Morbidity and Mortality Presentation Guidelines
Written by Tim Davie, last update 3/6/2016
The emphasis of your presentation should be on root-cause analysis (i.e., discussing why the problem happened and how to prevent it in the future), rather than simply on teaching points/literature updates. These should be included as well, but are not the focus.
We are modeling the format after one employed by Vanderbilt University, details here: http://www.ncbi.nlm.nih.gov/books/NBK43710/
You can use whatever format you want, including Google Slides, PowerPoint, Keynote, Prezi, etc. If you want a suggested template, there are some to choose from here:
Be sure to include your name and the name of the attending for the case on the introduction slide.
Regardless of what template you use, you should include these elements:
If you have a dark background and you’re trying to highlight text, please do it in yellow or white, not red. Red on black or red on dark gray tends to be very hard to read, especially from the back of the room.
Spend no more than 10 minutes on literature/teaching points (preferably ~5 minutes). Plan to dedicate most of the time to discussion/audience participation.
Have your Ichikawa (“fishone”) diagram filled out in advance with the various people, procedures, equipment, etc that were involved in the occurrence of the problem. During your presentation, allow the audience to discuss why they think the problem happened, and highlight certain parts of the diagram. Don’t take time during your presentation to fill out the parts of the diagram. Consider having the diagram broken up on various slides.
There is some flexibility here, and you’re welcome to use some artistic license. You’ve seen some have the diagram on a whiteboard, PowerPoint filled out, PowerPoint blank, etc. Just do what will work best to keep the audience focused on a root-cause analysis.
Allow the audience to brainstorm ways to prevent the same or similar problems from happening in the future. Some may be as simple as a medical knowledge deficit; some may be a complicated interplay between people, policies, systems, environment, etc. You may also consider additional addition bones on the fish, including communication, cognitive heuristics, & others.
What to expect:
Christian Dameff’s recommendation for web site to download videos from YouTube for embedding: http://www.clipconverter.cc/
Let me know if you have any questions!
The emphasis of your presentation should be on root-cause analysis (i.e., discussing why the problem happened and how to prevent it in the future), rather than simply on teaching points/literature updates. These should be included as well, but are not the focus.
We are modeling the format after one employed by Vanderbilt University, details here: http://www.ncbi.nlm.nih.gov/books/NBK43710/
You can use whatever format you want, including Google Slides, PowerPoint, Keynote, Prezi, etc. If you want a suggested template, there are some to choose from here:
- Dr. Epter’s template for PowerPoint
- Tim Davie’s template for Google Slides
- (if you have a good template for Prezi, Keynote, or another platform, please send it to me so I can include it!)
Be sure to include your name and the name of the attending for the case on the introduction slide.
Regardless of what template you use, you should include these elements:
- Triage information
- HPI, exam, past medical/surgical/social history, etc
- No need to include all the HPI from your note verbatim, just keywords and phrases (or pictures) on the slide, then verbalize things to the audience. If you did something goofy in your documentation (Dragonese, discrepancies, etc, please include them as this is an important part of the case discussion)
- Results (labs, imaging, etc)
- Whenever possible include the real EKG, radiographs, CT, etc from your patient. If you need help de-identifying images from PACS, let me know
- Timeline / MDM
- Again, no need to include all the paragraphs from your note verbatim, just keywords and phrases (with time stamps when relevant)
- Hospital and outpatient course if relevant
- Fishbone diagram and walk through of the root-cause analysis
- Please involve the audience – what was the essence of what went wrong, and why did it go wrong? What might we do to prevent this in the future? Is there a quality improvement project that can be generated from this case?
- Literature (brief, 1 or 2 papers)
- What you would do differently / concluding thoughts
- Take-home points
- References
If you have a dark background and you’re trying to highlight text, please do it in yellow or white, not red. Red on black or red on dark gray tends to be very hard to read, especially from the back of the room.
Spend no more than 10 minutes on literature/teaching points (preferably ~5 minutes). Plan to dedicate most of the time to discussion/audience participation.
Have your Ichikawa (“fishone”) diagram filled out in advance with the various people, procedures, equipment, etc that were involved in the occurrence of the problem. During your presentation, allow the audience to discuss why they think the problem happened, and highlight certain parts of the diagram. Don’t take time during your presentation to fill out the parts of the diagram. Consider having the diagram broken up on various slides.
There is some flexibility here, and you’re welcome to use some artistic license. You’ve seen some have the diagram on a whiteboard, PowerPoint filled out, PowerPoint blank, etc. Just do what will work best to keep the audience focused on a root-cause analysis.
Allow the audience to brainstorm ways to prevent the same or similar problems from happening in the future. Some may be as simple as a medical knowledge deficit; some may be a complicated interplay between people, policies, systems, environment, etc. You may also consider additional addition bones on the fish, including communication, cognitive heuristics, & others.
What to expect:
- 30 days in advance of your presentation I will email you with a reminder and a link to this document. At this point, you should have your case selected. If not contact Dr. Epter, myself, or chief residents immediately for help finding a case. Make sure you notify the attending involved in the case as early as possible.
- 14 days in advance you’ll get another email from with simply to remind you that you’re two weeks away, and that you need to have your draft slides submitted within the next week.
- 7 days in advance at the latest you need to submit your draft slides to myself, Dr. Epter, and to the attending involved. Send in one email with everyone copied so we can reply-all and not duplicate our effort. Your slides don’t need to be totally polished at this point, but should have most of the elements to allow meaningful feedback.
Christian Dameff’s recommendation for web site to download videos from YouTube for embedding: http://www.clipconverter.cc/
Let me know if you have any questions!
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Department of Emergency Medicine
Maricopa Medical Center Phoenix, AZ 85008 602-344-5808 - tel 602-344-5907 - fax copapride@gmail.com |
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