Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement

Objective: The morbidity and mortality conference (M&MC) is a traditional forum that provides clinicians with an opportunity to discuss medical error and adverse events. In an effort to promote patient safety at our institution, we implemented a monthly interdisciplinary morbidity, mortality, and improvement (MM&I) conference, which focused on systemwide problems. The participants included physicians, nursing staff, pharmacy, and other clinical departments, as well as senior hospital administrators. Methods: A Mortality Review Task Force selects cases for presentation at the monthly MM&I. A resident representative presents the case, and a designated senior faculty member facilitates a discussion of the case with audience participation. Key issues that contributed to the undesired outcome of the case are identified and outlined on a cause-andeffect diagram (Ichikawa diagram). Workgroups are created to target systems-based problems. At the end of the conference, attendees are asked to complete an evaluation and provide feedback for subsequent consideration by the task force. Results: Twenty-one cases (12 medical, 9 surgical) representing adverse events were presented at the MM&I conference from January 2005 to February 2007. The mean number of participants per session was 88 (range, 62-115). Adverse events triggering case selection included unexpected deaths (six), unplanned intubations (two), prolonged medical care in the setting of poor prognosis (one), delay in care (nine), and procedural complications (three). The most common factors contributing to adverse or “nearmiss” outcomes in these cases were communication failures and inadequate coordination of care. In all, 33 action items were created, and 23 (70 percent) have been completed to date. Conclusion: A structured hospital-wide MM&I conference is an effective means of engaging physicians, nurses, and key administrative leaders in the discussion of adverse events. The identification of potential system failures and the creation of workgroups to address specific systems-based problems can promote initiatives to improve patient care and safety. Background In order to provide high quality patient care, members of a multidisciplinary health care team must engage in objective, nonjudgmental review of adverse outcomes and commit to systematic process change. The morbidity and mortality conference (M&MC) is one forum that provides clinicians with an opportunity to discuss medical error and adverse events. The M&MC became a major part of physician education in the early 20 century, following the publication of the Flexner report on medical education in 1910 and the creation of the American College of