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After implementing a French version of a trigger tool validated for computerized detection of adverse events in patient's medical record, the study will be performed in three parallel randomized arms of three identical departments (each steaming from 6 types of medical, surgical or obstetrical departments with a total of 18 departments involved). This three arms will be: no intervention, education of department's staff by multi professional in situ simulation (adapted to the discovered adverse events), or simple but large diffusion of results and decisions of Morbidity Mortality Reviews.
The interventions will be performed during a two-years period.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Active experience feedback | Multi professional, in situ simulation , with scenarios based on the adverse events analyzed in MMR : After analysis of adverse effects in Morbidity Mortality reviews, we will create scenarios adapted to these events. Education of the randomized department's arm's staff will be performed by multi professional in situ simulation with these scenarios |
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| Passive experience feedback | Large diffusion of information about discussions and decisions of Morbidity Mortality Reviews : after the analysis of adverse effects in Morbidity Mortality reviews, a large scale dissemination activity of information about discussions and decisions towards the staff of the randomized departments' arms will be carried out. |
| |
| No experience feedback | MMR will be performed as usual, without any feedback to the medical staff |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Multi professional in situ simulation | Other | After the analysis of adverse effects in Morbidity Mortality reviews, we will create scenarios adapted to these events. Education of the randomized department's arm's staff will be performed by multi professional in situ simulation with these scenarios |
| Measure | Description | Time Frame |
|---|---|---|
| Occurence of adverse events related to medical care | Occurrence of any adverse effects detected by the trigger tool. Trigger tool is used to detect more patient's adverse events that voluntary medical report | During patient hospitalization, up to 2 years |
| Measure | Description | Time Frame |
|---|---|---|
| Severity of adverse events related to medical care | Severity of any patient's adverse effect detected by trigger tool. Severity of adverse events is measured by a severity score scale. | During patient hospitalization, up to 2 years |
| Contributive factors identification |
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Inclusion Criteria:
Exclusion Criteria:
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any stage of patients in the involved departments during the two-years intervention's period
| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Bernard BUI-XUAN, MD, PhD | Contact | +33 4 72 11 63 48 | bernard.bui-xuan@chu-lyon.fr | |
| Philippe MICHEL, MD, PhD | Contact | +33 4 72 40 71 03 | philippe.michel@chu-lyon.fr |
| Name | Affiliation | Role |
|---|---|---|
| Bernard BUI-XUAN, MD, PhD | Hospices Civils de Lyon | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Hospices Civils de Lyon - Direction DOQRU | Recruiting | Lyon | 69002 | France |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 35109900 | Derived | Michel N, Bui-Xuan B, Bapteste L, Rimmele T, Lilot M, Chollet F, Favre H, Duclos A, Michel P. Implementation of an in situ simulation-based training adapted from Morbidity and Mortality conference cases: effect on the occurrence of adverse events-study protocol of a cluster randomised controlled trial. Trials. 2022 Feb 2;23(1):106. doi: 10.1186/s13063-022-06040-2. |
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| Large diffusion of information | Other | After the analysis of adverse effects in Morbidity Mortality reviews a large scale dissemination activity of information about discussions and decisions towards the staff of the randomized departments' arms will be carried out |
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Contributive factors of adverse events using the "ALARM Method". The Alarm Method allows to determine the contributive factors which together create the adverse patients events. |
| During patient hospitalization, up to 2 years |