Creating a culture of safety to support clinicians and improve the quality of patient care is a goal for nearly all health care organizations. However, it can be difficult to envision specific efforts that can directly influence organizational culture. To promote transparency and reinforce a nonpunitive attitude throughout the organization, we have created a forum for the open, interdisciplinary discussion of patient safety problems reported through our voluntary incident reporting system. This forum is called Patient Safety Morbidity and Mortality (M&M) Conference.


Our goal is to promote transparency and a culture of safety by informing frontline providers about adverse events that occur at our hospital and engaging their input in root cause analysis, thereby encouraging reporting and promoting systems‐based thinking among clinicians. Achievement of this goal is evidenced by statistically significant improvements in staff perceptions of culture as measured in the AHRQ Hospital Survey on Patient Safety Culture administered prior to and following the implementation of the M&M conferences.


Convened under the purview of the organization's quality program and modeled on the traditional Morbidity and Mortality conferences, the conference is a monthly live meeting at which case studies are presented for retrospective (root cause) analysis by an interdisciplinary audience. At each month's conference, a selected adverse event is presented, discussed by a panel of representatives of each involved discipline, and then followed by a “mini” root cause analysis with full participation of audience members. Audience typically consists of 70–100 providers, including attending physicians, residents, advanced practice nurses, staff nurses, pharmacists, technicians, and management. Currently in its fourth year, the program is highly rated.


The Patient Safety M&M programs have been in place for approximately 4 years; more than 2500 clinicians have attended more than 50 programs. Improvements in culture have been reflected in statistically significant increases in culture survey responses over time. Conclusions include: involving frontline physicians and staff in an interdisciplinary examination of adverse events promoting transparency and systems‐level thinking, and flattening hierarchical relationships. Responding to clinicians' voluntary reports of adverse events encourages reporting by demonstrating an institutional commitment to learning from error and to a nonpunitive and transparent culture. Patient Safety M&M Conferences improve clinicians' perceptions of organizational culture.

Author Disclosure:

K. O'Leary, none; M. Szekendi, none; C. Barnard, none; G. Noskin, none.