What is this?
As family medicine doctors, we have a unique perspective on the patient narrative. Our scope of practice and focus on both individual and community health can provide a powerful window into patient care. This perspective can be particularly meaningful when things go awry or there are “near misses.” This forum is an opportunity for you to bring a case to the community for further discussion and identify ways to improve care in the future.
The term “Morbidity & Mortality” is specifically being avoided to encourage you to think outside the box. These cases don’t need to have a bad outcome. Contrary to some medical school experiences, the point of this is not to place blame or be publicly chastised. This is an opportunity to identify a case, perform a root cause analysis (RCA), identify a system-level intervention and initiate a systems-level QI process. Leadership and faculty are expected to come to these presentations with the hope that these discussions can be a springboard for true systems change.
What do I need to do?
Each resident will be responsible for Patient Safety Forum during their R3 year. These presentations will be held once a month and are scheduled during or just after your Ortho Rotation. You are responsible for this time slot with an assigned peer. If you cannot present during this time, you need to trade with one of your fellow R3s. See schedule below for details.
The basics of this process are…
- Identify a case with the Inpatient, MCH, Outpatient leadership
- Discuss the case with Linda Smoker at least 4 weeks prior to the presentation
- Notify faculty, residents, medical directors (e.g. MCH, IPS, Clinic) and other stakeholders that were involved in the case
- Talk to at least 3 stakeholders and invite them to the case presentation
- Design a HIPPA Secure presentation based on the RCA presentation template provided below
- Have the presentation ready to review 1 week prior to your presentation
- Perform the RCA as part of the presentation at resident school
- Suggest potential interventions to leadership
- Present a short follow up on your case at the following Patient Safety Forum (less than 2 minutes)
How faculty can help?
The faculty should be involved to help you pick a case and review your presentation before you give it. They are not responsible for putting together the presentation. Leadership will try to use your solutions as a starting point for potential QI interventions.
Please feel free to use Linda Smoker as a resource.
A few pointers that will save you time on your RCA presentation...
- Remember that the point of the resident school presentation is not to teach a specific learning topic. The objective is to teach residents how to do a root cause analysis and identify a systems-level intervention. Don't get mired down in the nuances of a specific disease process or treatment.
- Try to pick the outcome you want to avoid and design the presentation based on that outcome. Especially when it comes to the case itself, it can be easy to add too much information. Present only parts of the case that are relevant to the outcome that you plan to discuss.
- Be sure to design and save this document in a HIPPA Secure fashion (e.g., PPT on a work computer and sent in Outlook with **secure** in the subject line). Do not use Google Docs or other non-secure web-based platforms.
Additional Resources
Date Residents
08/23/23 Lakita Maulson, Chance Najera, Amanda Nguyen, Veronica Pace
10/25/23 Amity Calvin, Owen Hamilton, Shandiin Sam, Christian Smith
02/28/24 Kerry Zimdars, Colin Sevareid, Carlos Vargas
04/24/24 Jesus Guzman, Hannah Udell, Z Heeder
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