Morbidity and Mortality Conference: Both Ahead of its Time and Behind the Times

David W. Roberson, MD, FACS¹
Ajit Sachdeva, MD, FACS²
Gerald B. Healy, MD, FACS¹

¹Department of Otolaryngology, Childrens Hospital Boston
¹Department of Otology and Laryngology, Harvard Medical School
²American College of Surgeons

The "traditional" morbidity and mortality format

In most surgical departments, the Morbidity and Mortality conference (M&M) follows a fairly traditional format. Cases are identified by the attending or resident surgeon and collated into a monthly list. The M&M list is circulated several days prior to the conference. At M&M, each case is presented by a resident surgeon and general discussion follows. The discussion serves to classify morbidities as expected/unavoidable (eg, a certain percentage of post-tonsillectomy hemorrhage is "normal"), or unexpected/avoidable (eg, wound infection in a clean case). The unexpected/avoidable cases are generally then classified according to the responsible error of omission/commission. For example, a complication might ultimately be considered a "technical error" or an "error in surgical judgment," etc. In most M&M conferences, there is a cultural expectation that the resident and surgeon responsible for the patient should assume personal responsibility in some fashion. For example, attribution of a complication due to "nursing error" may be openly or covertly viewed as an attempt by the surgeon to avoid personal responsibility for his or her patient's outcome. The attribution of a complication to a non-physician cause may be met with resistance from the audience, and suggestions are made regarding steps the physician could have taken to avoid the complication. The unspoken message is that surgeons are expected to assume personal responsibility for their patients' outcomes; those who look to other factors may not have the ethic of personal responsibility expected in the mature surgeon.

This traditional M&M format has served surgeons and surgical patients well for decades. It has several very powerful strengths. For decades this format was state-of-the-art in error analysis and prevention. We argue in this commentary that while this format is still state-of-the-art in some respects; in other respects it has fallen behind in the current understanding of error analysis and prevention. There are two major reasons for this. Firstly, this traditional format was developed in an era of "one surgeon, one patient," and often fails to appropriately analyze or address the incredibly complex systems in which the modern surgeon functions. Secondly, there has been an explosion in the science of understanding, preventing, and ameliorating human error, and most surgical disciplines have simply not kept up with this literature. It will be helpful to first review the implications for surgeons of these two changes. An understanding of these two factors must precede a discussion of the strengths and weaknesses of traditional M&M.

The science of complex systems

Much medical and surgical education in the US is based on the recommendations in the Flexner report, issued in the early 1900s. At that time, the "system" of surgical care typically was one surgeon and an anesthetist or assistant. Major errors in diagnosis, management, or technical performance would almost always be made by the attending surgeon.

Today, a trauma patient in an academic medical center could be cared for by a host of physicians and surgeons, as well as nurses, respiratory therapists, pharmacists, and other providers. An additional several hundred or thousand pieces of equipment, computers, software, and complex machinery support their care. Hospitals attempt to build in safety nets (eg, pharmacists check the physician's drug orders and/or there are computerized order entry systems), all of which have a finite failure rate. If a patient receives a wrong drug, it is overly facile to say it is an "ordering error." Typically multiple human and mechanical systems (including, of course, the prescribing physician) have to fail for this situation to occur. We must understand why they all failed at that time on that day for that patient before we can design improvement strategies.¹ The traditional format of M&M is poorly suited for this task.

The science of human error

Much has been learned in the past few decades about how humans make mistakes.^2-6 This information has been applied in many "high stakes" fields including aviation, nuclear power, the military, and in some areas of medicine. Decades of study of organizations with extremely low failure rates have shown powerful similarities.^7,8 Among medical specialties, anesthesiology has led the way in using the science of human error to improve care.^9-15 Rigorous study of such issues as the effect of frequent breaks16 and sleepiness17 have led to policy changes that have reduced the rate of adverse events. Among institutions, the Veterans Administration has been in the forefront with the establishment of the National Center for Patient Safety and a country-wide effort to eliminate and ameliorate errors.^18-21

Much of this data is relatively new; physicians and surgeons are not, in general, well trained in this science. Thus it is not surprising that the traditional M&M often does not make full use of this information. What is surprising, in many ways, is how far ahead of its time traditional M&M originally was, and how many strengths it still retains.

Principles of the High Reliability Organization

Several strands of research have combined in the current understanding of the High Reliability Organization (HRO). One is the increasing understanding of how complex systems work well, or poorly.¹ Another is the increasing understanding of human failure patterns.^2,5 Also, attempts have been made to study organizations which rarely fail. So called HROs are organizations that have extremely low failure rates compared to other similar organizations.

Weick and Sutcliffe have identified five principles of the HRO. To greatly oversimplify, these organizations:

1. Are constantly concerned about failure and insist on learning from failure.
2. Go beyond simple explanations for problems and explore all contributing factors.
3. Are intensely focused on front-line operations (eg, senior management goes to great lengths to understand the front line tasks and working conditions).
4. Develop safety nets to catch and ameliorate errors.
5. Rely on expertise regardless of formal hierarchy (eg, a foreman will defer to a line worker who is more familiar with a particular machine).

Also, HROs focus on education to address safety issues. They have a pervasive, supportive culture that helps individuals learn from their mistakes. Errors and near misses are considered learning opportunities and individuals are not blamed or humiliated for mistakes. HROs also support flat hierarchies in which junior colleagues are encouraged to bring error-prone situations to the attention of their senior colleagues.

The traditional surgical M&M conference was decades ahead of its time in learning from failure, and in its focus on front-line ("real world") events. If well conducted, it may also help develop a "flattened hierarchy." The department chief who presents complications openly and accepts constructive criticism is modeling a willingness to learn from his/her peers with greater expertise in a particular situation.

However, traditional M&M has not done well in seeking out all contributing factors to problems, and in developing safety nets. Surgeons have traditionally insisted on what Bates and Gawande call "a fierce ethic of personal responsibility."²² It is almost axiomatic that the mature surgeon takes responsibility for his or her own complications, focuses on what he or she should have done differently, and disdains blaming others. We believe that the cultivation of individual accountability is essential in training superb surgeons. We also believe that, in 2005, a focus on individual accountability simply does not go far enough. It often leads to the characterization of adverse events as being due to a single cause (eg, "error in surgical judgment") when multiple causes contributed. It also has limited potential for improvement. Training and education can reduce the failure rate of the human brain. After a certain point, the value of individual training will plateau, since the human brain cannot be made infallible. In addition, M&Ms do not generally focus on near misses, which can present excellent learning opportunities. The failure of M&M to explore all causes and contributing factors to adverse events and the lack of focus in developing preventive systems are areas where it has not kept up with modern error science.

M&M for the 21st Century

At the present time, it is not clear what M&M for the 21st Century should look like. A number of innovative programs are being tried around the country and around the world.²³ Modern systems and error science, however, strongly suggest that M&M should retain a "real world" focus, and that errors should continue to be treated as a unique opportunity for learning. The conference should not be a forum where trainees (or attendees) are overwhelmed, distressed, or put on the defensive. For some departments this approach is already the case, while for others it may require an honest appraisal of the atmosphere of the conference and serious effort to change it.

Most lacking in traditional M&M are a complex view of human error and a commitment to developing systems approaches to preventing, catching, and ameliorating error. The challenge for the 21st Century is to integrate these principles into M&M without losing the tremendous strengths of the current format.

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Online July 13, 2005