This Article Full Text (PDF) All Versions of this Article: 1062860609332370v1 24/3/192    most recent References Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Saved Citations Download to citation manager Request Permissions Request Reprints Add to My Marked Citations Citing Articles Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by Berenholtz, S. M. Articles by Pronovost, P. J. Search for Related Content PubMed PubMed Citation Articles by Berenholtz, S. M. Articles by Pronovost, P. J. Social Bookmarking                         What's this?

Learning From Defects to Enhance Morbidity and Mortality Conferences

Johns Hopkins University, Baltimore, Maryland, sberenh1@ jhmi.edu

Theresa L. Hartsell, MD, PhD

Johns Hopkins University, Baltimore, Maryland

Peter J. Pronovost, MD, PhD

Johns Hopkins University, Baltimore, Maryland

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.

Key Words: patient safety • quality improvement • residency education • morbidity and mortality conferences

This version was published on May 1, 2009

American Journal of Medical Quality, Vol. 24, No. 3, 192-195 (2009)
DOI: 10.1177/1062860609332370


CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter    What's this?