医学
不利影响
胰腺癌
癌症
患者安全
普通外科
重症监护医学
外科
内科学
医疗保健
经济增长
经济
作者
Oumayma Lahnaoui,Amina Houmada,Amine Benkabbou,Abdelillah Ghannam,Brahim El Ahmadi,Zakaria Belkhadir,Raouf Mohsine,Amine Souadka,Mohammed Anass Majbar
标识
DOI:10.1136/bmjoq-2023-002657
摘要
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%.
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