J Clin Outcomes Manage
Primary care morbidity and mortality conference: new use of an old process
Goldszer RC, Rittenberg E, Gandhi TK, Katzman L, Sadoughi S, Bertone K, Winshall JS
Abstract Objective: To describe the development and implementation of and early experience with a primary care morbidity and mortality conference. Methods: A steering committee was formed to define the specifics of the program. Conferences are held 6 times per year and last approximately 1 hour. Participants are eligible for continuing education credits. At the conference, one of the hospitalís 12 primary care practices is responsible for presenting a case in which an error or near miss occurred. Responsibility for presenting the case and leading the discussion rotates among the?12 practices. A specialist is invited to comment on the case, and participants discuss what could have gone better and make suggestions for error prevention. Recommendations for improvement based on participantsí discussion are developed and circulated, and feedback is obtained. All primary care clinicians are notified of implemented changes. Results: The first conference was held in June 2005 and resulted in new guidelines for the care of patients following bariatric surgery. Additional recommendations have been developed and implemented. Participants find the discussions informative and educational. Conclusion: The primary care morbidity and mortality conference is a useful tool for improving the quality of care for primary care patients.
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