ConferencePatient safety is receiving growing attention worldwide with numerous studies showing that approximately 10% of patients admitted to hospital suffer an adverse event. Whereas efforts to eliminate errors and adverse events continue, it has long been acknowledged in healthcare, as well as in other industries, that organisations can and should learn from them. Within healthcare, a key component of workplace-based learning is the ‘morbidity and mortality’ meeting or conference (M&M). The goal of M&M is to provide clinicians with the opportunity to discuss errors and adverse events in an open manner, review care standards, and make changes if required.

However, the structure, content and format of M&Ms vary widely among institutions. To date there is no standardised presentation style or formal guideline on how best to present complications in a manner that maximises the learning value of the M&M. Lack of a consistent approach contributes to substantial variation in presentation quality and educational outcomes achieved – and perhaps more worryingly to the devaluation of the M&M in the eyes of both experienced clinicians and also more junior trainees (i.e. M&Ms becoming a mandatory ‘tick-box’ exercise). As a consequence, there is currently little evidence demonstrating the effectiveness of M&M as a learning or care improvement tool and mostly subjective perceptions of its value.

In collaboration with the Department of Surgery of the Oregon Health and Science University, we have been carrying out a research programme on assessing and improving the effectiveness of M&Ms. One of the outputs of this programme is a ‘Morbidity & Mortality Conference Manual’. The manual aims to provide a practical toolkit for effective M&M presentations – including (i) a standardised format for M&M presentation to improve presentation quality and learning outcomes for junior and senior attendees using the SBAR approach to standardising communications (Situation, Background, Assessment & Analysis, Review of literature and Recommendations), and (ii) a relevant assessment tool.


Relevant publications:

  • Mitchell EL, Lee DY, Arora S, Kenney-Moore P, Liem TK, Landry GJ, Moneta GL, Sevdalis N. Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study. Acad Med. 2013 Jun;88(6):824-30. PubMed
  • Mitchell EL, Lee DY, Arora S, Kwong KL, Liem TK, Landry GL, Moneta GL, Sevdalis N. SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations. Am J Surg. 2012 Jan;203(1):26-31. PubMed 


Dr N Sevdalis or Dr Erica Mitchell