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PSNet: Patient Safety Network
Journal Article

A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1.

Aboumatar HJ, Blackledge CG, Dickson C, et al. American journal of medical quality : the official journal of the American College of Medical Quality. 2007;22:232-8.

Morbidity and mortality ("M&M") conferences are standard components of training programs and are mandated by the Accreditation Council for Graduate Medical Education. Despite their ubiquity, a prior study of internal medicine and surgery conferences found that errors were discussed infrequently (particularly in internal medicine); thus, housestaff were being denied an important patient safety learning opportunity. In this study, researchers interviewed conference leaders from 12 departments at an academic hospital and found that only a minority identified patient safety and quality improvement as an important learning objective for the conference. Conferences generally did not include recommended elements for analyzing and learning from errors (e.g., assigning responsibility for follow-up). A prior article described how one residency program redesigned M&M to focus on patient safety and learning from errors.