The morbidity and mortality conference in preventing human error

The morbidity and mortality conference (M&MC) is an established medical tradition which is aimed at learning from mistakes and preventing future patient harm and death. In their paper titled The morbidity and mortality conference: the delicate nature of learning from error, Jay Orlander and colleagues referred to the M&MC as an attempt ‘to improve medical practice through examination of adverse outcomes and errors‘. Stressing that ‘the goal of the conference is not to criticize, but to profit by sharing and examining our experience’, they explained that any errors that are identified during the conference should be used as tools ‘to improve our skill as physicians’. The benefits of M&MC in preserving patient safety and reducing patient mortality have been demonstrated in many studies; for example, in a paper titled A report card system using error profile analysis and concurrent morbidity and mortality review, Anthony Antonacci and colleagues reported that mandatory M&MC’s lead to a 40% reduction in mortality over 4 years.

The Meeting of the Bird Kings. The Art League Gallery on Flickr.

The objectives of the M&MC are well established and were listed by Orlander and colleagues to include the following:

    • To ‘facilitate the open discussion of medical error’
    • To ‘identify events resulting in adverse patient outcomes’
    • To ‘foster discussion of adverse events’
    • To ‘identify and disseminate information and insights about patient care that are drawn from experience’
    • To ‘reinforce accountability for providing high-quality care’
    • To ‘create a forum in which physicians acknowledge and address reasons for mistakes
Handscroll. Basil Gilbert on Flickr.

The MM&C is a structured process with clearly delineated phases. In their paper titled A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models, Hanan Aboumatar and colleagues identified eight stages of the M&MC which are case selection, review, analysis, presentation, discussion, summary, recommendations and follow-up. In their recommendations for the selection and discussion of M&MC cases, Orleander and colleagues advised that:

    • Cases should be recent because of ‘the importance of facing medical error directly and in a timely manner
    • Cases should not be chosen merely to ‘demonstrate gross mismanagement
    • ‘Cases should be discussed in advance with the treating physicians so that the details of the error can be clarified’
    • Physicians ‘should be given the opportunity to present the case, the circumstances leading to the outcome, and the lessons they have drawn’
    • ‘A senior physician who is skilled at creating a supportive atmosphere‘ should moderate the discussions
The meeting of the council. giveawayboy on Flickr.

To guide the effective running of the M&MC, the Royal College of Surgeons of England issued a set of guidelines titled Morbidity and mortality meetings: a guide to good practice. Amongst its practical recommendations are that:

    • The M&MC should hold regularly
    • The M&MC should have sufficient ‘protected time‘ for discussing all cases
    • The M&MC should hold at the same venue if possible
    • The venue should be spacious and contain ‘sufficient IT facilities
    • The attendees should be ‘able to see and hear each other and view all presented data
    • All clinical cadres of the department are ‘expected to attend’
    • ‘Non-clinical managers with a role in service delivery or clinical governance should also be invited’

Similarly, Sean Berenholtz and colleagues proposed that three capabilities should be considered for an effective M&MC. In their paper titled Learning from defects to enhance morbidity and mortality conferences, they listed these as:

    • Getting the input of all clinicians involved in the incident
    • Using a structured framework to investigate contributory factors
    • Following up on recommendations
Paris Café. Pedro Ribeiro Simões on Flickr.

Orleander and colleagues also made helpful recommendations for the effective running of the MM&C, amongst which are that:

    • The discussion should ‘model a middle ground between minimization and magnification‘ of the error
    • The ‘moderator and/ or senior members of the staff should selectively recount similar or relevant errors that they have made and the lessons/ benefits that they have drawn from reflecting upon them’
    • The discussion should address ‘how to prevent future similar adverse events’
    • Any changes made should be ‘reported at later meetings of the M&MC’

Peter Pronovost and colleagues, in their paper titled Implementing and validating a comprehensive unit-based safety program, also advised that the presenting physician should encourage learning about safety by providing ‘an explanation of what occurred’, and by identifying ‘actions which will reduce the likelihood of this event reoccurring’.

Meeting in NYC for JKPP. Arturo Espinosa on Flickr.

Whilst the M&MC is universally acknowledged as a beneficial exercise, it has some potential disadvantages if it is not implemented appropriately. Referring to this as its ‘double-edged sword‘, Orleander and colleagues pointed out the M&MC may fail to confront mistakes because of the fear of discomfiting the affected individuals, and it may fail to address the underlying systemic causes of the errors uncovered. They also noted that the M&MC has the potential to evoke the following emotions in the affected physicians:

    • Anxiety
    • Fear of public humiliation
    • Fear of litigation
    • Potential ‘loss of respect
Study community meeting. Howard J on Flickr.

In the next post, we will review patient safety training in preventing human error.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s