactment of the procedure was created at the VA Palo Alto Patient Safety Center of Inquiry, with Oscar level performances by Drs. Steve Howard (the name used by Dr. Blitt during the conference), Erin Bushnell, and Kevin Fish. Dr. Gaba played the role of the off-camera surgeon, who portrayed some negative team behaviors. The mood in the OR was unpleasant and tense, setting the stage for the critical moment, when the complication was introduced. At one point in the video, the circulating nurse attempted to speak to Dr. Howard, who was working diligently to treat the high PAP and CO2 and alert him to the presence of air in the IV bag and tubing. Dr. Howard unintentionally interrupted her as he gave some directions for urgently needed lab results and blood. The nurse was distracted by the urgent request and ceased her effort to convey the information.

Based on the approach described by Dr. Caplan, the case was presented as a time line of events, drawn from the electronic record and video. Added to the data was information gleaned from post-event interviews with the event participants. Dr. Cooper, playing the role of a post-incident debriefer, described the review of the video with the nurse and her explanation of why she had not pointed out the air that she had noticed in the blood bag, which was being pumped under pressure from a manual infusor. On previous occasions, she had seen air in IV and blood bags before and raised her concern. But, she had been told “not to worry about it since it couldn’t cause a problem.” In the case under discussion, having her attention turned to the need to assist in treating the emerging clinical event, she was more easily distracted from continuing to raise the issue.

Dr. Gaba discussed the potential for use of video recording along with electronic medical records. The National Transportation Safety Board has recommended that video image recording be added to current requirements for aircraft flight data and cockpit voice recorders. This recommendation is controversial in aviation and will be even more controversial in health care, but Dr. Gaba suggested that the issue needed to be put on the table for debate over the coming years. Dr. Cooper reviewed the systems issues associated with the potential for VAE. Why is there air in IV bags? Why are pressure infusors used? What technologies are there to prevent air from entering the patient’s circulation? What procedures can be implemented to prevent injection of air? Clearly, there are unresolved problems associated with the potential for injection of air in amounts sufficient to cause injury. In this case, serious injury was averted, although the amount of air was enough to cause dramatic changes in vital signs and required prompt intervention. A show of hands revealed that the audience had substantial experience with air embolism introduced by inadvertent injection. No foolproof system exists to prevent VAE, although technology may now be available to address the issue.

The audience was actively engaged throughout the session, often challenging the issues and raising concerns about the use of electronic records and the barriers to video recording in operating rooms. Some argued that the automated record did not add much more than what could be gleaned from vital signs information already stored by most modern monitors. Others voiced concern over the practical, cost, and support issues involved in using electronic records. Much discussion ensued about patient and clinician privacy and confidentiality and the potential misuse of video recordings of procedures, despite their having been routine practice in trauma rooms for years.

The lessons drawn from the session were as follows:

  • Many forms of information not typically gathered can be used to learn more about adverse events.
  • Electronically captured information has the potential to help decipher the time course of clinical events more accurately than manual records.
  • A thorough investigation of adverse events can reveal otherwise unknown causes, some direct, some more subtle.
  • The M&M conference can be a good vehicle for promoting teaching safety and for investigation of adverse events. A supportive environment must be established to protect all involved. Use of the M&M for this purpose is in need of further study.
  • Video recording has potential for revealing new information about adverse events, but there are substantial barriers to its implementation.

 

Dr. Cooper is an Associate Professor at Harvard Medical School/Massachusetts General Hospital, Boston, MA and a member of the APSF Executive Committee.

Dr. Gaba is a Professor of Anesthesia at Stanford University and Secretary of the APSF.