A Focus on Improvement

Most academic medical institutions and even private practices hold Morbidity and Mortality (M&M) conferences. M&M sessions provide opportunities for health care providers to review and discuss the details of recent cases that resulted in adverse outcomes. A closed-door forum such as this helps both trainee and veteran alike learn from complications or missteps, as well as how to identify warning signs or symptoms that could potentially go unnoticed.

USE one EDITIn a few academic medical centers, however, including the Department of Internal Medicine, a third letter, I, is added to the monthly M&M conference, putting an equal emphasis on improvement. The MMI conference reaches beyond the facts and symptoms of a particular case, discussing a broad range of event inputs from communication among team members to equipment and working conditions, any of which may have contributed to the event.

Although all cases are treated with confidentiality, some have more positive endings. True, many can be difficult to analyze given their gravity, but the MMI conference maintains an approach that values any outcome as a teachable moment, an important opportunity for both education and positive growth. Attendees are encouraged to brainstorm as many inputs that led to the outcome as potential changes in process or documentation that could forestall hazards or that could help clarify roles and responsibilities in a variety of situations.

USE two EDITAttendees of MMI conferences are multidisciplinary, but they are “wonderful ways to include residents in patient safety culture,” says Dr. Carly Kuehn. As the outgoing Chief Resident of Quality and Patient Safety, Dr. Kuehn has been responsible in part* for organizing the monthly meetings along with faculty on the MMI committee. The committee identifies the individual who will present the case study and often arranges for a faculty member to also present if additional instruction or clarification is needed.

MMI conferences remain focused on results, on positive steps toward change. Dr. Kuehn notes that just in the last year, MMI conferences have produced a number of new approaches. They have led to hospital-wide Code Blue simulations, which help care teams prepare for environments in which knowing what to expect and how to behave can be critical. MMI conferences this year have also addressed alarm safety and ways in which specific medications might be better restricted to services where they are most commonly used.

*UDPATE: A department member emailed to request some additional information be included in this post: “(F)or the last few years Dr. (Ethan) Kuperman has (organized this conference) and he puts a lot of time and effort to make it successful. This went unrecognized for the longest time and, although it is not an official duty of his he continues to do it.”

We appreciate the additional information and regret the oversight in our initial post. Thank you, and thanks to Dr. Kuperman!

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