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Journal Article > Study
Mankad K, Hoey ETD, Jones JB, Tirukonda P, Smith JT. Clin Radiol. 2009;64:988-993.
This survey study found that practicing radiologists and their departments have an opportunity to learn from errors and need to increase their efforts at recording, addressing, and discussing them. A past AHRQ WebM&M commentary discussed a radiology "wet read" error that led to administration of thrombolytics in a patient without a true pulmonary embolism.
Journal Article > Review
George J. Postgrad Med J. 2017;93:148-152.
Morbidity and mortality (M&M) conferences were traditionally promoted as a strategy to learn from adverse events. This review explores the history of M&M conferences in medicine, including their use in identifying medical errors and their educational benefits. The author explains why M&M conferences that are multidisciplinary in nature and embody a blame-free approach to learning are likely to be more successful for the learner and for the organization supporting the program.