Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study

Acad Med. 2013 Jun;88(6):824-30. doi: 10.1097/ACM.0b013e31828f87fe.


Purpose: Surgical morbidity and mortality conferences (M&MCs) provide surgeons with an opportunity to confront medical errors, discuss adverse events, and learn from their mistakes. Yet, no standardized format for these conferences exists. The authors hypothesized that introducing a standardized presentation format using a validated framework would improve presentation quality and educational outcomes for all attendees.

Method: Following a review of the literature and the solicitation of experts' opinions, the authors adapted a validated communication tool-the SBAR (Situation, Background, Assessment, Recommendations) framework. In 2010, they then introduced this novel standardized presentation format into the surgical M&MCs at the Oregon Health & Science University. The authors assessed three outcome measures--user satisfaction, presentation quality, and education outcomes--before and after implementation of their standardized presentation format.

Results: Over the six-month study period, residents delivered 66 presentations to 197 faculty, resident, and medical student attendees. Attendees' performance on the multiple-choice questionnaires improved after the intervention, indicating an improvement in their knowledge. Presentation quality also improved significantly after the intervention, according to evaluations by trained faculty assessors. They noted specific improvements in the quality of the Background, Assessment, and Recommendation sections.

Conclusions: The M&MC plays a pivotal role in educating residents and improving patient safety. Standardizing the M&MC presentation format using an adapted SBAR framework improved the quality of residents' presentations and attendees' educational outcomes. The authors recommend using such a standardized presentation format to enhance the educational value of M&MCs, with the goal of improving surgeons' knowledge, skills, and patient care practices.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Humans
  • Medical Errors / prevention & control*
  • Prospective Studies
  • Quality Improvement*
  • Specialties, Surgical / standards*
  • Surgical Procedures, Operative / adverse effects*
  • Surgical Procedures, Operative / mortality*