Journal Article
Study

A systems approach to morbidity and mortality conference.

Szostek JH; Wieland ML; Loertscher LL; Nelson DR; Wittich CM; McDonald FS; Kolars JC; Reed DA.

Morbidity and Mortality (M&M) conferences are designed to explore systems that contribute to medical error or adverse outcomes in patient care. AHRQ WebM&M offers an online version of such conferences with presentation of cases and expert commentaries discussing relevant safety issues. In training programs, growth of M&M conferences also serves to teach important principles of quality and safety through a variety of different frameworks. This study shares a structured systems audit framework that was applied to M&M conferences to enhance resident awareness of systems issues. The framework facilitated discussion of improvement opportunities and fostered a positive safety culture in exploring the events presented. The authors provide a number of practical tools for adoption and share examples of using these tools in M&M conferences.