Restructuring the Morbidity and

Mortality Conference in a Department

of Pediatrics to Serve as a Vehicle for
System Changes

Clinical Pediatrics
51(11) 10791086
The Author(s) 2012
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0009922812461069
http://cpj.sagepub.com

Shervin Rabizadeh, MD, MBA1, W. Adam Gower, MD2,

Kurlen Payton, MD1, Kathryn Miller, BS3,
Kimberly Vera, MD, MSCI4, and Janet R. Serwint, MD3

Abstract
Purpose. Morbidity and mortality conference (MMC) serves an important role in medical care and education.
We restructured our Department of Pediatrics MMC to focus on multidisciplinary participation and improved
communication among disciplines, quality improvement, and system changes for safer clinical care and enhanced
learning from adverse outcomes. Method. The structure and philosophy of the Department of Pediatrics MMC was
changed. We present guiding principles for the restructuring process and evaluation results postrestructuring, which
examined achievement of conference goals, including quality improvement. Results. The MMC led to system changes
within the Department of Pediatrics as well as other parts of the hospital. Satisfaction with these changes was high
among conference participants, who felt that the conference achieved its goals of including multiple disciplines and
creating system changes. Conclusions.The successful change in the focus of the pediatric MMC conference resulted in
significant hospital-wide system changes, quality improvements, enhanced education, and departmental satisfaction.
Keywords
morbidity, mortality, system changes, multidisciplinary

Introduction
The morbidity and mortality conference (MMC) has
long been a forum for discussing adverse outcomes in
the academic medical setting.1 The Accreditation
Council for Graduate Medical Education (ACGME) has
recognized the educational value of resident participation in systematically analyzing practice and implementing changes with the goal of practice improvement.2
The format and methods by which cases are identified,
presented, and discussed vary widely among training
programs and disciplines across the United States and
Canada3,4 and even within our own institution.5
Although much has been published about both traditional and innovative uses of the MMC in internal medicine,1,3,6 emergency medicine,7-11 surgery,12-25 and other
disciplines as a forum for highlighting the core competencies of ACGMEs and quality improvement,12-14,26-29
there is a paucity of literature about the role of the MMC
in pediatrics.4,30 At the Johns Hopkins Childrens Center,
the MMC had become very similar to the weekly case

management conference in which interesting and

instructive cases were discussed by faculty members
with, primarily, residents and medical students in attendance. The nature and source of the morbidity and/or
mortality were often difficult to ascertain. Without a
unifying philosophy, these sessions did not produce
effective or lasting solutions.
We hypothesized that by clearly identifying goals for
the MMC and empowering those involved to reach these
goals, we could create a constructive venue for quality
improvement and a vehicle for initiating system change.
We restructured the conference to encourage discussions
1

Cedars-Sinai Medical Center, Los Angeles, CA, USA

Wake Forest School of Medicine, Winston-Salem, NC, USA
3
Johns Hopkins School of Medicine, Baltimore, MD, USA
4
Vanderbilt University, Nashville, TN, USA
2

Corresponding Author:
Shervin Rabizadeh, Cedars-Sinai Medical Center, 8635 W 3rd Street,
Suite 1165W, Los Angeles, CA 90077, USA
Email: Shervin.Rabizadeh@cshs.org

1080
about avoiding adverse events by focusing less on the
roles of individuals in the event and more on the system
and team management environment that enabled such
events. We anticipated that shifting the focus of discussion away from individual management would encourage increased attendance and participation at the
conference while providing a venue for initiating change
through open dialogue, with the goal of preventing future
morbidity and mortality (M&M). We emphasized the
importance of including all disciplines in discussions
about enacting system changes. In addition, we felt that
this could be an effective way to empower residents to
take the lead in identifying areas for quality improvement
in the Childrens Center and marshalling the resources
necessary for enacting change. The purpose of this article
is to (1) describe how our department changed the format
and philosophy of our MMC to address systems issues,
(2) describe content from the conferences during the first
2 years following this change, and (3) present evaluation
data from surveys collected from faculty, residents, and
hospital staff about the perceived effectiveness and satisfaction with this new approach.

Methods
New Conference Format
The Johns Hopkins Department of Pediatrics MMC is
an hour-long continuing medical education (CME)
approved twice monthly conference. Our revised goals
for this conference were to (1) identify events resulting
in adverse patient outcomes, (2) create and participate in
a forum in which health care providers acknowledge and
address reasons for medical errors, (3) modify behavior
and judgments by learning from past adverse events,
(4) address educational and systematic flaws that led to
adverse outcomes, and (5) identify a group to engineer
the identified needed changes and quality improvement.
The conferences are attended by Department of Pediatrics
faculty, fellows, residents, and medical students as well
as representatives from other disciplines, including nursing, pharmacy, social work, child life, pediatric surgical
subspecialties, and other interested parties. If the case
involves other departments, such as surgery or obstetrics
and gynecology, invitations are extended to representatives from these groups to attend and participate in the
discussion. Typically, a case with an adverse event is
presented in detail by one of the members of the M&M
team (see below) followed by discussions led by faculty
members and additional staff (nursing, pharmacy, etc)
involved in the case. The conference ends with a summary of the identified system errors as well as a plan for
future actions toward quality improvement.

Clinical Pediatrics 51(11)

Morbidity and Mortality Team

and Case Identification
The M&M team changes annually and is comprised of
6 senior pediatric residents, the 2 pediatric chief residents, and 4 faculty advisors, including the associate
residency program director. This team is charged with
the task of identifying cases with adverse outcomes
that have occurred at the Johns Hopkins Childrens
Center. The members of the M&M team are identified
at the beginning of the academic year and health care
providers are encouraged to share ideas for cases with
any member of the team. In addition, team members
solicit potential cases from faculty in high-acuity
units such as the pediatric emergency department,
pediatric intensive care unit, oncology, and the neonatal intensive care unit. Each M&M team resident is
given primary responsibility for developing several
case presentations during the year. Preparation for the
conference presentation includes review of all pertinent medical records, in-depth interviewing of the
staff members involved with the case, and inviting
speakers from the various disciplines to present and
participate in the discussion. The team member primarily responsible for the case develops a slide presentation on case details and other pertinent issues. At
the end of the case presentation, the primary team
member summarizes key points addressed during the
conference. From this, 1 to 3 action items are generated, and individuals are assigned to follow up on
discussed changes. The chief residents are responsible
for obtaining updates regarding progress made on the
action plans and system changes. The Department of
Pediatrics Chair and the Governing Executive
Committee are updated, and their involvement is
solicited for systems changes that involve departments other than pediatrics.

Case Overviews
Biannually, a conference is devoted to reviewing all the
cases presented in the previous 6 months. The cases are
summarized, and updates on the progress toward proposed system changes are reported. In addition, a summary table, consisting of a brief case presentation,
identified system errors, and updates on changes initiated by the case are distributed via e-mail to the
Department of Pediatrics faculty and residents and
members of other disciplines who had attended the
conference. The primary types of errors identified by
each case were grouped into categories by 2 of the
authors (KP and JRS). Any disagreements were settled
by group consensus.

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Rabizadeh et al
Table 1. Types of Primary Errors and Number Per Year Identified in the Conferences
Type of Error

2005-2006 Academic Year

2006-2007 Academic Year

3
2
1
3
2
3
0
3
1
0

2
0
0
1
1
2
1
1
3
3

Communication between providers

Communication with family
Equipment failure
Failure/Delayed diagnosis
Infection control
Medication/Allergy
Patient transport
Primary prevention
Resuscitation
Transfer of care

Evaluation Process
A survey was developed to evaluate the change in the
MMC format. The 17-question survey included demographics, responses to the proposed goals of the conference, and qualitative comments that addressed reasons
why participants attended, whether participants had
implemented system changes in their practice, the value
of the twice yearly MMC summary, and suggestions for
improvement of the conference. The survey was distributed via e-mail during June of 2006 and 2007, at the end
of each respective academic year. Data from 2 years of
evaluations were included to determine sustainability of
changes. Survey questions that addressed the MMC
goals used a standard 1 to 5 Likert response scale with
1 = strongly disagree and 5 = strongly agree. Space was
provided for additional free text commentary. The survey was sent to all Department of Pediatrics faculty and
residents as well as nurses, pharmacists, social workers,
and other interested individuals who had attended the
MMC. Survey reminders were also sent a total of 3 times
over a 6-week period. The surveys were returned to the
Senior Academic Program Coordinator in the Department
of Pediatrics (KM). Institutional review board approval
was obtained, and participants consented by agreeing to
complete the survey. Any identifying information was
removed prior to data extraction. Qualitative comments
were reviewed by 2 of the authors (KM and JRS), and
representative examples were selected.

Statistical Analysis
Data analysis was performed using the Statistical
Program for the Social Sciences, SPSS, version 10
(SPSS Inc, Chicago, IL). Frequencies were calculated,
and 2 analysis was performed comparing the 2 academic years.

Results
Demographics
A total of 18 MMCs were held during the academic year
2005-2006 and 14 during 2006-2007. An additional 2
conferences during each academic year were devoted to
the biannual reviews. There were 10 different categories
of error types leading to M&M identified from the cases
during the 2 academic years (Table 1). The majority
were a result of communication problems and issues
relating to medications and allergies. In reviewing the
survey results, the majority of the respondents were
physicians (Table 2). Other disciplines were represented
and included nurses, pharmacists, social workers, and
other interested individuals or staff who did not more
specifically identify themselves. Demographic analysis
revealed no significant differences between the 2 academic years; hence data were combined. Almost twothirds of survey responders attended more than 4
sessions during an individual academic year. Individuals
who did not attend regularly cited scheduling conflicts
as the primary reason for nonattendance.

Multidisciplinary Approach
Given the wide range of services involved in the care of
patients, one of the successes of this conference was
drawing individuals from a variety of services and
backgrounds. There was active participation and presentations by individuals from pediatric subspecialties
(36), nursing (13), pharmacy (5), surgical subspecialties
(4), ophthalmology (3), hospitalist service (3), anesthesia (3), infection control (3), hospital safety (3), radiology (2), pathology (2), obstetrics/gynecology (1), adult
emergency medicine (1), nutrition (1), Child Life (1),
and legal services (1). Survey respondents agreed that
the discussions were held in a nonthreatening manner

1082

Clinical Pediatrics 51(11)

Table 2. Demographics of Survey Participants

Attended 1 M&M
conference
Of those who attended
Discipline
Physician
Faculty
Fellow
Resident
Other disciplinea
Male gender
Number of sessions
attended
1-3
4-6
7
Received biannual summary

Percentage

81/94

86%

81

89%
32%
8%
60%
11%
31%

72
23
6
43
9
25

29
33
19
59

36%
41%
23%
73%

Abbreviation: M&M, morbidity and mortality.

a
Includes nursing, social work, pharmacist, bereavement coordinator,
child life worker.

with productive identification of problems and/or errors

leading to M&M as well as suggestions for implementing change. In fact, 95% of survey responders felt that
the MMC created a forum for different disciplines to
address reasons for medical errors.

Case Description and

Implemented Changes
Examples of cases discussed and the system changes
that occurred as a result of the MMC are presented
(Table 3). During the 2005-2006 academic year, one of
the most notable system changes involved a new hospital policy wherein positive pregnancy test results
(besides those obtained on the obstetrics unit) were
deemed critical action values, requiring immediate
notification to the patients caretakers with acknowledgement and documentation of the notification. The
impetus for this system change was secondary to a
MMC in which a group to champion the change was
identified. This group successfully lobbied for the new
policy through various hospital improvement committees. Although this error was identified during the MMC
of the Department of Pediatrics, the system change was
seen as beneficial for the entire hospital, and an institutional policy was amended. Another example of the
MMC leading to hospital policy change occurred in the
2006-2007 academic year. An insulin drip was mistakenly run in place of the ordered nalaxone drip secondary

to physical similarities in the medication bottles. The

pediatrics MMC was the impetus for forming a multidisciplinary group, including physicians, nurses, and
pharmacists, that successfully advocated a change in
hospital policy. As a result, nalaxone drips are now
administered in a 60-cc syringe (no longer in a bottle)
via a preprogrammed syringe pump, with the medication name scrolling across the pump screen. The third
case example illustrates the effect of the multidisciplinary approach of the conference in promoting change.
A large number of peripheral intravenous (IV) catheter
infiltrates were noted in Childrens Center patients via
data from the patient safety tracking system, an online
tool for all hospital caretakers for reporting safety issues
or adverse events in the hospital. The multidisciplinary
participation and discussion at the pediatric MMC provided the momentum for Childrens Center policy
changes directed at decreasing the number of peripheral
IV catheter infiltrates.

Survey Results
According to the majority of individuals who completed
the annual surveys, the new MMC format achieved its
goals and objectives (Figure 1). A total of 98% of individuals agreed or strongly agreed that this conference
allowed a practitioner to modify behavior and judgments
by learning from past adverse events, whereas 95% felt
that the conference was able to address educational and
systemic flaws that led to adverse outcomes. Additionally,
80% agreed or strongly agreed that the discussions were
held in a nonthreatening manner, whereas 70% agreed or
strongly agreed that a group was identified to move forward with needed changes and quality improvement. In
all domains, the positive responses were either sustained
or improved during the second year of study. Similar to
the survey results, comments showed appreciation and
strong support for the new MMC format (Figure 2).
Respondents also expressed satisfaction with the biannual summary. Suggestions for improvement centered
on greater participation of all disciplines, inclusion of
nonmedical aspects of the cases, and development of a
systematic way to identify cases.

Discussion
We have successfully implemented a new system for
the Department of Pediatrics MMC and, in doing so,
created a conference focused on education and quality
improvement. Our results indicate that we had active
participation from individuals with multidisciplinary
backgrounds engaged in nonthreatening discussions
about major patient-related M&M. Furthermore, system

1083

Rabizadeh et al
Table 3. Examples of MMC Cases Extracted From the Yearly Summary Table
Presenting Symptoms

Issue

Pregnancy test obtained on

16-Year-old girl
admission not noted to be
transferred in from
positive for 5 hours, postresult
outside hospital with
availability. After noting result,
seizures, hypertension,
patient diagnosed with eclampsia
and vision changes
and underwent emergent
and presumed to
Cesarian section
have venous sinus
thrombosis
Patient was treated with PCA
15-Year- old girl with
and naloxone drip for her pain
history of lupus
as well as temporarily on an
admitted with
insulin drip, which was eventually
pancreatitis and
transitioned to SC regimen
course complicated
for hyperglycemia. During
by significant pain and
hospital course, she developed
hyperglycemia
hypoglycemia refractory to
all interventions (ie, stopping
insulin). Required transfer to
PICU
In all, 36 IV infiltrate events
A high number of
were recorded, of which 24
peripheral IV catheter
caused significant morbidity and
infiltrates were noted
required additional treatment.
after routine review
The majority of the 24 were
of data in patient
receiving peripheral parenteral
safety net (an online
nutrition via the infiltrating IV
tool for all hospital
caretakers to report
any safety issues or
adverse events)

Morbidity/Mortality

System Changes

Delayed diagnosis of eclampsia because

caretakers were unaware of pregnancy
test results
Newborn died in NICU secondary to
respiratory failure
Patient fully recovered

Hospital-wide policy changed that

positive pregnancy test results
(besides those obtained on
obstetrics floor patients) made
critical action value requiring
immediate notification to patients
caretakers

Though it had been discontinued,

insulin was mistakenly hung instead
of naloxone, leading to the refractory
hypoglycemia. Insulin and naloxone
drips were contained in identical
bottles. Furthermore, the bottle had
correctly been labeled as insulin but
the IV tubing leading to the patient
was marked as naloxone leading to the
medication error. The patient did well
after the error was discovered
High number of peripheral IV infiltrates,
with two-thirds having associated
morbidity

Hospital-wide policy changed that

naloxone would be administered
in a 60-cc syringe (no longer
bottle) via a syringe pump that
will be programmed to have the
medication name scroll across the
pump screen

Childrens Center policy changed

that peripheral parenteral
nutrition will not be allowed
unless approved by pediatric
gastroenterology, nutrition, and
pharmacy after reviewing the need
and contents of the IV nutrition.
Also the PICC line service will
get list of all admissions listed by
diagnosis and touch base with
charge nurses on a daily basis, so
as to be aware of patients who
may need longer-term IV access

Abbreviations: MMC, morbidity and mortality conference; NICU, neonatal intensive care unit; PICU, pediatric ICU; OB, obstetrics; PCA, patient-controlled anesthesia; SC, subcutaneous; IV, intravenous; PICC, peripherally inserted central catheter.

changes were proposed during the conference, and

processes for implementing those changes were initiated. The conference led to hospital-wide system
changes as exemplified by the new policy for positive
pregnancy test notification on nonobstetrics units and
change in the delivery apparatus of nalaxone drips to
avoid medication error. In addition, certain departmental policies were changed, such as appropriate use of
peripheral IV access to reduce catheter infiltrates. The
annual survey demonstrated that participants felt that
the conference was effective in identifying relevant
system issues related to patient safety, fostering discussion of these issues and suggested changes, identifying groups of individuals to address the potential
changes, and successfully implementing them.
Scheduling conflicts, not a perceived lack of value of
the process, was the primary reason for nonattendance,
again supporting the overall satisfaction with the new
format of the conference.

The importance of didactic and case management

conferences cannot be overstated, but in changing the
MMC, we were able to transform an existing educational vehicle in pediatrics that has benefited not only
the knowledge base of caretakers but also led to system
improvements translating to better and safer care. As
evident in the survey results, the nonthreatening, multidisciplinary approach to the MMC was a well-received
adjunct to more traditional resident education and CME.
Changing the culture of a conference such as the
MMC is never a static process and requires evolution
with ongoing adaptation. One of the most important
aspects of the change in the MMC within our department is the ability for future growth with ongoing
adjustments. To build on our success in terms of attendance, multidisciplinary participation, problem identification, and impetus for policy changes, the MMC will
need to evolve based on participant feedback. We seek
to make this a dynamic process that responds to the

1084

Figure 1. Survey results

Figure 2. Representative comments made by conference participants in the annual survey

Clinical Pediatrics 51(11)

1085

Rabizadeh et al
changing conditions in both the patient care and medical
education environments. Our hope is that this will elicit
a more comprehensive cultural change in medical thinking, especially in pediatrics, where the most difficult
casesthe ones in which harm has occurred to the
patientwill be discussed in a confidential, nonthreatening manner with identification and initiation of systembased changes that will make for safer patient care.
We recognize the limitations of evaluation using a
postsurvey study method. Our ability to quantify the
impact of the change in the conference format is limited
because no baseline survey data were collected prior to
the implementation of this change. Additionally, no
objective data were collected to quantify whether proposed changes led to increased patient safety or a
decrease in adverse events. Furthermore, the survey was
susceptible to responder bias.
Despite these limitations, survey results and comments suggest that we have successfully reformatted the
MMC in our pediatrics department. The new conference
format has promoted a nonthreatening environment for
multidisciplinary discussions of adverse events and,
most important, the nidus for promoting system changes
that can have significant effect across the entire medical
center. This is best exemplified by the following comment from an anonymous MMC participant: A vast
improvement over prior years during which [in previous
years] we would talk about cases in which the ball was
dropped, shake our heads forlornly and walk out of the
room. Keep up the good work! We hope to further
improve the MMC and maintain its new position as an
important vehicle for identification of errors, learning
from errors, and promoting system changes.
Acknowledgments
We would like to acknowledge Dr George Dover and Dr Julia
McMillan for their support of the change in the MMC format
and their review of the manuscript. We would also like to
acknowledge Drs David Bundy, Elizabeth Hunt, Peter Rowe,
and Allen Walker who served as faculty advisors for the
M&M team. In addition, we would like to recognize the amazing work of the residents on the committee without whom
these changes would not be possible: Drs Naseem
Amrasingham, Margaret Brewinski, Joshua Dishon, Doran
Fink, Raquel Hernandez, Michael Nemergut, and Patrick
Wilson (2005-2006); Drs Aaron Chambers, Joan Dunlop,
Michelle Dunn, Rachel Johnson, Michael McCrory, and
David Shook (2006-2007).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.

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