We have all attended a poorly run Morbidity and Mortality Meeting. You know:- the one where the junior staff presented cases they were not involved with and were berated for decisions they didn’t make. The one where you sat in the corner, fingers and toes crossed that none of your cases would be presented, hoping you wouldn’t be publicly humiliated for an error you weren’t aware you had made. The one where the most senior doctor cast a judgement, and nobody dared to disagree.
It doesn’t have to be this way. It should not be this way. Here are 6 steps to facilitating a useful, interesting and (dare I say) enjoyable M&M.
1. Establish trust
If staff feel safe to report near misses and participate in case discussions, the opportunity is there to improve care for the next patient and prevent future serious incidents. This is the goal of M&M!
A positive safety culture is critical. This includes:
- A culture of reporting: to improve the system, and make it safer for our patients, we need to identify the potential risks. Reporting of both incidents and ‘near misses’ should be actively encouraged.
- Being flexible enough as a team and organisation to respond to this feedback from staff, and use this information to drive change.
- Shared accountability for patient safety between individual staff and organisations responsible for designing and improving the systems in which they work.
- A culture of learning from past performance – whether that be a serious incident, a near miss, or a success.
M&M meetings are a great opportunity to demonstrate your safety culture to the frontline staff in your department. The manner in which incidents are reviewed and presented can enable people to feel psychologically secure enough to report and discuss incidents without fear of personal criticism or blame.
2. Focus on the systems
The actions of a person are very rarely the root cause of an incident. There are almost always system factors that contribute to the decisions and actions of the frontline staff. To feel safe and facilitate robust case discussion, staff need to trust they won’t be blamed or shamed for incidents and near misses they report.
The question you are trying to answer is “What went wrong?”, not “Who is responsible?”.
Of course, work is not a completely blame-free environment. There are extremely rare situations of reckless behaviour and deliberate disregard for procedures with knowledge of a likely harmful outcome. These situations should be managed outside the M&M environment.
3. Language is important
Language is extremely important when modelling your safety culture. For example, adverse event ‘review’ is less accusatory than the word ‘investigation’. Stating ‘the doctor prescribed the wrong dose of medication’ implies they are to blame, but an improved version may be ‘the weigh scales were broken, so the patient’s weight was estimated, which led to the incorrect dose of medication being prescribed’. This second account is more helpful in determining the actual cause of the problem and has a lower chance of inhibiting staff from reporting similar events in future. Fixing the scales is also much more likely to reduce this same error happening to the next patient compared to punishing the prescribing doctor in the form of ‘retraining’ or ‘education’.
The language used by senior leaders within the health service is particularly important. Culture needs to be modelled from the very top.
4. No surprises!
Involved team members should be told that their case will be presented at the meeting. No surprises on the day, please!
In our emergency department, every paediatric resuscitation is discussed with the team involved. They provide feedback on what went well, identify opportunities for improvement, and propose solutions. The team are aware that these cases will all be discussed at M&M, and their input helps to guide the discussion and recommendations.
Involved team members should be invited to actively participate in case discussions, though they can remain anonymous if they prefer. If the discussion is safe, without blame, and systems-focussed this will encourage participation.
5. Involve the whole team
Gone are the days where M&M is facilitated and attended by medical staff only. Successful healthcare outcomes rely on interactions between medical, nursing, pharmacy and other allied health team members, as well as input from the patient and their family. Adverse events will also have contributing factors from multiple disciplines, and all staff members can provide contributions from their own perspectives. Team members from all disciplines should have the opportunity to facilitate case discussions at M&M and be invited to attend.
6. Celebrate Success!
Mostly, things go well. This is because humans are generally fabulous at adapting within the system to prevent errors by responding to unpredictable events such as patient surges, technology glitches, or…. pandemics. It is equally important to learn from what went well and determine WHY it went well. Celebrate success and discuss how can you replicate it for the next patient. The inclusion of Awesome and Amazing cases is not only great for staff morale but can also contribute to improving patient safety just as much as M&M case discussion.
Resources for further reading
Boysen, Philip G. “Just Culture: A Foundation for Balanced Accountability and Patient Safety.” The Ochsner Journal, vol. 13, 2013, pp. 400-406. PubMed, https://pubmed.ncbi.nlm.nih.gov/24052772/. Accessed 29 11 2021.
Douros, George. “The trouble with M&Ms”. Life In The Fastlane, Nov 2020, https://litfl.com/the-trouble-with-morbidity-and-mortality-meetings/
Shorrock, Steven. “Just culture: Who are we really afraid of?”. Humanistic Systems: Understanding and Improving Human Work, Nov 2016, https://humanisticsystems.com/2016/11/24/just-culture-who-are-we-really-afraid-of%EF%BB%BF/
Szekendi, Marilyn K., et al. “Using patient safety morbidity and mortality conferences to promote transparency and a culture of safety.” The Joint Commission Journal on Quality and Patient Safety 36.1 (2010): 3-AP2.