Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety

Jt Comm J Qual Patient Saf. 2010 Jan;36(1):3-9. doi: 10.1016/s1553-7250(10)36001-6.


Background: Although creating a culture of safety to support clinicians and improve the quality of patient care is a common goal among health care organizations, it can be difficult to envision specific efforts to directly influence organizational culture. To promote transparency and reinforce a nonpunitive attitude throughout the organization, a forum for the open, interdisciplinary discussion of patient safety problems--the Patient Safety Morbidity and Mortality (M&M) Conference--was created at Northwestern Memorial Hospital (Chicago). The intent of the M&M conference was to inform frontline providers about adverse events that occur at the hospital and to engage their input in root cause analysis, thereby encouraging reporting and promoting systems-based thinking among clinicians.

Methods: Convened under the purview of the organization's quality program, and modeled on the traditional M&M conferences historically used by physicians, the conference is a monthly live meeting at which case studies are presented for retrospective (root cause) analysis by an interdisciplinary audience.

Results: Since its start in 2003, approximately 60 patient safety M&M programs have been presented. Audiences typically represent a mix of physicians, nurses, pharmacists, management, therapists, and administrative and support staff. Staff perceptions of culture, as measured by the Hospital Survey on Patient Safety Culture, showed statistically significant improvements over time.

Discussion: Ensuring the patient safety M&M conference program's sustained success requires an ongoing commitment to identifying events of clinical importance and to pursuing the productive discussion of these events in an open and safe forum. Patient safety M&M conferences are a valued opportunity to engage staff in exploring adverse events and to promote transparency and a nonpunitive culture.

MeSH terms

  • Attitude of Health Personnel
  • Group Processes*
  • Humans
  • Interdisciplinary Communication
  • Medical Errors / prevention & control
  • Morbidity*
  • Mortality*
  • Organizational Culture*
  • Quality of Health Care / organization & administration
  • Safety Management / organization & administration*