• Jed D Gonzalo, Gregory M Bump, Grace C Huang, and Shoshana J Herzig.
• J Grad Med Educ. 2014 Mar 1;6(1):139-46.

BackgroundMorbidity and mortality (M&M) conferences provide a forum for discussing adverse events and systems-based practice (SBP) issues; however, few models for implementing multidisciplinary, systems-focused M&M conferences exist.ObjectiveTo implement a new systems-focused M&M conference and evaluate success in focusing on adverse events and systems issues in a nonpunitive, multidisciplinary manner.MethodsWe implemented a new M&M conference into our large university-based internal medicine residency program. Using content analysis, we qualitatively analyzed audio recordings of M&M conferences from the first year of implementation (2010-2011) to determine the frequency of adverse events (injury resulting from medical care), SBP discussion, and allocation of blame. Multidisciplinary attendance was evaluated by attendance logs. Surveys assessed change in interns' perceptions of M&M conferences before and after the conference series (measured by median Likert-scale response) and trainee/faculty attitudes regarding the goal of M&M conferences.ResultsThere were 226 attendees (66 faculty, 160 residents/fellows) at 9 M&M conferences. Average attendance per conference was 71, with representation from 16 disciplines. All M&M conferences (100%) included adverse events, SBP discussion, and lacked explicit individual blame. Interns' perceptions improved, including their belief that the M&M conference's purpose is systems improvement (4.35 versus 4.71, P  =  .02) and complications are discussed without blame (3.81 versus 4.34, P  =  .01). After experiencing M&M conferences, trainees/faculty reported favorable ratings, including beliefs that the M&M conference is important for education (97%) and the purpose is systems improvement (95%).ConclusionsThe implementation of a new systems-focused M&M conference resulted in a conference series focusing on adverse events and associated system issues in a nonpunitive, multidisciplinary context.

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