Medical morbidity and mortality conferences: past, present and future

Abstract

Morbidity and mortality conferences (MMCs) have three potential aims-to improve patient safety by reducing adverse events and preventable deaths, to improve overall quality of care as part of the hospital governance structure and as educational learning events. At present, medical MMCs vary widely in format and attendance from hospital to hospital. The evidence for MMCs actually reducing adverse events and preventing avoidable deaths is disappointing. There is better evidence for their educational role. The majority of medical deaths in hospitals are frail older people with poor life expectancy in whom inadequate care is more likely to be due to errors of omission rather than commission. Medical MMCs should be multidisciplinary and led by a senior clinician to encourage discussion and reflection in a 'blame-free' environment. They should be learning events for both clinicians and the organisation as a whole with a structure to support this.

Morbidity and mortality meetings to improve patient safety: a survey of 109 consultant surgeons in London, United Kingdom

“…The focus on QI within an M&M meeting may improve patient safety culture within an institution [2]. Hoffman et al introduced ‘quality minute’ slides on QI to their M&M meetings and observed increases in patient safety incident (PSI) reporting following each presentation [27].…”

“…The Morbidity & Mortality (M&M) meeting is a forum where adverse outcomes can be discussed. They have the potential to improve patient outcomes [1], quality of care, attitudes towards patient safety [2] and they contribute to the education of clinical staff [3]. They are a mandatory requirement in the United States [4] and should also be attended by all UK surgeons according to Good Surgical Practice [5].…”

Quality Improvement Focused Morbidity and Mortality Rounds: An Integrative Review

“…However, the recurring theme yielded from the literature is that there should be a standardized method for case selection [6]. There should also be a mandatory reporting system in place, wherein cases are selected from this repository outlining systems failures with potentially preventable outcomes [5][6][7][8][9][10]. Studies to date stress the importance of not merely presenting a depiction of weird and wonderful cases, or cases in which death could be attributable solely to the disease process itself [9].…”

“…There should also be a mandatory reporting system in place, wherein cases are selected from this repository outlining systems failures with potentially preventable outcomes [5][6][7][8][9][10]. Studies to date stress the importance of not merely presenting a depiction of weird and wonderful cases, or cases in which death could be attributable solely to the disease process itself [9]. Furthermore, near misses, defined as events that have potential harm but are detected prior to reaching the patient, have particular value for discussion in these conferences from a patient safety and systems perspective [10,11].…”

Electronic Voting to Improve Morbidity and Mortality Conferences

“…This element is reflected by the major role M&M play in educational initiatives. In the USA, M&M have become a required part of training for both surgical and medical residents and many countries, including the UK, have followed suit [ 7 , 32 ].…”