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Best Practices for Morbidity and Mortality Conferences for Obstetrics and Gynecology Departments

Author: Mallory Kremer, MD, and Jaclyn Nunziato, MD

Mentor: Timothy Klatt, MD and William Leininger, MD
Editor: SASGOG Patient Safety Task Force

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Morbidity and mortality (M&M) conferences provide a unique opportunity to deconstruct patient care and gain insight into systems-based challenges contributing to adverse outcomes. Although nearly all institutions hold regular M&M conferences, the structure of these sessions varies widely and there is limited evidence regarding best practices. 

M&M conferences serve multiple purposes within most departments. For trainees, M&M conferences are an educational tool to address major Accreditation Council for Graduate Medical Education competencies such as medical knowledge, communication skills, and systems-based practice. The conferences also allow the entire cohort to learn from rare diagnoses or adverse outcomes. In addition, M&M conferences should be used to identify systems issues for quality improvement initiatives and to promote a culture of safety within the department consistent with Just Culture principles. The charter for M&M conferences should be up to date and accessible. 

Department-specific criteria for case selection should be developed to capture a range of inpatient and ambulatory cases, including near misses and adverse events. Emphasis should be placed on the need for timely and consistent submission of all cases that meet criteria.

Ideally, presented cases are prescreened to identify learning points, and the presentation should be planned to facilitate discussion of these points. M&M conferences benefit from an inclusive and collaborative approach, with invitations extended to nurses, pharmacists, and representatives from other departments, such as emergency medicine or anesthesia, when applicable. Cases with positive outcomes can also be presented to highlight instances when the system works well. 

Each session should begin with a brief reiteration that M&M conferences represent a confidential and safe learning environment. Traditionally, the trainee involved in the case gives the presentation. Some departments do not require provider names on case submissions, and some may assign uninvolved trainees to present cases to allay perceived judgment or shame. The case presentation should briefly describe the clinical course and include pertinent laboratory results, imaging findings, procedures, pathology, and outcomes. The discussion should focus on the predefined learning points. When intended to generate improvement initiatives, a moderator with familiarity of quality improvement principles should facilitate the discussion. Certain cases can be selected for longer presentations, such as a root cause analysis. The fishbone model can aid in examining contributing factors. Topics to explore include medical decision-making, system weaknesses, communication, equipment issues, social determinants of health, structural racism, and health disparities. Some presentations include a literature review or allow time for Socratic teaching with trainees. This should be focused and concise. The discussion should center on why the event happened more than what happened.     

Examining what could have been done differently can prompt the creation of action items that are SMART (Specific, Measurable, Attainable and Assignable, Relevant, and Timely). Consistency and follow-through on action items are vital to avoid learned helplessness in response to systems errors. Best practices include designating a person responsible for each action item, a due date, a performance target, and a low-resource workflow for measuring success. Some M&M conferences include 5 to 10 minutes of “quality updates” every session, or a separate conference is periodically held to review progress toward desired changes.  

Further Reading:

Kravet SJ, Howell E, Wright SM. Morbidity and mortality conference, grand rounds, and the ACGME's core competencies. J Gen Intern Med. 2006 Nov;21(11):1192-4. doi: 10.1111/j.1525-1497.2006.00523.x. PMID: 17026729; PMCID: PMC1831665.

Giesbrecht V, Au S. Morbidity and Mortality Conferences: A Narrative Review of Strategies to Prioritize Quality Improvement. Jt Comm J Qual Patient Saf. 2016 Nov;42(11):516-527. doi: 10.1016/S1553-7250(16)42094-5. Epub 2016 Nov 9. PMID: 28266920.

Published February 2022, Reaffirmed November 2023

********** Notice Regarding Use ************

The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. (“SASGOG”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. SASGOG reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. SASGOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither SASGOG nor its respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

Copyright 2022 The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. All rights reserved. No re-print, duplication or posting allowed without prior written consent.


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