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      The critical role of learning from investigating and debriefing adverse events

      review-article
      1 , 2 ,
      Journal of Thoracic Disease
      AME Publishing Company
      Adverse events, debriefing, thoracic surgery

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          Abstract

          Debriefing after and learning from adverse surgical events is becoming an integral component of our clinical practices and hospital systems. Morbidity and mortality conferences have been the foundation for this process; however, the approach has evolved to be more constructive with root cause analyses and identification of action items to prevent future adverse events. Additional quality improvement resources include the voluntary National Surgical Quality Improvement Program (NSQIP) and the Society of Thoracic Surgeons (STS) databases, which provide seeds for a systematic process of improving patient care. With large databases come not only a route for studying outcome expectedness but also an objective numeric source for development of risk scores to stratify patients and assist with shared decision making. There is also recognition of the collateral damage of adverse events, which, includes the second victims defined as the individuals other than the patient. After an adverse event the second victim can either thrive, just survive or drop-out, and institutional systems should be in place to care for this victim and prevent their travel down the road to burnout. As a contemporaneous topic, burnout impacts not only surgeon wellness but also negatively affects the clinical workforce, which includes nurses in addition to physicians. “To err is human” but to care is ethereal.

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          The natural history of recovery for the healthcare provider "second victim" after adverse patient events.

          When patients experience unexpected events, some health professionals become "second victims". These care givers feel as though they have failed the patient, second guessing clinical skills, knowledge base and career choice. Although some information exists, a complete understanding of this phenomenon is essential to design and test supportive interventions that achieve a healthy recovery.
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            The morbidity and mortality conference: the delicate nature of learning from error.

            The morbidity and mortality conference (M&MC) appears to have sprung from the efforts of physicians to improve practice through the examination of medical errors and bad outcomes. The modern M&MC has had limited examination (and almost none outside surgery and anesthesia), but may be straying from the precepts from which it evolved. Learning from one's errors is important, but confronting them is difficult and is particularly delicate when done in conference. If the effort is successful, it can serve as a model. If unsuccessful, it can instead convey the lesson that attempting to learn from error is at best unproductive and at worst unpleasant. Thus, the M&MC is a double-edged sword, and particular attention should be given to the way that it is conducted. The authors review the historical roots and current literature on the M&MC, discusses relevant literature on medical error, and offers a definition, guiding principles, and a set of guidelines for a modern internal medicine M&MC. The ideas are presented not as a blueprint, but rather to stimulate a debate on the merits of establishing a framework for a working model, in order to refocus on the tradition of self-analysis and critical thinking in a manner that is productive for all participants.
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                Author and article information

                Journal
                J Thorac Dis
                J Thorac Dis
                JTD
                Journal of Thoracic Disease
                AME Publishing Company
                2072-1439
                2077-6624
                August 2021
                August 2021
                : 13
                : Suppl 1
                : S3-S7
                Affiliations
                [1 ]deptCenter for Esophageal Diseases, Heart and Vascular Institute , Cleveland Clinic Foundation , Cleveland, OH, USA;
                [2 ]deptDepartment of Surgery, Boston Medical Center , Boston University School of Medicine , Boston, MA, USA
                Author notes

                Contributions: (I) Conception and design: Both authors; (II) Administrative support: Both authors; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: Both authors; (V) Data analysis and interpretation: Both authors; (VI) Manuscript writing: Both authors; (VII) Final approval of manuscript: Both authors.

                Correspondence to: Dr. Virginia R. Litle, MD. Division of Thoracic Surgery, Department of Surgery, Boston University, 88 East Newton Street, Collamore Building, Suite 7380, Boston, MA 02118, USA. Email: Virginia.litle@ 123456bmc.org .
                Article
                jtd-13-S1-S3
                10.21037/jtd-2020-epts-01
                8371545
                34447586
                b7e96e87-d513-405e-b17e-ea757e26d0f9
                2021 Journal of Thoracic Disease. All rights reserved.

                Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0.

                History
                : 07 April 2020
                : 10 July 2020
                Categories
                Review Article

                adverse events,debriefing,thoracic surgery
                adverse events, debriefing, thoracic surgery

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