title: Learning from defects to enhance morbidity and mortality conferences.
abstract: While required by the Accreditation Council for Graduate Medical Education (ACGME) and recommended by the Institute of Medicine, there are few published studies demonstrating that morbidity and mortality conferences (MMCs) are an effective strategy to improve patient care. To learn from medical incidents and improve patient care, care-givers need to: (1) elicit input from all staff involved in the incident, (2) use a structured framework to investigate all underlying contributing factors, and (3) assign responsibility for management and follow-up on recommendations. Many MMCs lack these key elements. The specific aims of this article are to describe the use of the learning from a defect tool as a strategy to meet ACGME requirements, advance medical education, and enhance traditional MMCs in one fellowship program at an academic medical institution. In addition, this approach improved patient care and provided a foundation for our fellows to use to address patient safety defects after fellowship.
authors.affiliation: Johns Hopkins University, Baltimore, Maryland, USA. sberenh1@ jhmi.edu
authors.forename: Sean M
authors.initials: SM
authors.lastname: Berenholtz
authors.forename: Theresa L
authors.initials: TL
authors.lastname: Hartsell
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pronovost
mesh_terms: D006785:Hospitals, University / Q000458:organization & administration*; D006801:Humans; D007396:Internship and Residency / Q000458:organization & administration*; D019300:Medical Errors / Q000517:prevention & control*; D011340:Problem Solving; D011367:Professional Staff Committees / Q000458:organization & administration*; D011785:Quality Assurance, Health Care / Q000458:organization & administration*