At the Crossroad with Morbidity and Mortality Conferences: Lessons Learned through a Narrative Systematic Review

Table 1

(a) Articles for medicine and subspecialties, primary care, and ICU (10 articles). (b) Articles for surgery and its subspecialties, obstetrics, and anesthesia (25 articles). (c) Articles for both medicine and surgery (3 articles).

(a)

Study/setting	Stated objective	Category	Type of study	Main results and conclusion
Kirschenbaum et al., 2010 [18]; ICU; Academic	Determining if audit of patients plus a focused MMC improved patient care in ICU	Goal	Interventional: before and after survey	MMCs result in improved rapid response and hospital outcomes (number of cardiac arrests decreased from 3.1/1000 to 0.6/1000, , deaths decreased from 34/1000 to 24/1000, ).
Ksouri et al., 2010 [19]; ICU; Academic	Evaluating MMC in ICU for improving quality of care and patient safety	Goal, structure, process	Retrospective	MMCs provide educational value and can be used to assess quality of care, patient safety, and interpersonal and team communication.
Kuper et al., 2010 [20]; Academic	Exploring the role of MMC in medical education	Goal, structure	Prospective/ethnographic: interviews, evaluation of notes, and audiotape of MMC	MMCs are effective vehicles to address competencies in patient safety and quality improvement. A disjunction between teaching valued by staffs and learning valued by students were noted.
Szostek et al., 2010 [21]; Academic	Determining educational value of system audit	Goal, structure, process	Interventional: before and after survey	MMCs with system audit have higher educational values, 95% (versus 61% preimplementation) and stimulating increased interest in education as well as ensuring improved quality of care.
Bechtold et al., 2008 [22]; Academic	Describing new MMC experience	Goal, structure, process	Interventional: before and after survey	New MMC format allows good educational forum with increased participation. Educational intervention and recommendations were more likely to be carried out.
Hasan and Brown, 2008 [23]; Academic	Proposing a format as a model for MMC in academic center for gastroenterology	Structure, process	Prospective: chart review	Overall complication rate of 0.76%, within that reported in the literature. Monthly MMCs are a means of monitoring patient care and enhancing trainee education.
Goldszer et al., 2006 [24]; Community	Describing MMC in primary care center	Goal, structure, process	Prospective	The MMC format is a useful tool to improve patient care.
Kravet et al., 2006 [25]; Academic	Evaluating the role in teaching 6 competencies of ACGME with MMC implemented in Grand Round	Goal, structure	Cross-sectional: survey	MMCs in Grand Rounds are effective (well attended) and add diversity in topic and teaching methods.
Denis et al., 2003 [17]; Community	MMC format assessed as a quality improvement tool in gastroenterology	Goal, process	Prospective: chart review	Systematic prospective recording of complications and careful exhaustive retrospective analysis during MMC are efficient and complementary tools for continuous quality improvement.
Esselman and Dillman-Long,  2002 [26]; Academic	Refocusing MMC onto system issues and avoiding placing blame on individuals	Goal, structure, process	Retrospective	MMCs are important in quality improvement when focusing on system issues.

(b)

Study	Setting; discipline	Stated objective	Category	Type of study	Main results and conclusion
Falcone and Watson, 2012 [27]	Academic; surgery	Assessing participation and cost benefit of teleconference in MMC	Goal, structure	Retrospective; cost-effective analysis	Teleconferencing allows for increased faculty attendance at MMC (5 per conference, ) and is cost-effective (annual net savings of 7624).
Falcone et al., 2012 [28]	Academic; surgery	Describing reporting patterns of general surgery residents. Describing adverse events rates compared to published data	Process	Retrospective cohort	Underreporting of nonfatal adverse events: 2.5% versus 4.3% reported in literature; majority of adverse events were from death (24.1%), hematologic or vascular complications (16.7%), and gastrointestinal complications (16.1%).
Thomas et al., 2012 [29]	Academic; surgery	Integrating minor complication reporting in MMC for its educational value	Goal,; structure,; process	Interventional: before and after survey	Postimplementation of reporting of minor adverse outcomes in MMC; 95% of surveyed population () stated that this provides improved quality assurance (71%, ).
Bevis et al., 2011 [30]	Academic; obstetrics	Characterizing the MMC as a cost-effective and efficient approach for addressing the ACGME competencies	Goal, structure	Retrospective	MMCs address 100% practice-based learning and medical knowledge, 19% systems-based practice, 10% communication, and 6% professionalism or ethics.
Kauffmann et al., 2011 [31]	Academic; surgery	Multidisciplinary MMC presents a unique opportunity to incorporate all 6 ACGME competencies effectively and efficiently	Goal, structure, process	Retrospective	Multidisciplinary MMCs are useful in rapidly achieving quality improvement while creating opportunities for system health care delivery initiatives.
Kim et al., 2010 [32]	Academic; surgery	Examining the content and process of MMCs and testing the hypothesis that a structured format can improve teaching and learning	Goal, structure	Interventional: before and after survey	A structured MMC format improves the identification of the cause for complication (3.11 to 4.56, ). 67% of surveyed population expressed an overall improved experience in quality of care.
Steiger et al., 2010 [33]	Academic; neurosurgery	Describing methods to identify critical cases, the system of analysis, classification of MMC, and resulted impact	Goal, process	Retrospective	A reliable system is employed by MMC to identify cases, providing good instruments for quality control and problem oriented teaching. Impact on quality improvement remains questionable.
Antonacci et al., 2009 [34]	Academic and community; surgery	Describing comprehensive surgeon report card system based on MMC, in a nonpunitive error analysis fashion	Goal, structure, process	Prospective	MMCs result in a 40% reduction of gross mortality (). Quality issues were identified as 3 times greater than required by New York State regulations.
Berenholtz et al., 2009 [12]	Academic; surgery	Describing learning from a defect tool as a strategy to meet ACGME requirements and enhance traditional MMCs	Goal, structure, process	Prospective	MMCs present a helpful strategy to learn from medical incident and improve patient safety and quality of care. Adverse events are usually failures in the system.
Bender et al., 2009 [35]	Academic; surgery	Determining heterogeneity of assessment in peer-reviewed MMC and evaluating biases	Process	Prospective: survey	Significant disagreement noted amongst assessors leading authors to conclude that the reliability of peer review is questionable.
Dissanaike et al., 2009 [36]	Academic; surgery	Comparing the perceptions of preventability of mortalities and severity of complications of MMC attendees	Structure, process	Prospective	Surgical residents assign higher severity to trauma-related complications than other groups. More objective grading tools are necessary to improve the adequacy of MMC.
Greco et al., 2009 [37]	Academic; surgery	Describing the authors’ experience with incorporating a clinical librarian into the process of MMCs	Goal, structure	Prospective	The clinical librarian program has improved the quality of MMC presentations.
Folcik et al., 2007 [38]	Academic; surgery	Describing a two-tiered process MMC with dedicated subcommittee for quality improvement for ACGME competencies	Goal, structure, process	Prospective: reviewed MMC note, survey	MMCs with a dedicated quality improvement subcommittee decrease time to implementation of changes (3-4 months compared to 10–12 months).
Prince et al., 2007 [39]	Academic; surgery	Analyzing which features of MMC associated with greater educational value and increasing confidence in the future	Goal, structure	Prospective: survey	Audience interaction improves educational value and increased confidence in managing complex problems presented in MMC (). This is achieved by increased questioning and explanation, radiology images read by presenters, and moderators facilitating discussion.
Goldfarb and Baker, 2006 [40]	Community; surgery	Sharing a reproducible process for presenting, analyzing, and reducing surgical morbidity and mortality	Goal, structure, process	Retrospective: chart review	MMCs help in directing changes to resident training, hospital systems, and surgical practice.
Hutter et al., 2006 [41]	Academic; surgery	Comparing data as reported in a traditional MMC versus National Surgical Quality Improvement Program (NSQIP)	Goal	Retrospective: MMC data reviewed	MMCs underreport adverse events when compared to NSQIP: 1/2 deaths and 3/4 complications were not presented, especially in patients with incurable disease, transferred care, and “medical” problems.
Miller et al., 2006 [42]	Academic; urology	Comparing complications reported at the MMC versus NSQIP	Goal,; process	Retrospective: chart review	MMCs have low sensitivity for detection of complications (25%). NSQIP may be better for urologic quality improvement endeavors.
Rosenfeld et al., 2005 [43]	Community; surgery	Evaluating new MMC for ACGME competencies	Goal, structure, process	Retrospective: chart review	The restructuring of MMC so that a case is analyzed according to ACGME general competencies improved general interest and educational value. MMCs provide opportunities to teach ACGME general competencies.
Murayama et al., 2002 [44]	Academic; surgery	Evaluating impact of changes made to our MMC (5–10 min case summary, literature review, and faculty discussion with moderator)	Goal, structure	Interventional: before and after survey	Surgical residents perceive significant improvements after changes to the MMC process. This is not the case for surgical staff.
Risucci et al., 2003 [45]	Academic; surgery	Assessing interrater agreement before and after initiation of a modified MMC (presentation of 3 cases of 30 minutes with literature review)	Structure, process	Interventional: before and after survey	After modification of MMC, the majority of surveyed population perceives that consensus has been reached more often (96% of cases versus 70% cases ) especially for avoidability of complications (54% of cases versus 23 of cases, ).
Veldenz et al., 2001 [46]	Academic; surgery	Determining educational value of MMC in surgical residency program	Goal, structure, process	Retrospective	A weekly peer-reviewed MMC provides educational value with ongoing examination of common problems encountered in the delivery of surgical care.
Hamby et al., 2000 [47]	Academic; surgery	Determining the effectiveness of routine incorporation of local practice data in MMC	Goal, structure, process	Prospective: chart review	Incorporating prospective outcome data into the MMC provides increased educational values and opportunities for quality improvement.
Feldman et al., 1997 [48]	Academic; surgery	Comparing the incidence of adverse outcomes recorded in a prospective general surgery database with that of MMC	Structure, process	Prospective: chart review	Although most severe complications (87.5%) are recorded at MMC, a large proportion of complications remain unreported. Rigorous monitoring of outcomes may contribute further to improvements in quality of care.
Thompson and Prior, 1992 [49]	Academic; surgery	Determining the role and efficacy of surgical MMC in a current quality assurance program	Goal	Retrospective: chart review	Although many adverse events are not identified by MMC, these conferences remain an important component of quality assurance program.
Baele et al., 1991 [50]	Academic; anesthesia	Describing the format of MMC in detail	Goal,; structure, process	Prospective: chart review	MMCs offer a good educational role for residents through sharing of experiences, using a “no-blame” attitude. MMCs improve prevention of complications.

(c)

Study	Setting	Stated objective	Category	Type of study	Main results and conclusion
Szekendi et al., 2010 [16]	Academic	Sharing the authors’ experience with a patient safety oriented MMC over 7 years	Goal, structure, process	Interventional: before and after survey	Shift in staff perceptions of culture: increased voluntary reporting (by 66%), improved patient safety, and amelioration of quality of care.
Aboumatar et al., 2007 [2]	Academic	Describing MMC formats across multiple clinical departments; comparing MMC processes with previously published medical incident analysis models; and exploring how MMCs could be modified to advance medical education and improve patient care	Goal, structure, process	Cross-sectional: survey	MMCs vary in structure and process and fail to use known analytic framework. Well conducted MMCs provide valuable educational and quality assurance benefits. MMC should elicit input from all caregivers involved, follow a structured approach to identify system defects, and ensure adequate follow-ups on recommendations.
Pierluissi et al., 2003 [4]	Academic	Determining the frequency at which MMCs include adverse events and errors; determining whether errors are discussed and attributed to a particular case	Structure, process	Cross-sectional and prospective	Cultural difference between internal medicine and surgery noted. In internal medicine, fewer cases are presented (1.5 versus 2.7 cases, ) but more time is spent on case presentation and discussion (34.1 minutes versus 11.7, ). Fewer cases included adverse events (37% versus 72%, ) or errors (18% versus 42%, ).