Improving patient outcomes necessitates creating a culture of safety. The well known concept of the trajectory of error is a series of preventable human errors. Despite the best efforts of medical professionals, human error continues to confound the achievement of a “zero harm” healthcare system. In order to create such a culture of safety, one must first understand the factors contributing to human error. While old paradigms sought to explain failure by blaming individuals for poor judgment or wrong decisions, and prevent error by increasing complexity of the system, the new view of human error takes a different approach. Human error is rather a “symptom of trouble deeper inside the system” and can only be addressed by understanding that human error is not random but is connected to the system in which an individual operates. Furthermore, a culture of safety can only be created by fostering its practice at “all levels of an organization”[13
]. Adverse events are multi-factorial in nature, and require a system- based approach to correct. As holes in the system are identified, it is crucial to place data in context by reconstructing the situation that produced and accompanied the event, so as to resist the temptation to rely solely on hindsight to identify errors. While one cannot change the human tendency to occasionally err, the conditions under which individuals work can be changed to make unsafe actions less likely to occur[14
]. Solutions to prevent error require commitment from all levels, and must be monitored over time to evaluate efficacy. High Reliability Organizations, such as nuclear power plants and air traffic control systems are those that must operate as near as possible to a failure-free standard, or great harm may come to a great many people[14
]. These organizations serve as models of how to deal with unexpected events by careful attention to ongoing operations, anticipation of pitfalls, resilience in the face of failures, involvement of experts, and a commitment to establishing a culture of safety[15
]. The healthcare enterprise should strive to be included in this group of “zero harm” organizations.
Subsequent to the IOM report highlighting the need to address medical mistakes, methods to improve the system of healthcare delivery, and thereby patient care, have been implemented by hospitals across the country. This focus on patient safety extends to the education sector with increasing demands placed on residency programs to incorporate curriculum to address these topics explicitly. Training programs are uniquely poised to address issues of patient safety and improved quality of care as they strive to train the next generation of physicians in the “science and methods of patient safety and quality improvement” [16
]. Meanwhile, work hour restrictions continue to whittle away the time available for education, and programs struggle to find a balance between service and education in an 80-hour work week. It is into this setting that the ACGME endorsed the Outcome Project in 1999, to assess the outcomes of residency education across six general competencies- patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice [17
Even though our institution's MM&M conference was not initially based upon the ACGME Competencies on its inception, the insightful residency program can incorporate these principles into every aspect of its curriculum to maximize educational opportunities. The ACGME mandate to incorporate the six general competencies into resident education provides an opportunity to integrate competencies and patient safety by the establishment of a Multidisciplinary Morbidity and Mortality conference. Furthermore, such an approach facilitates compliance with ACGME requirements without further stretching already-limited educational time. We believe that a Multi-disciplinary Morbidity & Mortality Conference provides a unique opportunity to achieve these principles, particularly the more difficult ones of PBLI and SBP, although we recognize that other educational conferences may offer a similar opportunity. In solidifying the healthcare team concept, programs not only foster communication between medical providers and empower all members of the healthcare team to contribute to quality improvement, but also educate the next generation of physicians to build a culture of cooperation in their own practices, thus improving patient outcomes. This environment of open communication and cooperation becomes even more important when one understands that failures of communication underlie three-quarters of adverse events and represent an important system flaw. Multidisciplinary conferences provide a forum where cooperation among specialties must be encouraged, and each group may benefit from the expertise of the other disciplines[7
Limitations of this study include its description of an MM&M conference at a single institution, which may not be generalizable to other institutions. While the implementation of a similar conference at other institutions may be expected to offer similar success in initiatives to improve patient care, considerable time is required to make such a conference successful. Support from institutional administration, program directors, and safety officers, as well as backing from the diverse members of the peri-operative enterprise are required to ensure success. The establishment of a dedicated committee to monitor and track and long-term compliance with quality-improvement initiatives arising from the MM&M conference is beneficial to ensure timely changes to the healthcare delivery system. In addition, the results discussed here are largely qualitative in nature and describe the process of implementing a MM&M conference at our institution. Additional research is needed to quantify the impact of this conference on patient safety and quality improvement. Finally, determination of the topics presented and ACGME General Competency addressed by each case are subjective, although they have been determined by three reviewers in our study.