• M L Bechtold, S Scott, K Nelson, K R Cox, K C Dellsperger, and L W Hall.
• Department of Internal Medicine, University of Missouri Health Care, University of Missouri-Columbia, Columbia, Missouri, USA.
• Postgrad Med J. 2008 Apr 1; 84 (990): 211-6.

ProblemAlthough Morbidity and Mortality conferences (MMC) were originally designed to promote quality care through careful analysis of adverse events, focus on individual actions or the fear of incrimination may interfere with identification of system issues contributing to the adverse outcomes.DesignPre- and post-intervention assessments of participant attitudes toward patient safety and conference redesign were performed utilizing an attitudinal survey. Participants provided a unique identifier for paired-means procedure. A list of contributing factors, recommended solutions, and targeted system improvements was maintained with ongoing progress recorded.SettingDepartment of Internal Medicine training program at University of Missouri-Columbia, an academic health care center affiliated with the University of Missouri Hospitals and Clinics and the Harry S. Truman Veteran's Administration Hospital.ParticipantsResidents and fellows from the Department of Internal Medicine residency program.Educational Objectives(1) Distinguish between culture of blame/shame and patient safety culture, (2) Identify gaps in quality contributing to adverse outcomes, (3) Identify strategies to close gaps, (4) Participate in root cause analysis, demonstrating an ability to review an adverse event and recommend an action plan.Strategies For ChangeAn interdisciplinary team modified the internal medicine MMC to emphasize a better understanding of patient safety principles and system-based practice interventions. For each adverse event analyzed, root causes were identified, followed by discussion of system interventions that might prevent future such events.Key Measures For Improvement(1) Attitudes of residents and fellows regarding patient safety, as measured on a 20 item, five-point ordinal scale (strongly disagree to strongly agree) survey, (2) System improvements generated from the Patient Safety M&M Conferences (PSMMC), and (3) Attendance at PSMMC.Effects Of ChangeClinical outcomes: Conference participants offered 121 system improvement recommendations; 39 suggested system interventions were pursued based upon the likelihood of achieving high impact changes. These targeted changes were assigned to department/facility representatives with 23 (59%) improvements implemented, 11 (28%) partially implemented or in progress, and five (13%) abandoned due to impracticality or redundancy. Educational outcomes: Surveys were completed by 58 residents and fellows before and after modification of conference format. Six of the 20 survey items showed significant change with four of these changes occurring in the desired direction. Eleven of the remaining 14 responses changed in the desired direction, but did not reach statistical significance. Average MMC attendance increased from 41+/-8 to 50+/-10 (p<0.03) participants.Lessons LearntThe new PSMMC initiated multiple improvements in the quality of patient care without sacrificing attendance or attitudes of the residents or fellows. The new PSMMC promotes opportunities for participants to improve quality of patient care in a safe and nurturing environment.

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