Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality.
The morbidity and mortality (M&M) conference is one of medicine's most longstanding traditions. This study applied the systems approach to analyze cases presented at surgical M&M conferences over a 3-year period at one academic hospital and used insights from a modified root cause analysis process to identify common underlying problems in care. The authors categorized the majority of preventable errors as resulting from disorganized care, which included diagnostic errors, failure to rescue, and lack of situational awareness. Although M&M conferences have been criticized for failing to address systems issues, this and other recent studies demonstrate how this traditional process may be reengineered to achieve patient safety goals.