Morbidity and mortality (M&M) is a common conference across medical specialties. It originated in the early 1900s when a surgeon named Ernest A. Codman, MD, attempted to create a systematic way of reporting errors and standardizing practices and procedures. Back then, error tracking and reporting were not the norm, and he lost privileges at his hospital for trying to introduce any evaluation of surgeon competence. He persevered in his work and is now recognized as the founder of the M&M conference. This conference allows surgeons to reflect upon their performance and receive invaluable feedback from their peers on preventing future adverse outcomes. It is (generally speaking) a medicolegally protected peer-review conference to discuss complications and undesired outcomes and is an invaluable tool in resident education. Beyond individual surgeon performance, discussion of cases identifies systemic problems and errors that can be changed to create a more sustainable solution.
In neurosurgery, where the stakes of brain surgery or a complex spinal surgery are high, the complications can result in life-altering injury or even death. When people hear the name “Dr. Death” (Christopher D. Duntsch, MD), they probably think of the podcast about a neurosurgeon who was sentenced to life in prison after seriously injuring or killing 33 patients. While this represents an extreme outlier in our profession, these types of complications are precisely what we hope to identify through discussion with our colleagues. Common cases presented in M&M include any patient death surrounding the time of surgery, new neurological deficit, unplanned return to the operating room, readmission to hospital, deviation from the expected post-operative clinical course, wrong-site surgery or post-operative complication.
M&M conference is one of the best opportunities to provide high-yield teaching to residents and faculty regarding delivering safe, high-quality care. Everybody can learn from their mistakes — and M&M is the vehicle used in the medical setting to ensure that we continuously learn and improve what we do. There are many examples of topics discussed in M&M that subsequently spearhead a quality improvement (QI) project.
I was fortunate to be a part of one of the first cohorts of the Program Directors in Patient Safety and Quality Educators Network (PDPQ), working with the Accreditation Council for Graduate Medical Education (ACGME) to create a sustainable quality improvement and patient safety (QIPS) curriculum in neurosurgery. Neurosurgery was one of three pilot specialties involved in this program, which is now going on its fifth year and has expanded to 11 specialties. We met weekly for six months with leaders within neurosurgical programs across the country and other specialties to develop a clear plan for improving resident learning in QIPS. One area that would always come up in our breakout discussions was how M&M was foundational in all programs and thus could be used as an excellent educational tool.
If all neurosurgery programs standardize the M&M process, we discussed how this could allow for national patient safety metrics and process improvements that can be applied across many institutions. After the second cohort of PDPQ participants, two colleagues and I spearheaded our ”M&M Optimization Project,” in which we asked participants to utilize a new standardized M&M format (based on published literature). We recruited 15 programs to use the new format, which categorized the specific concern in each case; our hypothesis was that the standardized format would lead to more discussions, improved education, and more identifiable actionable items and interventions.
The outcome of our pilot was favorable, as indicated by the participants’ survey responses. Since implementation at my institution, I have seen more structured changes come out of our M&M discussions in the past year. The faculty and residents have noted more engagement and education, and many resident QI projects and departmental QIPS initiatives have stemmed from this new format. It is clear that M&M is a necessary tool for checks, balances and accountability and a powerful educational tool for patient safety and quality improvement. It fosters lifelong learning and improvement science in our specialty.
Editor’s Note: We hope you will share what you learn from our posts in the Making and Maintaining a Neurosurgeon series. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #Neurosurgery.
Christina M. Sayama, MD, MPH, FAANS
Oregon Health & Science University
Portland, Ore.