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PSNet: Patient Safety Network
Journal Article

Interdisciplinary Quality Improvement Conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes.

Gerstein WH, Ledford J, Cooper J, et al. American journal of medical quality : the official journal of the American College of Medical Quality. 2016;31:162-8.

This study describes the implementation of a systems-focused morbidity and mortality conference at a Veterans Health Administration medical center designed to augment patient care and promote interdisciplinary teamwork and transparency, while addressing residency requirements. The intervention demonstrated lasting improvements in systems issues, consistent with prior data using this learning format.