Journal Article

Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients.

Bilimoria KY; Kmiecik TE; DaRosa DA; Halverson A; Eskandari MK; Bell RH Jr; Soper NJ; Wayne JD.

Morbidity and mortality (M&M) conferences have traditionally been a venue for discussion of complications or potential errors in clinical care. Incident reporting systems are a different mechanism to learn about adverse events (AEs) and potentially foster a positive safety culture. However, getting physicians to use them is challenging. This study describes the development of a Web-based system to capture physician-reported AEs, including entries from weekly M&M conferences. Investigators used the new tool to better categorize complications, identify patterns or trends, and generate quality improvement efforts. An accompanying invited critique [see link below] lauds the study's efforts and points out that surgical cases that don't make it into an operating room must also be included in M&M conferences for the same learning benefits.