Using the Mortality and Morbidity Conference to Improve Patient Safety Karen Cosby MD Cook County Hospital/Rush Medical College ICEP Academic Forum

What is M&M? Someone dies Something bad happens Someone does something wrong Assumption: –There was an “error” –It was “preventable”

Why do we have M&M Conference? It’s tradition! It’s honorable It’s good for education It looks good for QA

What is the goal of M&M? Education: A case conference with: – mystery, intrigue, suspense! Learn from our mistakes Educate new trainees Teach accountability

Traditional M&M Conferences Accounts for failures Teach accountability Education: the best teaching hour in curriculum Sometimes results in shame Sometimes, a hazing ritual. Education is only part of the potential of M&M

Tradition isn’t Everything The Traditional M&M fails to realize it’s full potential There is more to be gained….

The Enlightened Approach to M&M “The DISSIS Approach” D = Discovery I = Insight I = Insight S = Strategies S = Solutions I = Improvement I = Improvement S = Satisfaction

The Enlightened M&M Model Acknowledges complexity Identifies human and system factors Encourages open discussion Actively seeks solutions

Discovery Investigate Discuss and Probe Allow new facts to surface Appreciate complexity of case Include cognitive and system factors to be discovered

The Question of Anonymity: ?Benefits Protective Preserves Self-Esteem May remove defensive nature

The Problem with Anonymity Limits fact finding and discovery Limits insight Encourages secrecy Adds to shame, fear Limits problem-solving

Exposing the Clinician Who Erred Allows conversation Provides a more balanced view of the error (for audience and clinician) Audience can help moderate tendency toward maladaptive behavior There is some opportunity for absolution

Insight: The “Aha!” Moment Full discovery of facts Audience discussion Expand audience to cross disciplines and roles May provide the best learning opportunity

Insanity: Doing the same thing over and over again and expecting different results. Albert Einstein (attributed)

Strategies and Solutions How can we do better? Each case should have: –A lesson for medical decision-making –A system problem to pursue –A plan

Optimizing M&M Conference to Drive Improvement Use Group Dynamics to solve problem –Fresh ideas –Creative solutions –Forge alliances –Promote teamwork –Foster collaborative spirit An “expert” to offer guidance and advice

Optimizing the M&M Conference to Drive Improvement Identify System Factors in every case –Can you design a system that could help another person avoid the same error?

When the problems are really big… M&M can serve as a meeting ground Neutral academic setting Fascinating case discussion Allows heroes to emerge: –new policy –new agreements

The Multidisciplinary M&M Target and assemble the right audience: power players who can make change Collect the cases: –1 case is interesting –2 cases seem like bad luck –3 cases make a pattern that can’t be ignored State the problem Ask for a solution!

Special Cases: Better by Design Multidisciplinary M&MS: Ectopic RLQ pain in women Aortic dissections Abdominal pain in the elderly Look for the problem in YOUR institution

Improvement State what’s been done to address issues. Existing problems that need fresh solutions Recruit your audience to find solutions Changes role of the individual from passive, enduring punishment to active problem-solver.

Satisfaction There is nothing more painful than the shame of failure made public There is nothing more invigorating than meeting a challenge and solving a tough problem

M&M Can Be: A rational approach to solving real problems Done well it will : –Provide good medical education –Give insight –Find creative solutions to real problems. –Teach clinicians a healthy approach to managing medical error.

Long Term Gain Traditional M&M teaches accountability, but creates shame. The Enlightened M&M teaches life-long strategy for dealing with error, a healthy constructive approach to real life practice. One approach documents error; the other changes things for the better.

“Failure is not an option” Gene Kranz

Every failure is an opportunity for improvement