Modification of the Surgical Morbidity and Mortality Meetings as a Tool to Improve Patient Safety

Abstract

The recognition of the inevitability of errors in fields such as aviation, nuclear technology, electronics and pharmaceutical industries has been followed by impressive quality improvement and error reduction since the turn of the last century. In surgery, the incorporation of this concept has been slow despite the increased attention of the public, media and professional groups. These groups believe that encouraging the reporting and study of errors will lead to system improvements and a safer healthcare. Openness to discussion and study of errors with an understanding that errors must be accepted as evidence of systems flaws and not character flaws has consistently been central to their message. The morbidity and mortality meeting also referred to as the golden hour of surgical education, is one of surgery’s most important forums for discussion of adverse events and errors. It is a required component of training under the regulations of postgraduate residency programs in surgery. Typically, the resident presents the patient’s clinical course and the rationale for the care provided. These decisions are then criticized by the experienced senior surgeons in attendance and any perceived errors in patient care are highlighted. This format uses as its primary premise that residents learn from their mistakes and through this education, the subsequent quality of patient care is improved. However, despite its recognized educational value, the morbidity and mortality meeting as it exists in many institutions is grossly inadequate to justify its traditional and ongoing role in surgical quality control and patient safety. Critical issues of patient safety are discussed but the essential safety lessons that are important to the education of the resident are often glossed over or ignored. Against a background of requirements on the need to ensure quality education for residents and an increasing public demand for improvements in patient safety, there is an urgent need to modify the mortality and morbidity meeting as it is a powerful tool to teach safety lessons from real-life cases and to make those lessons into a living curriculum.

Keywords