Learning From Errors: Curriculum Guide for the Morbidity and Mortality Conference With a Focus on Patient Safety Concepts

Abstract

Introduction Morbidity and mortality conferences are Accreditation Council for Graduate Medical Education–required educational series that are part of all residency training programs. This conference offers trainees an opportunity to discuss patient cases where errors or complications may have occurred. Conventionally, most of the allotted time is spent on case presentation and therapeutic debates, which is a lost opportunity to teach fundamental principles of patient safety, error analysis, and strategies for system-wide improvement. The goal of this resource is to refocus the content of morbidity and mortality and transform it into a platform for teaching patient safety principles and emphasizing error reduction strategies. Methods It was delivered as a 1-hour workshop session once a month during usual conference times. The workshop includes a mortality case review followed by a small-group activity in which trainees are assigned specific safety tasks, including systematic analysis of an error, conducting root cause analysis, and resident peer review. Results Postsurveys demonstrated that 90% of the trainees either agreed or strongly agreed that the safety concepts they learned would likely improve the quality of care they provide to future patients. Discussion We learned that morbidity and mortality could be used to effectively teach principles of patient safety and could create system-wide improvements.

The Mystery Dinner RCA: Using Gamification and Simulation to Teach Root Cause Analysis

“… 9 – 11 A novel attempt to overcome educational barriers has been the creation of freely available mock RCA workshops. 12 – 15 While such workshops are useful training tools, they typically provide skeleton frameworks with local error investigation that still requires significant faculty time. Furthermore, most workshops target a specific training population 13 , 14 and have not been studied across a variety of GME and UME learners.…”

Expanding Training in Quality Improvement and Patient Safety Through a Multispecialty Graduate Medical Education Curriculum Designed for Fellows

“…To date, although MedEdPORTAL has many QI educational resources, [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] none focus on the learner at the fellowship level. Our resource builds upon the framework and content of existing curricula to expand and advance QIPS practice across the continuum of professional development, with a goal of developing the knowledge, skills, and attitudes necessary among fellows-in-training to enhance leadership and scholarship in PS, QI data acquisition, interpretation, and project design and implementation.…”

Care Escalation: Teaching Residents How to Effectively Communicate Patient Care Concerns

“…A MedEdPORTAL “learning from errors” curriculum has been published that uses morbidity and mortality cases to teach residents how to perform root cause analyses and identify sources of error, including failure to escalate care; however, teaching how or when to escalate concerns is not a major focus. 10 Given the importance of care escalation in patient safety, the complexity of physical, cognitive and social barriers in escalation, and the lack of training provided to residents, this novel curriculum is critical for resident learners.…”