Discussion of Medical Errors in Morbidity and Mortality Conferences

In many occupational areas such as aviation and nuclear power generation, recognition and discussion of errors has led to quality improvement and fewer errors. Medicine has lagged behind despite increased interest in eliminating errors by professional, governmental, and private organizations. This study sought to determine how often morbidity and mortality conferences in residency programs include adverse events and errors in their case presentations. Trained physician observers prospectively analyzed 332 case presentations at 4 academic hospitals in the United States. They included 232 conferences in surgery and 100 in internal medicine. An error was defined as the failure of a planned action to be completed as intended or the use of an incorrect plan to achieve a particular goal. Adverse events were unintentional injuries resulting from medical management rather than disease. Adverse events were included in 37 of medical and 72 of surgical case presentations. Errors resulting in an adverse event were noted in 18 and 42 of presentations, respectively. The proportions of adverse events associated with an error, 48 in medicine and 59 in surgery, did not differ significantly. Five medical patients and 14 having surgery died because of an error. Errors were discussed in 10 of medical and 34 of surgical cases, a difference significant at the P<0.001 level. Compared with surgical conferences, medical presentations that mentioned errors were less likely to discuss them as errors per se and more likely to ignore them altogether. In both groups of conferences, when errors were discussed as such, only 40 were discussed explicitly. Three of 7 errors associated with 5 deaths in medicine (43) were not discussed; this was the case for only 6 of fatal surgical errors. In surgical conferences, errors were likelier to be attributed to an individual, team, or system (79 vs. 38). Attempts to ensure that adverse events and errors are openly discussed might be especially important in the area of internal medicine. Surgical conferences could overemphasize the individual’s role and underemphasize system defects. In both areas, conference leaders have an opportunity to model the explicit discussion of errors.