Enhancing patient safety: a system-based analysis of morbidity and mortality conferences in managing postoperative bleeding following gastric and pancreatic cancer surgery.

Autor:	Lahnaoui O; National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco oumaima.lahnaoui@um5s.net.ma., Houmada A; National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco., Benkabbou A; National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco., Ghannam A; National Institute of Oncology - Intensive Care Department, Mohammed V University in Rabat, Rabat, Morocco., Al Ahmadi B; National Institute of Oncology - Intensive Care Department, Mohammed V Souissi University, Rabat, Morocco., Belkhadir Z; National Institute of Oncology - Intensive Care Department, Mohammed V University in Rabat, Rabat, Morocco., Mohsine R; National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco., Souadka A; National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco., Majbar MA; National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco.
Jazyk:	angličtina
Zdroj:	BMJ open quality [BMJ Open Qual] 2024 Mar 13; Vol. 13 (1). Date of Electronic Publication: 2024 Mar 13.
DOI:	10.1136/bmjoq-2023-002657
Abstrakt:	Morbidity and mortality conferences (MMCs) have evolved beyond their traditional educational role to become instrumental in enhancing patient safety. System-based MMCs offer a unique perspective on patient safety by dissecting systemic factors contributing to adverse events. This paper reviews the impact of MMC in managing postoperative bleeding after gastric and pancreatic cancer surgery, within the constraints of limited resources. The study conducted at the National Institute of Oncology in Rabat, Morocco, analysed 18 MMC of haemorrhage following gastric and pancreatic surgeries and allowed to identify two patterns of cumulative factors contributing to adverse events. The first one relates to organisational issues and the second to postoperative management. Fifteen recommendations of improvement emerged from MMC addressing elements of these patterns with an implementation rate of 53.3%. Competing Interests: Competing interests: None declared. (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)
Databáze:	MEDLINE
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