M&M has traditionally been a physician attended conference. It is an excellent way to review cases in a non punitive manner. The concept is to look at the events that transpired during a patients stay in order to improve care. Let’s face it we learn from all experiences, the good and the not so good. For whatever reason M&M hasn’t been something that has been open to the nursing ranks, and if you think about it that seems like a missed opportunity. Nurses are at the bedside delivering the care that is ordered. In the event that something occurred and the patient had a less than desirable outcome, this would be a great place to learn and ultimately improve our own practice.
As and ED nurse I can definitely recall getting a really sick patient working with our team to stabilize them and off to ICU they would go. We rarely would hear back about how the patient made out. If you’ve worked in a busy ED you know that there is very little time for follow up, but if we did have the time, imagine what we could learn.
Not long ago a patient came in with respiratory distress related to CHF. The patient had a long standing history of heart failure and an EF of about 20%. Hewas put on bipap and a nitro drip. His BP tanked while on the drip and he was given a fluid bolus. He eventually stabilized and was moved to a step-down room. A few weeks later his relative was in the ED and I found out he had died within a few days of his arrival.
Our facility has a policy for vasoactive drips, q 5 minute vitals until the patient is titrated. Unfortunately for whatever reason this patient wasn’t
monitored according to policy and the fluid bolus was given to correct the hypotension.
His death frustrated me. I did what I thought should be done. I spoke with the educator and an assistant director and suggested that the nurse who was caring for the patient review the policy. I’m not sure if that was ever done. I had suggested that the entire staff be reminded of the policy, because this was possibly something that could have been prevented.
M&M could be very helpful in nursing education. Perhaps this situation could have become something that changed a practice because it would essential provide a 360 view of this patient’s experience as well as a platform for improvements in a department.
As nursing professionals we can only improve if we know where we need to improve. Moving someone out of an ED or ICU isn’t the end of their care journey.