Background: Discussion of medical errors in patient care is often not formally taught in most residencies or medical schools. Yet the skill set needed for addressing patient adverse events when they occur and preventing similar occurrences in the future is instrumental for the practice of medicine. A Morbidity and Mortality Conference (M&M) is one way training programs have approached this curriculum gap, traditionally using a format focusing on a particular resident’s performance.
Purpose: Our revision of the M&M conference model places the focus on the topics surrounding patient safety and quality improvement. This curriculum also serves as a teaching tool for developing strategies for coping with emotional responses related to patient harm. Our patient safety conference meets multiple family medicine milestones that cross with similar milestones in internal medicine and pediatrics, particularly with sections dealing with the emphasis on patient safety, system improvement and professional conduct and accountability.
Description: Patient Safety Conference (PSC) is designed with a similar format to a modified root cause analysis/systems analysis. During their inpatient team leading months, senior residents identify a case where a medical error occurred. The resident completes an online self-reflection survey designed to guide him or her through critically analyzing the case. Once the resident has identified some of the themes of the case, he or she does a brief literature search of these areas. The resident meets with one of the supervising faculty to discuss the survey, literature search results and strategies for guiding a group discussion. The resident leads an interactive group discussion with an audience of his or her peers. This includes setting the tone and reviewing the goals of the discussion and ground rules, the case presentation and group discussion focusing on identifying themes contributing to the error and actionable solutions. Common themes include communication, transitions of care and missed diagnosis. The resident concludes the session by presenting what he or she found in the literature. Afterward, the resident writes a one-page plan to improve patient safety and prevent future recurrences of similar errors.
Conclusions: Over the first 12 months of initiation, the PSC was evaluated using a resident questionnaire. Results showed positive, statistically significant changes in multiple questions related to learner perceptions of patient safety and self-efficacy related to QI processes. PSC was viewed as an emotionally safe venue to discuss errors in 49 of 50 surveys. PSC was statistically associated with resident’s ability to identify adverse events, root causes and process gaps, and ability to design QI initiatives. This innovative approach to educating trainees about patient safety and QI can be adapted to multiple specialties and settings.