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PSNet: Patient Safety Network
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, et al. Archives of surgery (Chicago, Ill. : 1960). 2009;144:305-11; discussion 311.

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.