Envisioning the Future Morbidity and Mortality Conference: A Vehicle for Systems Change

Abstract

The traditional morbidity and mortality conference (MMC) was originally pioneered in the early 20th century as a way to evaluate the clinical practice1 and was adopted for hospitals by the American College of Surgeons in 1916. Throughout the years, it has provided education to trainees2 and served as a forum to discuss challenging cases for attending physicians. However, traditional MMCs frequently involved assignments of blame, “Monday morning quarterbacking,” and did not address systemic issues. Furthermore, they frequently excluded nurses and allied medical staff, thus losing valuable insight.3 Recently, with the advent of the patient safety movement, the traditional MMC has been revisited and refined as a systems-based MMC to serve as a patient safety strategy, both for surfacing adverse events and serving as a mechanism to understand causation, and perhaps most importantly, institute timely interventions.4