The trouble with M&Ms

The widespread acceptance of cognitive bias theory, self-reflection and mindful practice can, in the absence of an equal weighting in systems-thinking training, lead to the notion that most errors are the result of individual failings. This self-recrimination can be compounded by ‘traditionally’ run M&Ms.

How do we move away from the old “name/blame/shame/train” cycle of M&Ms?

Smarter people than me out of Canada and Sydney have been thinking about this and agree on most of the following.

The facilitator

A comparison to simulation is pertinent here – anyone can do it, but without training there’s a good chance you aren’t going to do it that well and you might even damage those involved. There is a world of incident investigation and patient safety literature that medical school and specialist training just doesn’t teach. Your state’s department of health will have free formal incident training days (why use the best techniques on the disasters that have already happened and not the near misses?) and there are also patient safety clinical lead courses.

Case selection

In conjunction with your Quality director review the following for potential cases

• deaths
• serious adverse events
• state-wide Incident Management System reports (related to clinical incidents)
• complaints
• cases requiring open disclosure
• cases referred by clinicians

Find a case that has all 3 of the following

1. Adverse outcome
   1. death, disability, harm or injury
   2. near miss
2. Preventable
3. Lesson to be learnt about system or cognitive issues – not just ‘try not to let it happen again’

Have a structured approach to analysis

Use a template that (e.g.Austin ED template (pdf) or the NSW template):

• informs about higher level investigation – state-wide reporting process/ health service investigative pathways/ Coroner’s court pathways etc
• uses the same investigative techniques and concepts that are used by higher level investigations – thus can feed into these/ familiarise participants with these concepts should they ever have to contribute:
  • ‘Just Culture’
  • uses a structured approach to systems thinking/contributory factors (eg: London Protocol – also known as Vincent Framework) – think of every tick box a hole in James Reason’s Swiss Cheese. There are many more and it’s not possible to recall them all so a checklist helps.
  • A structured way approach to cognitive autopsy (NSW CEC version of Croskerry’s cognitive autopsy)
  • assess likelihood of solution effectiveness (Hierarchy of Solution Effectiveness).
  • The concept of having a timeline and responsible people for change.

Discuss with involved providers

Once again, anyone can do this but just like simulation debriefing or formal debriefing after an incident, a bit of training goes a long way in terms of:

• Reassuring them that the process is not an exercise of recrimination
• Encouraging self-reflection and but discouraging self-recrimination (NSW CEC version of Croskerry’s cognitive autopsy plus Reason’s culpability tree help).
• Recognizing second victim syndrome and facilitating peer and or formal support
• Realising that without specific guidance about systems thinking, thinking about self-reflection/recrimination is all the provider has (London Protocol/RCA flipbook)
• Realising that the provider would likely want to help prevent this from happening again. Working with them to look at the patient safety literature for effective solutions (Action Hierarchy helps). The involved provider’s opinions should be sought as to whether proposed solutions would have helped on the day.

On the day

Have your M&Ms presentations be multidisciplinary – nurses, inpatient teams etc- patient safety as a team event as much as any resuscitation.

Have a standing agenda that includes:

• Review of progress of outstanding recommendations/actions
• Summary of
  • deaths
  • serious adverse events
  • state-wide Incident Management System reports (related to clinical incidents)
  • complaints
  • cases requiring open disclosure
• Set the tone of the process with a pre-brief – say something like
  • “Everyone involved in this case was, like you, doing what they thought was the right thing to do at the time otherwise they wouldn’t have done it. Do not focus on what should have happened (counterfactual reasoning) – focus on what actually did and why it seemed like the right decision to the person making it at the time.”
  • “Learning ends where judgement begins; if people feel they are being ‘held to account’ it means they are less likely to ‘tell their account’ and we won’t learn a thing.”

• Provider details should be anonymous to minimise provider perception of blame. As most errors are system errors, the details of the individual usually don’t affect the take home message. The providers should be encouraged to attend (recognising that if they don’t, then second victim syndrome is likely at play and should be followed up). The providers can identify themselves if they want to and are more likely to do so in a constructive way (both with explaining what happened and with regards to the viability of the solution) if they have been engaged by the facilitator to understand the process beforehand. The attendance of the consultant involved to support the trainees, to show that errors can happen to anyone and to show faith in the process is good standard to aim for.
• As the facilitator
  • 10 mins for a time-line (What happened?).
  • 15 mins for going through the systems + cognitive issues (Why did it happen and why does normally not happen?)
  • 15 mins for solutions (How can it prevented from happening again?).
  • When considering strategies, search the excellent patient safety literature resources out there – NSW Clinical Excellence Commission for one.
  • Use the Action Hierarchy to rate the strength of your strategies and its likely effect on preventing recurrence – can your strategy be bumped up the Hierarchy?
• Have a take home point
  • Avoid prescribing vigilance/perfection as a safety strategy – it just doesn’t work.
  • Have a timeline and a champion for this change – this needs your director’s and quality committee support and facilitation. Without this step, it’s hard to say you have either a learning or safety culture.
  • Disseminate a summary with take-home points and provide update on previous recommendations’ progress.

Ideally, a summary of your meetings will make it to

• Your health service’s quality committee
• A state/nation-wide registry where the frequency of errors can be measured and solutions can be shared

LITFL Reading

• The trouble with cognitive biases
• The trouble with mindfulness

References and links

• Calder LA, Kwok ES, Adam cwinn A, et al. Enhancing the quality of morbidity and mortality rounds: the Ottawa M&M model. Acad Emerg Med. 2014;21(3):314-21. [PMID 24628757]
• Clinical Excellence Commission. 2016. Guidelines for conducting and reporting Mortality & Morbidity. Clinical Review meetings. Sydney: Clinical Excellence Commission.
  
• McColl, T. MEdIC Series: Case of the M&M Shame Game – Expert Review and Curated Community Commentary. ALIEM.