Table 1 Patient safety morbidity and mortality conference timelines
1–3 months before conferenceCases sent to CQI coordinator
3–4 weeks before conferenceCases presented to facilitator for selection
3–4 weeks before conferenceResident and CQI coordinator identify themes highlighted
1–3 weeks before conferenceResident submits case write-up for review
1 week before conferenceCase write-up completed
Conference: 60 min
    2–4 minStatus reports from previous conference projects provided
    5 minCase presentation by resident
    15 minLarge group case analysis brainstorming
  • Why did it happen?

  • Identify contributing causes

    20 minSmall group work—moderated by trained group facilitators
  • What can we change to prevent this from happening again?

  • Propose solutions to prevent recurrence

    10 minSmall group representative reports back to large group
    5–10 minDepartmental action plan outlined with items assigned
    Within 1 weekDocumentation of outcomes
Monitor participant evaluations
    2–4 weeksResponsible party addresses assigned action and develops action plan
    MonthlyVerbal updates at conference
Develop and disseminate electronic monthly performance improvement (PI) update for residents/fellows/faculty
Track system actions to ensure completion
  • CQI, continuous quality improvement.