Download PDF
CC BY 4.0 · Eur J Pediatr Surg 2023; 33(02): 114-119
DOI: 10.1055/s-0043-1760836
Review Article

The Morbidity and Mortality Conference: A Century-Old Practice with Ongoing Potential for Future Improvement

Marit S. de Vos 
1   Directorate of Quality and Patient Safety, Leiden University Medical Center, Rotterdam, the Netherlands
,
Merel J. Verhagen
2   Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
,
Jaap F. Hamming
2   Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
› Author Affiliations
› Further Information
   Permissions and Reprints

Abstract

Objective To discuss practical strategies to consider for morbidity and mortality conferences (M&M).

Materials and Methods This article reflects on (i) insights that can be drawn from the M&M literature, (ii) practical aspects to consider when organizing M&M, and (iii) possible future directions for development for this long-standing practice for routine reflection.

Results M&M offers the opportunity to learn from past cases in order to improve the care delivered to future patients, thereby serving both educational and quality improvement purposes. For departments seeking to implement or improve local M&M practice, it is difficult that a golden standard or best practice for M&M is nonexistent. This is partly because comparative research on different formats is hampered by the lack of objective outcome measures to evaluate the effectiveness of M&M. Common practical suggestions include the use of (i) a skillful and active moderator; (ii) structured formats for case presentation and discussion; and (iii) a dedicated committee to guide improvement plans that ensue from the meeting. M&M practice is affected by various sociological factors, for which qualitative research methods seem most suitable, but in the M&M literature these are sparsely used. Moreover, aspects influencing an open and blame-free atmosphere underline how local teams should tailor the format to best fit the local context and culture.

Conclusion This article presents practice guidance on how to organize and carry out M&M This practice for routine reflection needs to be tailored to the local setting, with attention for various sociological factors that are at play.

Keywords

morbidity and mortality conferences - team meetings - patient safety - quality improvement - continuing education


Publication History

Received: 30 October 2022

Accepted: 03 November 2022

Article published online:
31 January 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Orlander JD, Barber TW, Fincke BG. The morbidity and mortality conference: the delicate nature of learning from error. Acad Med 2002; 77 (10) 1001-1006
    CrossrefPubMedGoogle Scholar
  • 2 ACGME Program Requirements for Graduate Medical Education in General Surgery. Accessed November 25. 2022, at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/440_general_surgery_2017-07-01.pdf
    PubMedGoogle Scholar
  • 3 Kaderbesluit CCMS (Dutch).; 2014. Accessed November 25. 2022, at: http://knmg.artsennet.nl/Opleiding-en-herregistratie/CGS/Regelgeving/Huidigeregelgeving.htm
    PubMed
  • 4 Gordon L. Gordon's Guide to the Surgical Morbidity and Mortality Conference. Philadelphia, PA:: Hanley & Belfus; 1994
    PubMedGoogle Scholar
  • 5 Smaggus A, Mrkobrada M, Marson A, Appleton A. Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and educational goals: a systematic review. BMJ Qual Saf 2018; 27 (01) 74-84
    CrossrefPubMedGoogle Scholar
  • 6 Verhagen MJ, de Vos MS, Smaggus A, Hamming JF. Measuring what matters at morbidity and mortality conferences: a scoping review of effectiveness measures. J Patient Saf 2022; 18 (04) e760-e768
    CrossrefPubMedGoogle Scholar
  • 7 Rowland P, Cupido N, Albert M, Kitto S. Morbidity and mortality rounds in the medical literature: a text based analysis of shifting knowledge regimes. SSM - Qualitative Research in Health 2022; 2: 100169 DOI: 10.1016/j.ssmqr.2022.100169.
    CrossrefPubMedGoogle Scholar
  • 8 Berenholtz SM, Hartsell TL, Pronovost PJ. Learning from defects to enhance morbidity and mortality conferences. Am J Med Qual 2009; 24 (03) 192-195
    CrossrefPubMedGoogle Scholar
  • 9 Aboumatar HJ, Blackledge Jr CG, Dickson C, Heitmiller E, Freischlag J, Pronovost PJ. A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1. Am J Med Qual 2007; 22 (04) 232-238
    CrossrefPubMedGoogle Scholar
  • 10 de Vos MS. Healthcare Improvement Based on Learning from Adverse Outcomes. PhD thesis. Leiden University Medical Center; 2018. Accessed November 24, 2022, at: https://hdl.handle.net/1887/67419
    PubMedGoogle Scholar
  • 11 Xiong X, Johnson T, Jayaraman D, McDonald EG, Martel M, Barkun AN. At the crossroad with morbidity and mortality conferences: lessons learned through a narrative systematic review. Can J Gastroenterol Hepatol 2016; 2016: 7679196 DOI: 10.1155/2016/7679196.
    CrossrefPubMedGoogle Scholar
  • 12 Sellier E, David-Tchouda S, Bal G, François P. Morbidity and mortality conferences: their place in quality assessments. Int J Health Care Qual Assur 2012; 25 (03) 189-196
    CrossrefPubMedGoogle Scholar
  • 13 Flynn-O'Brien KT, Mandell SP, Eaton EV, Schleyer AM, McIntyre LK. Surgery and medicine residents' perspectives of morbidity and mortality conference: an interdisciplinary approach to improve ACGME core competency compliance. J Surg Educ 2015; 72 (06) e258-e266
    CrossrefPubMedGoogle Scholar
  • 14 Gore DC. National survey of surgical morbidity and mortality conferences. Am J Surg 2006; 191 (05) 708-714
    CrossrefPubMedGoogle Scholar
  • 15 Kim MJ, Fleming FJ, Peters JH, Salloum RM, Monson JR, Eghbali ME. Improvement in educational effectiveness of morbidity and mortality conferences with structured presentation and analysis of complications. J Surg Educ 2010; 67 (06) 400-405
    CrossrefPubMedGoogle Scholar
  • 16 de Vos MS, Marang-van de Mheen PJ, Smith AD, Mou D, Whang EE, Hamming JF. Towards best practices for surgical morbidity & mortality conferences: a mixed methods study. J Surg Educ 2018; 75 (01) 33-42
    CrossrefPubMedGoogle Scholar
  • 17 Bosk C. Forgive and Remember: Managing Medical Failure. Chicago, IL:: Chicago University Press; 1979
    Google Scholar
  • 18 Kuper A, Nedden NZ, Etchells E, Shadowitz S, Reeves S. Teaching and learning in morbidity and mortality rounds: an ethnographic study. Med Educ 2010; 44 (06) 559-569
    CrossrefPubMedGoogle Scholar
  • 19 de Vos MS, Hamming JF, Marang-van de Mheen PJ. Barriers and facilitators to learn and improve through morbidity and mortality conferences: a qualitative study. BMJ Open 2017; 7 (11) e018833 DOI: 10.1136/bmjopen-2017-018833.
    CrossrefPubMedGoogle Scholar
  • 20 Cromeens B, Brilli R, Kurtovic K, Kenney B, Nwomeh B, Besner GE. Implementation of a pediatric surgical quality improvement (QI)-driven M&M conference. J Pediatr Surg 2016; 51 (01) 137-142
    CrossrefPubMedGoogle Scholar
  • 21 Wasser T, Grunschel BD, Stevens A. et al. Transforming systems of care through a novel resident-led approach to morbidity and mortality conferences. Acad Psychiatry 2016; 40 (06) 893-897
    CrossrefPubMedGoogle Scholar
  • 22 Gerstein WH, Ledford J, Cooper J. et al. Interdisciplinary quality improvement conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes. Am J Med Qual 2016; 31 (02) 162-168
    CrossrefPubMedGoogle Scholar
  • 23 Frey B, Doell C, Klauwer D. et al. The morbidity and mortality conference in pediatric intensive care as a means for improving patient safety. Pediatr Crit Care Med 2016; 17 (01) 67-72
    CrossrefPubMedGoogle Scholar
  • 24 Carroll JS, Edmondson AC. Leading organisational learning in health care. Qual Saf Health Care 2002; 11 (01) 51-56
    CrossrefPubMedGoogle Scholar
  • 25 Dixon-Woods M, Leslie M, Tarrant C, Bion J. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci 2013; 8 (01) 70 DOI: 10.1186/1748-5908-8-70.
    CrossrefPubMedGoogle Scholar
  • 26 Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in healthcare: lessons from the Health Foundation's programme evaluations and relevant literature. BMJ Qual Saf 2012; 21 (10) 876-884
    CrossrefPubMedGoogle Scholar
  • 27 Orlander JD, Fincke BG. Morbidity and mortality conference: a survey of academic internal medicine departments. J Gen Intern Med 2003; 18 (08) 656-658
    CrossrefPubMedGoogle Scholar
  • 28 Sacks GD, Lawson EH, Tillou A, Hines OJ. Morbidity and Mortality Conference 2.0. Ann Surg 2015; 262 (02) 228-229
    CrossrefPubMedGoogle Scholar
  • 29 Bechtold ML, Scott S, Dellsperger KC, Hall LW, Nelson K, Cox KR. Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety. Postgrad Med J 2008; 84 (990) 211-216
    CrossrefPubMedGoogle Scholar
  • 30 Kwok ESH, Calder LA, Barlow-Krelina E. et al. Implementation of a structured hospital-wide morbidity and mortality rounds model. BMJ Qual Saf 2017; 26 (06) 439-448
    CrossrefPubMedGoogle Scholar
  • 31 Santomauro CM, Kalkman CJ, Dekker SWA. Second victims, organizational resilience and the role of hospital administration. J Hosp Adm 2014; 3 (05) 95-103
    PubMedGoogle Scholar
  • 32 Edmondson AC. Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care 2004; 13 (Suppl. 02) ii3-ii9
    PubMedGoogle Scholar
  • 33 Edmondson AC, Lei Z. Psychological safety: the history, renaissance, and future of an interpersonal construct. Annu Rev Organ Psychol Organ Behav 2014; 1 (01) 23-43
    CrossrefPubMedGoogle Scholar
  • 34 Slater N, Sekhon P, Bradley N. et al. Morbidity and mortality conferences in general surgery: a narrative systematic review. Can J Surg 2020; 63 (03) E211-E222
    CrossrefPubMedGoogle Scholar
  • 35 Calder LA, Kwok ESH, Adam Cwinn A. et al. Enhancing the quality of morbidity and mortality rounds: the Ottawa M&M model. Acad Emerg Med 2014; 21 (03) 314-321
    CrossrefPubMedGoogle Scholar
  • 36 de Vos MS, Hamming JF, Marang-van de Mheen PJ. Learning from morbidity and mortality conferences: focus and sustainability of lessons for patient care. J Patient Saf 2021; 17 (03) 231-238
    CrossrefPubMedGoogle Scholar
  • 37 Verhagen MJ, de Vos MS, Hamming JF. Taking morbidity and mortality conferences to a next level: the resilience engineering concept. Ann Surg 2020; 272 (05) 678-683
    CrossrefPubMedGoogle Scholar
  • 38 Myren BJ, de Hullu JA, Hermens RPMG, Koksma JJ, Zusterzeel PLM. Patient involvement via videoconference at the morbidity and mortality (M&M) meeting during COVID-19. BMJ Open Qual 2022; 11 (01) e001691 DOI: 10.1136/bmjoq-2021-001691.
    CrossrefPubMedGoogle Scholar
  • 39 Myren BJ, Hermens RPMG, Koksma JJ, Bastiaans S, de Hullu JA, Zusterzeel PLM. Openness to new perspectives created by patient participation at the morbidity and mortality meeting. In: Patient Education and Counseling. Vol. 104. Elsevier Ireland Ltd; 2021: 343-351 DOI: 10.1016/j.pec.2020.08.008
    CrossrefGoogle Scholar
  • 40 Murayama KM, Derossis AM, DaRosa DA, Sherman HB, Fryer JP. A critical evaluation of the morbidity and mortality conference. Am J Surg 2002; 183 (03) 246-250
    CrossrefPubMedGoogle Scholar
  • 41 Bal G, Sellier E, Tchouda SD, François P. Improving quality of care and patient safety through morbidity and mortality conferences. J Healthc Qual 2014; 36 (01) 29-36
    CrossrefPubMedGoogle Scholar
  • 42 Hutter MM, Rowell KS, Devaney LA. et al. Identification of surgical complications and deaths: an assessment of the traditional surgical morbidity and mortality conference compared with the American College of Surgeons-National Surgical Quality Improvement Program. J Am Coll Surg 2006; 203 (05) 618-624
    CrossrefPubMedGoogle Scholar
  • 43 Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion of medical errors in morbidity and mortality conferences. JAMA 2003; 290 (21) 2838-2842
    Google Scholar
  • 44 Dimick JB, Greenberg CC. Understanding gaps in surgical quality: learning to count what cannot be counted. Ann Surg 2013; 257 (01) 6-7
    CrossrefPubMedGoogle Scholar
  • 45 Mosher BD, Anderson CI, Nelson C, Kepros JP. The significance of nontechnical root causes in morbidity and mortality conference: the delivery of surgical care as a science. J Am Coll Surg 2009; 209 (03) S96 DOI: 10.1016/j.jamcollsurg.2009.06.240.
    CrossrefPubMedGoogle Scholar
  • 46 Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems approaches to surgical quality and safety: from concept to measurement. Ann Surg 2004; 239 (04) 475-482
    CrossrefPubMedGoogle Scholar
  • 47 Dekker SWA, Leveson NG. The systems approach to medicine: controversy and misconceptions. BMJ Qual Saf 2015; 24 (01) 7-9
    CrossrefPubMedGoogle Scholar
  • 48 Hollnagel E, Woods DD, Leveson N. Resilience Engineering: Concepts and Precepts. Adelshot, UK:: Ashgate; 2006
    Google Scholar
  • 49 McHugh SK, Lawton R, O'Hara JK, Sheard L. Does team reflexivity impact teamwork and communication in interprofessional hospital-based healthcare teams? A systematic review and narrative synthesis. BMJ Qual Saf 2020; 29 (08) 672-683
    CrossrefPubMedGoogle Scholar