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Huddleston JM, Diedrich DA, Kinsey GC, Enzler MJ, Manning DM. J Patient Saf. 2014;10:6-12.
Huddleston JM ; Diedrich DA ; Kinsey GC; et al. Learning from every death. J Patient Saf. 2014; 10: 6-12
This commentary describes how design and implementation of an institutional mortality review system evolved over 10 years. The reporting program offers insights about how to promote and enhance organizational learning.
A multidisciplinary model for reviewing severe maternal morbidity cases and teaching residents patient safety principles.
Ogunyemi D, Hage N, Kim SK, Friedman P. Jt Comm J Qual Patient Saf. 2019;45:423-430.
Why do hundreds of US women die annually in childbirth?
Slomski A. JAMA. 2019;321:1239-1241.
The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives.
Durstenfeld MS, Statman S, Dikman A, et al. Am J Med Qual. 2019 Jan 18; [Epub ahead of print].
Mortality and morbidity rounds (MMR) in pathology: relative contribution of cognitive bias vs. systems failures to diagnostic error.
Eichbaum Q, Adkins B, Craig-Owens L, et al. Diagnosis (Berl). 2018 Dec 4; [Epub ahead of print].
How common are cognitive errors in cases presented at emergency medicine resident morbidity and mortality conferences?
Chu D, Xiao J, Shah P, Todd B. Diagnosis (Berl). 2018;5:143-150.
Comparison of military and civilian methods for determining potentially preventable deaths: a systematic review.
Janak JC, Sosnov JA, Bares JM, et al. JAMA Surg. 2018;153:367-375.
Surveying care teams after in-hospital deaths to identify preventable harm and opportunities to improve advance care planning.
Lucier D, Folcarelli P, Totte C, Carbo AR, Sokol-Hessner L. Jt Comm J Qual Patient Saf. 2018;44:84-93.
Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and educational goals: a systematic review.
Smaggus A, Mrkobrada M, Marson A, Appleton A. BMJ Qual Saf. 2018:27:74-84.
The "Quality Minute"—a new, brief, and structured technique for quality improvement education during the morbidity and mortality conference.
Hoffman RL, Morris JB, Kelz RR. JAMA Surg. 2017;152:883-884.
The role of morbidity and mortality rounds in medical education: a scoping review.
Benassi P, MacGillivray L, Silver I, Sockalingam S. Med Educ. 2017;51:469-479.
Medical morbidity and mortality conferences: past, present and future.
George J. Postgrad Med J. 2017;93:148-152.
Morbidity and mortality conferences: a narrative review of strategies to prioritize quality improvement.
Giesbrecht V, Au S. Jt Comm J Qual Patient Saf. 2016;42:516-527.
Implementation of a structured hospital-wide morbidity and mortality rounds model.
Kwok ESH, Calder LA, Barlow-Krelina E, et al. BMJ Qual Saf. 2017;26:439-448.
Leveraging a redesigned morbidity and mortality conference that incorporates the clinical and educational missions of improving quality and patient safety.
Tad-Y DB, Pierce RG, Pell JM, Stephan L, Kneeland PP, Wald HL. Acad Med. 2016;91:1239-1243.
Engaging pediatric resident physicians in quality improvement through resident-led morbidity and mortality conferences.
Destino LA, Kahana M, Patel SJ. Jt Comm J Qual Patient Saf. 2016;42:99-110.
Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study.
François P, Prate F, Vidal-Trecan G, Quaranta JF, Labarere J, Sellier E. BMC Health Serv Res. 2016;16:35.
Transforming the morbidity and mortality conference to promote safety and quality in a PICU.
Cifra CL, Bembea MM, Fackler JC, Miller MR. Pediatr Crit Care Med. 2016;17:58-66.
The morbidity and mortality meeting: time for a different approach?
Fraser J. Arch Dis Child. 2016;101:4-8.
Incorporating metacognition into morbidity and mortality rounds: the next frontier in quality improvement.
Katz D, Detsky AS. J Hosp Med. 2016;11:120-122.
Morbidity and mortality conference in emergency medicine residencies and the culture of safety.
Aaronson EL, Wittels KA, Nadel ES, Schuur JD. West J Emerg Med. 2015;16:810-817.
The morbidity and mortality conference in pediatric intensive care as a means for improving patient safety.
Frey B, Doell C, Klauwer D, et al. Pediatr Crit Care Med. 2016;17:67-72.
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. Am J Med Qual. 2016;31:162-168.
Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality.
Anderson CI, Nelson CS, Graham CF, et al. J Surg Res. 2012;177:43-48.
Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety?
Higginson J, Walters R, Fulop N. BMJ Qual Saf. 2012;21:576-585.
Practice-based learning and improvement: a two-year experience with the reporting of morbidity and mortality cases by general surgery residents.
Falcone JL, Lee KKW, Billiar TR, Hamad GG. J Surg Educ. 2012;69:385-392.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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