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PSNet: Patient Safety Network
Journal Article
Study

Learning from morbidity and mortality conferences: focus and sustainability of lessons for patient care.

de Vos MS, Hamming JF, Marang-van de Mheen PJ. J Patient Saf. 2021;17(3):231-238.

Morbidity and mortality (M&M) conferences are a useful tool for teams to investigate and learn from adverse events. In this observational study, researchers interviewed clinicians attending surgical M&M conferences to explore the types, and recurrence of, lessons learned. Clinicians ascribed most lessons to technical or individual-level issues, and observed the challenges to sustaining changes at a systems-level. Researchers suggest M&M formats should shift to a broader focus to implement and sustain lasting system-level improvements.