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  1. David P Stevens

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      EDUCATIONAL QUALITY IMPROVEMENT REPORT: A REVISED MORBIDITY AND MORTALITY CONFERENCE THAT EMPHASISES SAFETY AND SYSTEM REDESIGN

      Figure 1

      Morbidity and mortality conferences (MMCs) provide a rich opportunity for emphasising safety and system redesign that can offer both improved patient care and better health professional education. This report describes changes in MMCs that resulted in root cause analyses of adverse events, but also coupled this with system interventions designed to prevent recurrence. Conference participants and subsequent improvement teams generally consisted of faculty clinicians and resident trainees. During this study 121 system improvement opportunities were identified, of which 39 were pursued because they offered likelihood of achieving high impact change. Of these, 87% were either completely …

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