 |
|
Discussion of Medical Errors in Morbidity and Mortality Conferences
Edgar Pierluissi, MD;
Melissa A. Fischer, MD, MA Ed;
Andre R. Campbell, MD;
C. Seth Landefeld, MD
JAMA. 2003;290:2838-2842.
Context Morbidity and mortality conferences in residency programs are intended to discuss adverse events and errors with a goal to improve patient care. Little is known about whether residency training programs are accomplishing this goal.
Objective To determine the frequency at which morbidity and mortality conference case presentations include adverse events and errors and whether the errors are discussed and attributed to a particular cause.
Design, Setting, and Participants Prospective survey conducted by trained physician observers from July 2000 through April 2001 on 332 morbidity and mortality conference case presentations and discussions in internal medicine (n = 100) and surgery (n = 232) at 4 US academic hospitals.
Main Outcome Measures Frequencies of presentation of adverse events and errors, discussion of errors, and attribution of errors.
Results In internal medicine morbidity and mortality conferences, case presentations and discussions were 3 times longer than in surgery conferences (34.1 minutes vs 11.7 minutes; P = .001), more time was spent listening to invited speakers (43.1% vs 0%; P<.001), and less time was spent in audience discussion (15.2% vs 36.6%; P<.001). Fewer internal medicine case presentations included adverse events (37 [37%] vs 166 surgery case presentations [72%]; P<.001) or errors causing an adverse event (18 [18%] vs 98 [42%], respectively; P = .001). When an error caused an adverse event, the error was discussed as an error less often in internal medicine (10 errors [48%] vs 85 errors in surgery [77%]; P = .02). Errors were attributed to a particular cause less often in medicine than in surgery conferences (8 [38%] of 21 medicine errors vs 88 [79%] of 112 surgery errors; P<.001). In discussions of cases with errors, conference leaders in both internal medicine and surgery infrequently used explicit language to signal that an error was being discussed and infrequently acknowledged having made an error.
Conclusions Our findings call into question whether adverse events and errors are routinely discussed in internal medicine training programs. Although adverse events and errors were discussed frequently in surgery cases, teachers in both surgery and internal medicine missed opportunities to model recognition of error and to use explicit language in error discussion by acknowledging their personal experiences with error.
Author Affiliations: San Francisco Veterans Affairs Medical Center (Drs Pierluissi and Landefeld), San Francisco General Hospital (Dr Campbell), and Departments of Surgery (Dr Campbell) and Epidemiology and Biostatistics (Dr Landefeld), School of Medicine, University of California, San Francisco; and Palo Alto Veterans Affairs Medical Center, Stanford University, Palo Alto, Calif (Dr Fischer). Dr Pierluissi is now with San Mateo Medical Center, San Mateo, Calif. Dr Fischer is now with the Division of Primary Care, University of Massachusetts, Worcester.
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety
Bechtold et al.
Postgrad. Med. J. 2008;84:211-216.
ABSTRACT
| FULL TEXT
Lost Opportunities: How Physicians Communicate About Medical Errors
Garbutt et al.
Health Aff (Millwood) 2008;27:246-255.
ABSTRACT
| FULL TEXT
Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety
Bechtold et al.
Qual Saf Health Care 2007;16:422-427.
ABSTRACT
| FULL TEXT
A Descriptive Study of Morbidity and Mortality Conferences and Their Conformity to Medical Incident Analysis Models: Results of the Morbidity and Mortality Conference Improvement Study, Phase 1
Aboumatar et al.
American Journal of Medical Quality 2007;22:232-238.
ABSTRACT
Rates and types of events reported to established incident reporting systems in two US hospitals
Nuckols et al.
Qual Saf Health Care 2007;16:164-168.
ABSTRACT
| FULL TEXT
Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection.
Shojania et al.
ANN INTERN MED 2006;145:592-598.
ABSTRACT
| FULL TEXT
Choosing Your Words Carefully: How Physicians Would Disclose Harmful Medical Errors to Patients.
Gallagher et al.
Arch Intern Med 2006;166:1585-1593.
ABSTRACT
| FULL TEXT
Nursing Morbidity and Mortality Conferences: Promoting Clinical Excellence
Pagano and Lookinland
Am J Crit Care 2006;15:78-85.
FULL TEXT
Residents Report on Adverse Events and Their Causes
Jagsi et al.
Arch Intern Med 2005;165:2607-2613.
ABSTRACT
| FULL TEXT
Improving the ICU: Part 2
Garland
Chest 2005;127:2165-2179.
ABSTRACT
| FULL TEXT
|
