The Morbidity and Mortality Conference: Opportunities for Enhancing Patient Safety

Abstract

Since the 20th century, health care institutions have used morbidity and mortality conferences (MMCs) as a forum to discuss complicated cases and fatalities to capitalize on lessons learned. Medical technology, health care processes, and the teams who provide care have evolved over time, but the format of the MMC has remained relatively unchanged. The present article outlines 5 key areas for improvement within the MMC along with prescriptive and actionable recommendations for mitigating these challenges. This work incorporates the contributions of numerous researchers and practitioners from the educational, training, debrief, and health care fields. With the best practices and lessons learned from various domains in mind, we recommend optimizing the MMC by (1) encouraging a culture that leverages expertise from multiple sources, (2) allocating ample time for innovative thinking, (3) using a global approach that considers individual, team, and system-level factors, (4) leveraging learnings from errors as well as near misses, and (5) promoting communication, innovative thinking, and actionable planning. The 5 evidence-based recommendations herein serve to ensure that MMCs are structured learning events that promote, encourage, and support safe, reliable care. Furthermore, the outlined recommendations seek to capitalize upon the MMC's opportunity to engage early discovery as well as proactive risk assessment and action-oriented solutions.B ecause of the prevalence of adverse events, the health care sector has made efforts to improve patient safety and quality care. The morbidity and mortality conference (MMC) is a forum to improve patient care through the disclosure and review of error and near-miss events by analyzing errors to gain insights and extract knowledge to improve care processes and outcomes. 1,2 To elaborate further, MMCs are traditionally regularly scheduled meetings in which select patient case studies and provider-raised issues are reviewed to (1) determine the appropriateness and evidence-base of the clinical provision of care when weighed against accepted best practices, (2) learn from patient cases where errors and complications occurred, and (3) determine whether future errors can be prevented or mitigated by adjusting actions and judgments. [3][4][5][6] Morbidity and mortality conferences are similar to debriefs (i.e., a forum of reflection and planning to improve performance 7 ); that is, participants in debriefs as well as MMCs reflect on a previous experience or case to identify actions, construct meaning, and uncover lessons that can be applied to improve outcomes. 7 Similar to MMCs, properly executed debriefs can improve performance of individuals and teams but only if they achieve their desired objectives. 7 Morbidity and mortality conferences are designed to educate the disciplines based on the experiences of a select, unfortunate few. 8,9 This education, ideally, leads to positively changed clinical practice, 10 and some advocate for increasing the frequency of the MMC. 11 Across health...

Defining a High-Quality and Effective Morbidity and Mortality Conference

“…Nine studies included in the systemic review were neither survey nor intervention based . Four studies were consensus guidelines, evidence-based recommendations, or narrative reviews of the role of QI in MMCs …”

“…A total of 179 full-text records were reviewed, and 59 studies met the inclusion criteria (Figure 1). After classification by type, there were 16 survey-based studies (27.1%), 34 intervention-based studies (57.6%), and 9 studies that were neither survey nor intervention based (15.3%) (eTables 1-3 in the Supplement, respectively). The mean MERSQI score for the included studies was 6.7 (range, 5.0-9.5) of a maximum possible 18, which implied that the studies were of average quality.…”

Parent Participation in Morbidity and Mortality Review: Parent and Physician Perspectives

“…Providing answers to parents can help alleviate parent self-blame and ensure accountability for system change ( 29 ). Additionally, parents identified wanting to incorporate positive feedback into the review process as well, highlighting excellence in care received, a concept not dissimilar from the suggestion of incorporating successes into the M&M process and humanizing the process ( 16 , 25 , 26 , 29 , 33 , 34 ).…”

“…Several studies have examined the M&M conference and provided suggestions for restructuring and improving the M&M process. These suggestions include (1) standardizing case selection and presentation (23,25,26), (2) learning not only from errors but also near misses and successes (24,26), (3) fostering discussion by appointing a skilled facilitator to moderate discussion, allocating sufficient time to allow innovative thinking, and ensuring a safe environment to express opinions (23,25,26), (4) attaining and valuing input from multiple sources which consider individual, team, and system-level factors (21,26), (5) reviewing and assessing prior quality improvement initiatives derived from previous M&M processes (23), and (5) deriving action plans and assigning follow-up reflective of learnings identified during the M&M conference (21,25,26).…”

Discussing Complications after Surgery Consists of Multiple Dimensions

“…1,2 Complications must be reported, documented, and discussed, to collectively learn from adverse events and to prevent them in the future. 3,4 Multiple recent analyses provide information on the beneficial aspects of systematic prospective assessment of adverse events in the surgical management of patients to obtain the real incidence and extent of complications. [5][6][7] This strategy is the keystone to prepare for (serious) adverse events for the morbidity and mortality conferences, which, if necessary, result in amendments of the standard operating procedures (SOP) based on the discussions.…”