Evolving from Morbidity and Mortality to a Case-based Error Reduction Conference: Evidence-based Best Practices from the Council of Emergency Medicine Residency Directors

Abstract

BACKGROUND Learning from medical errors and near-misses based on retrospective, single-case outcomes is an ubiquitous part of medical training, so much so that morbidity and mortality (M&M) conferences are a required component of graduate medical education in the United States and have been since 1983. 1 Despite widespread use of the M&M conference, its format remains heterogenous with significant variation between programs. 1,2 The origin of the M&M conference can be traced to the early 20th century when Ernest Codman, a surgeon and outspoken reformer at Massachusetts General Hospital, introduced the end-results system, which employed end-result cards to publicly document individual surgeon's outcomes. 2 While this system of blame assignment was met with intense opposition at the time, it largely informed the initial iteration of the M&M conference. 2 Despite over a century of shared experience with M&M conferences among medical centers, many of the limitations of the primitive M&M conference still exist today. These include haphazard retrospective collection of data, focus on isolated and anecdotal events without consideration of previous similar events, recall bias, lack of meaningful audit, narrow focus on individual performance, lack of systems-based thinking, and lack of

Two-Year Profile of Preventable Errors in Hospital-Based Neurology

“…This normalizes the practice of addressing errors, enables systems changes to occur even outside the context of adverse patient events, and creates a culture of constant cognizance of patient safety as recommended in the literature. 22 As such, our number of individual cases discussed is substantially higher than those reported in analogous studies. [5][6][7] Our model includes review of every presentation by the QI director, who recommends modifications to case descriptions to reflect a Systems Audit approach 23 with the exception of acute stroke cases for which Ishikawa diagrams are used.…”

Faculty Recruitment, Retention, and Representation in Leadership: An Evidence-Based Guide to Best Practices for Diversity, Equity, and Inclusion from the Council of Residency Directors in Emergency Medicine

“…This article is the seventh in a series of evidencebased best practice reviews from the Council of Residency Directors in Emergency Medicine (CORD) Best Practices Subcommittee. [10][11][12][13][14][15] With the assistance of a medical librarian, we searched MEDLINE via PubMed for articles published from inception to January 21, 2021, using robust and sensitive keyword variations that relied on PubMed's automatic termmapping to apply the appropriate medical subheadings terms focused on diversity, equity, and inclusion (Appendix). We also reviewed the bibliographies of all relevant articles for additional studies.…”

救急医が感じる診断エラーにおけるストレスとそれに配慮したmorbidity and mortality カンファレンスのあり方(The role of morbidity and mortality conferences and stress in diagnostic errors perceived by emergency physicians)

“…このような学習文化におけるM&Mにおいて，どのような環境づくりが重要かはわかっていなかった。今回の結果からは従来から言われているようにエラーから学ぶ組織文化や個人を責めるものではないことを基盤とし，システム改善に焦点を当てることが重要であることに加えて，エラーを経験した当事者がその感情と向き合う時間を確保することも重要な要素である 11), 12)。すなわち患者安全のためにM&Mを効果的に運営するためには，個人の恥をはじめとした心理的負担を軽減したあり方に配慮する必要があると考えられた。さらに他科と協働して患者の診療にあたる機会の多い救急医に特有な要素として，エラーの振り返りや再発防止の改善が自部門のみで完結することは少なく，他科とM&Mの文化を共有していくことの重要性が明らかとなった。…”