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PSNet: Patient Safety Network
Journal Article

Discussion of medical errors in morbidity and mortality conferences.

Pierluissi E, Fischer MA, Campbell AR, et al. JAMA. 2003;290:2838-42.

Traditional morbidity and mortality conferences were designed to focus on educational opportunities to learn from an error or adverse event. This study examined how frequently such conferences actually fulfilled their mission by observing more than 330 of them in both internal medicine and surgery. Investigators discovered that internal medicine conferences involved more lengthy case presentations and discussions, more time listening to invited speakers, and less time in audience discussion. Surgery conferences more frequently presented errors and adverse events and also attributed errors to a particular cause. The authors discuss the lost opportunity for learning and the potential for closing such gaps with improved conference facilitation and an emphasis on using specific language and modeling directed towards system improvement. AHRQ WebM&M offers an online version of such a conference with presentation of cases and expert commentaries discussing relevant safety issues.