Morbidity and Mortality Conference

The purpose of the M&M Conference is to provide a safe venue for residents to identify areas of improvement, and promote professionalism, ethical integrity and transparency in assessing and improving patient care. The M&M Conference also provides a forum to teach curriculum on quality improvement and medico legal issues to residents and students and to foster a climate of openness and discussion about medical errors.

Preparation

The M&M Case Preparation Guide and Worksheet should be used to create your presentation.

The conference also promotes leadership, research, and scholarly activity and incorporates into a learning opportunity the six core ACGME competencies of:

• Patient care
• Medical knowledge
• Practice-based learning and improvement
• Interpersonal and communication skills
• Professionalism
• Systems-based practice

Participants

• faculty moderator and resident presenter
• all residents are expected to attend
• all faculty are invited and expected to attend
• anyone involved in the case with direct knowledge of the systems and events relevant to the discussion (this may include other physicians, nurses, pharmacists, therapists, lab personnel, and representatives of ancillary departments).

Case Selection

Cases should be selected from the entire practice population. Cases (inpatient or outpatient), should involve:

• a poor or unintended outcome which might have been due to or worsened by error or system problems, or
• "near-misses," where there was an error or misstep in care delivery that could have led to a poor patient outcome, or
• an interesting and unique case that may provide new learning and inquiry
• Resident Presenter should complete the M & M Conference Preparation Worksheet and review in advance with the Faculty Moderator.

Ground Rules

• Follow the format
• No finger-pointing - focus on systems of care rather than individual errors
• Confidentiality - avoid patient identifiers (no names, dates, record numbers) and do not discuss casually outside the conference

Conference Format

• PowerPoint Presentation limited to 30 minutes
• Introduction and Overview by Faculty Moderator
• Case Presentation by Resident
• Overview of the case
• Review timeline of events
• Describe how the patient care issue(s) caused potential or actual harm to the patient, family, or a healthcare professional
• Identify any evidenced-based literature that is applicable
• Identify the ACGME competency the patient care issue related to
• Identify the nature of the patient care issue
• Identify the "Take Home Points"
• Recommend any clinical or system changes that should be considered to prevent this patient care issue from occurring in the future
• Faculty moderator facilitates the discussion of the case and Take Home Points- 15 minutes