Morbidity and Mortality

PAGENAME conferences (M&M) are traditional, recurring conferences held by medical services at academic medical centers and by most large private medical and surgical practices. They are essentially peer reviews of mistakes occurring during the care of patients. The objectives of a well-run M&M conference are to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications. Conferences are nonpunitive and focus on the goal of improved patient care. M&M conferences occur with regular frequency, often weekly, biweekly or monthly, and highlight recent cases and identify areas of improvement for clinicians involved in the case. They are also important for identifying systems issues (e.g., outdated policies, changes in patient identification procedures, arithmetic errors, etc.) which affect patient care.

Morbidity and Mortality conferences have a long tradition in the practice of medicine, having originated in the early 1900s with Dr. Ernest Codman at Massachusetts General Hospital in Boston. It is almost 100 years since Ernest Codman wrote a monograph on this subject, which caused his colleagues to banish him from the Massachusetts General Hospital. Ernest Codman's ideas contributed to the standardization of hospital practices—including a case report system that ascribed responsibility for adverse outcomes— by the American College of Surgeons in 1916. As the medical profession evolved, physicians grew accustomed to discussing their errors at mortality conferences, where autopsy findings were presented, and in published case reports. By 1983, the ACGME began requiring that accredited residency programs conduct a weekly review of all complications and deaths.