Overview & Objectives

• Promote a just culture and system learning around complications and deaths [1].
• Meet education and accreditation expectations for regular, structured case review [2].
• Standardize definitions and data capture across all departments, enabling reliable hospital-wide metrics.
• Surface actionable improvements (process, communication, equipment, training) and close the loop.

Key Definitions

• Case: Any inpatient or procedural encounter with a significant complication or death reviewed at M&M.
• Complication: An unintended event or condition arising during care (e.g., bleeding, infection, medication error).
• Preventable Event: Reasonable evidence a different action/system would likely have avoided the outcome.
• Sentinel Event: A particularly serious, often reportable patient-safety incident [3].
• Attribution/Cause: System, Technical, Unavoidable, Patient-related, Other (see “Classification”).

Data Capture (Standard Fields)

Use the standardized data elements below (aligned with the Excel template). These support consistent monthly and departmental statistics.

• Date; Department; Attending Physician; Patient ID (optional/de-identified for slide review); Age; Sex.
• Diagnosis; Procedure (if applicable); Complication Type; Mortality (Y/N).
• Cause (System/Technical/Unavoidable/Patient-related/Other); Lessons Learned; Preventable (Y/N/Undetermined); Notes.

Tip: Keep the master “M&M Data Entry” file on a secure drive. Use validated dropdowns to reduce entry variation. Export monthly pivot summaries for slides.
[Add link to your Excel template here]

Classification (Attribution)

• System: Handoffs, staffing, environment, policy gaps, access, coordination [1].
• Technical: Procedure/device technique, equipment failure, wrong selection/use.
• Unavoidable: Outcome consistent with disease severity despite appropriate care.
• Patient-related: Adherence challenges, social determinants, physiology/anatomy.
• Other: Use sparingly; specify in Notes.

Monthly Metrics (Hospital-Wide & by Department)

• Total Cases: Count of reviewed cases in month.
• Mortalities: Count of deaths among reviewed cases; Mortality Rate = mortalities ÷ total cases.
• Complications: Number with non-blank complication type; Complication Rate = complications ÷ total cases.
• Preventable Events: Count “Y”; Preventable % = preventable ÷ total cases.
• Top Cause: Most frequent attribution for the month (system/technical/etc.).

Use pivot tables to display metrics by month and by department; chart mortality rate, preventable %, and complications trend [4].

Workflow & Governance

1. Case Identification (Week 1): Services flag candidates; submit standard data fields to M&M coordinator.
2. Screening (Week 1–2): Chair + service lead confirm inclusion; assign presenters; gather de-identified materials.
3. Preparation (Week 2–3): Presenter drafts 5–7 slides: case summary, timeline, key data, root-cause themes, action items.
4. Conference (Week 4): 60 min. Structure: 2–3 cases; discussion guided by system factors and learning objectives [2].
5. Action & Follow-Up: Document decisions (who/what/when). Track completion and re-review next month.

Conference Schedule

Cadence: Monthly (e.g., 2nd Tuesday, 7:00–8:00 AM). Update to your official time/venue.

• Required attendees: service chiefs (or delegates), residents/fellows, nursing leadership, QI/safety.
• Optional: pharmacy, respiratory therapy, case management, risk management.

Confidentiality & Just Culture

This is a protected Quality Improvement activity. Discussion is non-punitive and focused on system learning. Do not include direct identifiers in slides; avoid chart numbers on projected materials. Handle notes and source documents per hospital policy and applicable privilege protections [3].

References

1. Institute for Healthcare Improvement (IHI). Fundamentals of patient-safety and system-level improvement.
2. ACGME Common Program Requirements. Expectations for regular morbidity & mortality conferences.
3. The Joint Commission. Sentinel Event Policy & guidance on serious reportable events.
4. WHO/Agency for Healthcare Research and Quality (AHRQ). Patient safety taxonomies and measurement resources.