Morbidity and mortality conference

This article is about conferences to review poor or unusual outcomes in medical centers. For other uses of the term "morbidity and mortality", see Morbidity and mortality.

Morbidity and mortality (M&M) conferences are traditional, recurring conferences held by medical services at academic medical centers, most large private medical and surgical practices, and other medical centers. They are usually peer reviews of mistakes occurring during the care of patients. The objectives of a well-run M&M conference are to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications.[1] Conferences are non-punitive and focus on the goal of improved patient care. The proceedings are generally kept confidential by law.[2] M&M conferences occur with regular frequency, often weekly, biweekly or monthly, and highlight recent cases and identify areas of improvement for clinicians involved in the case. They are also important for identifying systems issues (e.g., outdated policies, changes in patient identification procedures, arithmetic errors, etc.) which affect patient care.[1][3]

Morbidity and Mortality conferences have long been part of the practice of medicine, having originated in the early 1900s with Ernest Codman at Massachusetts General Hospital in Boston. He lost his staff privileges there after suggesting the evaluating of surgeon competence. Codman's ideas contributed to the standardization of hospital practices — including a case report system that ascribed responsibility for adverse outcomes — by the American College of Surgeons in 1916. As the medical profession evolved, physicians grew accustomed to discussing their errors at mortality conferences, where autopsy findings were presented, and in published case reports. By 1983, the ACGME began requiring that accredited residency programs conduct a weekly review of all complications and deaths.

References

  1. 1 2 Campbell, W. (1988). "Surgical morbidity and mortality meetings". Annals of the Royal College of Surgeons of England. 70 (6): 363–365. PMC 2498614Freely accessible. PMID 3207327.
  2. ↑ Gawande, Atul (2002). Complications: A Surgeon's Notes on an Imperfect Science. Macmillan. pp. 47–74. ISBN 0-8050-6319-6.
  3. ↑ Orlander, J.; Barber, T.; Fincke, B. (2002). "The morbidity and mortality conference: the delicate nature of learning from error". Academic Medicine. 77 (10): 1001–1006. doi:10.1097/00001888-200210000-00011. PMID 12377674.

Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix. Web M+M – The Agency for Healthcare Research and Quality, September 2007. http://webmm.ahrq.gov

Gordon LA. The Zen of M&M – American College of Surgeons Residency Assist Page June, 2011 http://www.facs.org/education/rap/gordon0511.html

External links

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