Table 1 Patient safety morbidity and mortality conference timelines

Timeline	Preparation
1–3 months before conference	Cases sent to CQI coordinator
3–4 weeks before conference	Cases presented to facilitator for selection
3–4 weeks before conference	Resident and CQI coordinator identify themes highlighted
1–3 weeks before conference	Resident submits case write-up for review
1 week before conference	Case write-up completed

Conference: 60 min
2–4 min	Status reports from previous conference projects provided
5 min	Case presentation by resident
15 min	Large group case analysis brainstorming
	Why did it happen?
	Identify contributing causes
20 min	Small group work—moderated by trained group facilitators
	What can we change to prevent this from happening again?
	Propose solutions to prevent recurrence
10 min	Small group representative reports back to large group
5–10 min	Departmental action plan outlined with items assigned

Follow-up
Within 1 week	Documentation of outcomes
Within 1 week	Monitor participant evaluations
2–4 weeks	Responsible party addresses assigned action and develops action plan
Monthly	Verbal updates at conference
	Develop and disseminate electronic monthly performance improvement (PI) update for residents/fellows/faculty
	Track system actions to ensure completion