How does learning occur from adverse events, near misses, and errors?
Morbidity and mortality conferences are a way of learning from adverse events. The conferences are held by hospital departments on a regular basis and use a format in which cases are presented to a group, followed by an open discussion including opportunities for improvement.
The cases typically involve patients who experience significant complications and harm as a result of their medical care (i.e. patients who experience massive hemorrhage, surgical complications, or a neonate with birth injury). Attendees have traditionally included attending physicians, residents, and department leadership. Some hospitals may also include nursing, which allows for an understanding of the nursing perspective and possible other contributing factors to the clinical scenario. Morbidity and mortality conferences are a requirement of the Accreditation Council for Graduate Medical Education (ACGME) for accredited residency training programs.
In summary, morbidity and mortality conferences offer an opportunity to openly discuss how errors may have happened, determine root causes and allow learning among participants in order to prevent future errors and harm.
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Fondahn, E., Lane, M., & Vannucci, A. (2016). The Washington Manual of patient safety and quality improvement. Wolters Kluwer.