SRS Newsletter
September 2013
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Morbidity and Mortality Committee Update

Douglas C. Burton, MD
Morbidity and Mortality Committee Chair

Douglas C. Burton, MD

2012 M&M Data Collection Presented at the 48th Annual Meeting & Course in Lyon, France
On Friday, September 20, at 7:09-7:16 AM in Forum 4 at the Cite Centre de Congres, Lyon, France (during the Members’ Business Meetings), Dr. Burton will present the results of our 2012 M&M data collection, compare and contrast the results with past collection years and glean the pros and cons. After the Annual Meeting, the general 2012 M&M results will be posted on the members-only site. 

Time Clock Increase on M&M Collection Site
Good news!  The time limit has increased to 30 minutes, from 15 minutes, while entering M&M data!  Remember, each time you click the “Click to save data and update totals” button at the bottom of the grid page your data will be saved and the timer will restart to an additional 30 minutes.

New Discrepancy Report for Complications
In an effort to continue to monitor the accuracy of data entered, we have created and implemented a discrepancy report. Your online M&M report will now be flagged for a discrepancy when the sum from the grid page does not match what has been entered in the “record complication” section or when the sum from the “record complication” section does not match the complication number(s) entered on the grid page. Therefore, all numbers entered under the complication columns in the grid page must match up with what is recorded in detail and vise versa.

For example: 

  • You entered three acute infection cases on the grid page, under the infection column, when you began reporting, however, you only recorded the details on two of the cases thinking you would go back and enter the third case before the deadline but never did; your report will be flagged with a discrepancy.  
  • You recorded complication details on two cases of visual acuity loss but did not record them on the grid page, under the visual acuity loss column; your report will be flagged with a discrepancy.
  • You entered one death and one neurologic deficit case on the grid page but never recorded any complication details in the “record complication” section; your report will be flagged with a discrepancy.

How do I know if I have a discrepancy in my reporting?
There are three ways you are alerted of a discrepancy in your reporting.

  1. You will not be allowed to attest your report and will be asked to review your to-do-list.
    1. Down fall: you do not attest your report at all or wait until right before the deadline to attest; hence you will not know about the discrepancy and/or will not have time to fix it.
  2. You will be contacted via email by the SRS office to fix the discrepancy.
    1. Down fall: you do not open your emails from the SRS office.
    2. Down fall: you do not forward the message to the person in your office that does the reporting for you.
  3. Your to-do-list will inform where the discrepancy is.

Snap shot of the to-do-list from M&M site: 


To-Do-List
This section indicates the difference between what was recorded on the grid page and what has been recorded in the “record complication” section.
• You have to record 1 more complication case(s) resulting in death.
• You have to record 1 more complication case(s) with neurological deficit.
• You have to record 2 more complication case(s) resulting in visual acuity loss.
• You have to record 1 more complication case(s) with acute infection.

How do I fix the discrepancy?

  1. Review your to-do-list to verify where the problem is.
  2. Go back in to your M&M report and make the pertinent changes and save again.
  3. After fixing your discrepancy you will be allowed to attest your report and your to-do-list will revert back to zero, meaning that your complications recorded match-up with what is listed on the grid page.

Please be aware that you will be contacted via email sometime in January to fix any discrepancies. This will allow you three months to fix any issues and to attest your report after the issues have been fixed.

Hard Copy Complication Data Questionnaire for Download (coming in October)
Per member request, we have created a hard copy complication data questionnaire that contains all of the complication questions from the online system. We hope that this document will make record keeping easier and will increase the accuracy of reporting.  

Revisiting the Definitions of Complication Terms
In an effort to be clear on what to enter in the complication sections the committee created definition of terms. Please let us know if you have any questions.  

Death:  Death that is attributable to a complication of the surgery or occurred during the surgical event. Current module goes for >21 days if in fact traceable to the surgery or lingering complication.

Visual acuity loss (formally termed blindness): Any change in visual acuity listed by time of identification within the hospital stay. Classification by pathology usually requiring specialty consultation.

Neurologic deficit (formally termed paralysis): Any change in the spinal cord, nerve roots, or peripheral nerves apparent within the time frames listed in the module.
Acute infection: Acute Infections that occur at the operative site in the post operative period of up to 12 weeks.

Please remember that if and when you enter any complications you must fully complete the detailed modules for each complication in the “record complication” section. If not, your report will be flagged with a discrepancy.

Our data collection is only as good as the information that is entered, correctly!!  Please, please pay special attention. 

Request for Proposal (RFP) for M&M Data Research
A special member benefit is the opportunity to glean M&M data for your own research. A couple of years ago the Board of Directors agreed to fund data extraction from the M&M database for individual research.

In an effort not to duplicate projects we have provided a list of current research. There is also a bibliography of published papers using the M&M database, which demonstrates the usefulness and value of our M&M collection process as well as to serve as a guide to future researchers as they consider studies using the M&M database.

The next three deadlines for M&M RFP’s are:

Request for Proposal Deadline Notification M&M Data Delivered Via Email
September 1 October 1 November 1
November 1 December 1 January 1
January 1 February 1 March 1

The process and guidelines for submitting an RFP is located on the Members-Only section of the SRS website under Morbidity and Mortality.

Any questions please contact:
Doug Burton, M&M Committee Chair at DBurton@kumc.edu or
Nilda Toro, M&M Committee staff liaison at ntoro@srs.org

Thank you for your continued dedication to the M&M collection process.  It is greatly appreciated.

Chair: Douglas C. Burton, MD Committee Members: Paul A. Broadstone, MD; Yongjung J. Kim, MD; Gregory V. Hahn, MD; Annalise N. Larson, MD; William F. Lavelle, MD; Darren R. Lebl, MD; Kamran Majid, MD; Alejo Vernengo-Lezica, MD; Robert F. Heary, MD; Howard M. Place, MD; Jonathan E. Fuller, MD; Karl E. Rathjen, MD; Praveen V. Mummaneni, MD; Joseph M. Verska, MD