Key Points

Introduction

The morbidity and mortality (M&M) conference is a forum common to most medical specialties in which clinicians discuss medical error and adverse events. The M&M conference became a regular feature of clinical practice and a major part of physician education early in the twentieth century, following the publication of the Flexner report on medical education and the creation of the American College of Surgeons.

Early in the twentieth century, Dr E.A. Codman, a surgeon at the Massachusetts General Hospital, introduced the end result system to improve clinical practice and reduce medical error. As part of this system, Codman developed the concept of what he termed “the end result card,” to document a patient’s symptoms, clinical diagnosis, treatment plans, complications, final diagnosis, and annually updated outcome. A detailed analysis of the cause was recorded for any case with an adverse event. Codman promoted the ideas of open acknowledgment of the end results, publishing results of the reviews, and establishing committees empowered to correct errors that were identified. Despite early intense opposition from physicians, Codman’s work influenced the standardization of hospital practices by the American College of Surgeons in 1916. Twenty years later, the Philadelphia County Medical Society established the Anesthesia Mortality Committee, an early precursor of the M&M conference. Its objective was to facilitate discussion and to share knowledge about fatalities secondary to anesthesia, and “other interesting anesthetic situations.” The committee was a multi-institutional physician review group that aimed to improve the standards of care. The Committee name later was changed to the Anesthesia Study Commission (ASC) and its purview included not just a review of fatalities but also other clinical issues that impacted patient outcome. Anesthesiologists, surgeons, and internists representing a variety of institutions composed the ASC and the meetings were open to “all physicians, residents and interns… as well as numerous nonresident visitors.” The commission generated periodic public reports of its activities. In a 1945 review and a follow-up report in 1947, Ruth and Ruth and colleagues reported that at least two-thirds of fatalities reviewed were classified as preventable and that the commission’s conclusions often differed from the causes of death included on death reports. This early experience has affected how M&M conferences are conducted to the present day. From the beginning, the M&M conference has had a twofold purpose: education and system improvement. The ASC was founded to improve anesthesia practice through an open review of cases in which medical errors were likely to be found. Meetings were held monthly, and error was confronted directly albeit anonymously. Ruth outlines an inherent conflict in the Committee’s discussions between the educational goals and a fear of incrimination on the part of participants. This strain is relevant even today.

In a report of the experience with a system-wide M&M conference at Vanderbilt, it was noted that the M&M conference has evolved primarily into a forum for education and a venue to discuss “fascinomas” or interesting cases. The Accreditation Council for Graduate Medical Education (ACGME), has made the conference a required component of surgical resident training following a format similar to that used by the ASC. The M&M conference also is common practice among internal medicine, pediatrics and other training programs. The format of the conference varies tremendously among academic programs, and the goals of the conference often are not clearly defined. Cases commonly are selected because of their educational interest or potential teaching value and may not include discussion of adverse or nonroutine events. Biddle analyzed the topics discussed at one hospital’s anesthesia M&M conferences. He found that most involved neither morbidity nor mortality, with the bulk classified as educational. A cross-sectional review by Pierluissi and colleagues of the internal medicine M&M conference found that there was little time for discussion of error, with most of the discussion time spent on case presentation and guest speaker commentary. The investigators pointed out that it is important to discuss adverse events and medical errors. Open discussion promotes learning, which can lead to reduced errors and increased safety. Focusing the discussion on improving the system of care minimizes individual defensiveness and the mistaken belief that an error will not recur if the “culprit” is identified and appropriately managed. Individuals participating in an open, nonjudgmental exchange of ideas contribute to improving the system and advancing safety. In the United States, the ACGME has recognized that physician trainees need to develop competency in six major areas to become effective physicians. Based on published and ongoing experience, the authors believe that a forthright discussion of adverse events, which includes accountability for any necessary follow-up improvement actions, enhances learning in all six areas. Patient care is improved because the system of care is made safer. Discussion of contributing factors, including those that are patient-specific and disease-specific, along with a better understanding of how other factors contribute to a good or adverse outcome increases medical knowledge. Nonjudgmental, forthright discussions among physicians and other members of the health care team about adverse events should improve interpersonal communication and professionalism. Analyzing patient outcomes (practice-based learning) and understanding how the system of care affects patient outcome (systems-based practice) allows physicians and others to learn together.

Frequently, when error is discussed in an M&M conference, the focus is on an unexpected occurrence instead of understanding the processes of care that contributed to the error. Trainees attending the conference frequently think that the purpose of the discussion is to assign blame for an error instead of to improve patient safety. Systems-based issues are rarely identified and, often, there is not enough time allowed to discuss specific interventions to improve patient care across systems of care. The authors surmise that this occurs for several reasons. Physicians, nurses, and other health care workers have been trained in a strong culture of intense personal accountability that focuses on individual responsibility for both positive and negative patient outcomes. Even though Codman introduced the end result system nearly 100 years ago, the emphasis on improvement has evolved to identifying individual error and shortcoming that, when corrected, should result in better patient outcome. Yet over the course of the twentieth century, health care has changed from the care of a patient by an individual doctor or nurse at home to care provided by doctors, nurses, and others within a system. Organizations which accredit institutions (eg, The Joint Commission, the ACGME) and certify individual physicians as specialists (eg, American Board of Medical Specialties and its component Boards) have been established with the notion of assuring the public of a level of quality. Training physicians and other health care workers in practice-based learning and systems-based practice has been emphasized only in the last decade or so. The authors expect that, although individual accountability will remain a major component of M&M conferences, these discussions will also include a reasoned assessment of systems issues.

Introduction

The morbidity and mortality (M&M) conference is a forum common to most medical specialties in which clinicians discuss medical error and adverse events. The M&M conference became a regular feature of clinical practice and a major part of physician education early in the twentieth century, following the publication of the Flexner report on medical education and the creation of the American College of Surgeons.

Early in the twentieth century, Dr E.A. Codman, a surgeon at the Massachusetts General Hospital, introduced the end result system to improve clinical practice and reduce medical error. As part of this system, Codman developed the concept of what he termed “the end result card,” to document a patient’s symptoms, clinical diagnosis, treatment plans, complications, final diagnosis, and annually updated outcome. A detailed analysis of the cause was recorded for any case with an adverse event. Codman promoted the ideas of open acknowledgment of the end results, publishing results of the reviews, and establishing committees empowered to correct errors that were identified. Despite early intense opposition from physicians, Codman’s work influenced the standardization of hospital practices by the American College of Surgeons in 1916. Twenty years later, the Philadelphia County Medical Society established the Anesthesia Mortality Committee, an early precursor of the M&M conference. Its objective was to facilitate discussion and to share knowledge about fatalities secondary to anesthesia, and “other interesting anesthetic situations.” The committee was a multi-institutional physician review group that aimed to improve the standards of care. The Committee name later was changed to the Anesthesia Study Commission (ASC) and its purview included not just a review of fatalities but also other clinical issues that impacted patient outcome. Anesthesiologists, surgeons, and internists representing a variety of institutions composed the ASC and the meetings were open to “all physicians, residents and interns… as well as numerous nonresident visitors.” The commission generated periodic public reports of its activities. In a 1945 review and a follow-up report in 1947, Ruth and Ruth and colleagues reported that at least two-thirds of fatalities reviewed were classified as preventable and that the commission’s conclusions often differed from the causes of death included on death reports. This early experience has affected how M&M conferences are conducted to the present day. From the beginning, the M&M conference has had a twofold purpose: education and system improvement. The ASC was founded to improve anesthesia practice through an open review of cases in which medical errors were likely to be found. Meetings were held monthly, and error was confronted directly albeit anonymously. Ruth outlines an inherent conflict in the Committee’s discussions between the educational goals and a fear of incrimination on the part of participants. This strain is relevant even today.

In a report of the experience with a system-wide M&M conference at Vanderbilt, it was noted that the M&M conference has evolved primarily into a forum for education and a venue to discuss “fascinomas” or interesting cases. The Accreditation Council for Graduate Medical Education (ACGME), has made the conference a required component of surgical resident training following a format similar to that used by the ASC. The M&M conference also is common practice among internal medicine, pediatrics and other training programs. The format of the conference varies tremendously among academic programs, and the goals of the conference often are not clearly defined. Cases commonly are selected because of their educational interest or potential teaching value and may not include discussion of adverse or nonroutine events. Biddle analyzed the topics discussed at one hospital’s anesthesia M&M conferences. He found that most involved neither morbidity nor mortality, with the bulk classified as educational. A cross-sectional review by Pierluissi and colleagues of the internal medicine M&M conference found that there was little time for discussion of error, with most of the discussion time spent on case presentation and guest speaker commentary. The investigators pointed out that it is important to discuss adverse events and medical errors. Open discussion promotes learning, which can lead to reduced errors and increased safety. Focusing the discussion on improving the system of care minimizes individual defensiveness and the mistaken belief that an error will not recur if the “culprit” is identified and appropriately managed. Individuals participating in an open, nonjudgmental exchange of ideas contribute to improving the system and advancing safety. In the United States, the ACGME has recognized that physician trainees need to develop competency in six major areas to become effective physicians. Based on published and ongoing experience, the authors believe that a forthright discussion of adverse events, which includes accountability for any necessary follow-up improvement actions, enhances learning in all six areas. Patient care is improved because the system of care is made safer. Discussion of contributing factors, including those that are patient-specific and disease-specific, along with a better understanding of how other factors contribute to a good or adverse outcome increases medical knowledge. Nonjudgmental, forthright discussions among physicians and other members of the health care team about adverse events should improve interpersonal communication and professionalism. Analyzing patient outcomes (practice-based learning) and understanding how the system of care affects patient outcome (systems-based practice) allows physicians and others to learn together.

Frequently, when error is discussed in an M&M conference, the focus is on an unexpected occurrence instead of understanding the processes of care that contributed to the error. Trainees attending the conference frequently think that the purpose of the discussion is to assign blame for an error instead of to improve patient safety. Systems-based issues are rarely identified and, often, there is not enough time allowed to discuss specific interventions to improve patient care across systems of care. The authors surmise that this occurs for several reasons. Physicians, nurses, and other health care workers have been trained in a strong culture of intense personal accountability that focuses on individual responsibility for both positive and negative patient outcomes. Even though Codman introduced the end result system nearly 100 years ago, the emphasis on improvement has evolved to identifying individual error and shortcoming that, when corrected, should result in better patient outcome. Yet over the course of the twentieth century, health care has changed from the care of a patient by an individual doctor or nurse at home to care provided by doctors, nurses, and others within a system. Organizations which accredit institutions (eg, The Joint Commission, the ACGME) and certify individual physicians as specialists (eg, American Board of Medical Specialties and its component Boards) have been established with the notion of assuring the public of a level of quality. Training physicians and other health care workers in practice-based learning and systems-based practice has been emphasized only in the last decade or so. The authors expect that, although individual accountability will remain a major component of M&M conferences, these discussions will also include a reasoned assessment of systems issues.