Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety.
Approach to Improving Safety
- Error Reporting
- Root Cause Analysis
- Morbidity and Mortality Conferences
- Culture of Safety
- Transparency and Accountability
Setting of Care
Morbidity and Mortality (M&M) conferences are a time-honored part of medical training. However, these conferences are only rarely used to discuss medical errors or patient safety problems. Even when errors are discussed, learning opportunities may be limited due to lack of a formal mechanism for analysis and follow-up. This article discusses how one academic hospital restructured their monthly M&M conference to focus specifically on patient safety and quality improvement learning objectives. Cases were selected based on voluntary error reports and were presented in a root cause analysis format in an interdisciplinary fashion. Implementation of the restructured conference was associated with improvement in safety culture perception (as measured by the AHRQ Hospital Survey on Patient Safety Culture), and the nursing and pharmacy departments subsequently implemented similar conferences.