Morbidity and mortality (M&M) conferences are standard components of medical training programs and are designed to explore the factors contributing to medical errors and adverse patient outcomes. However, prior research has found that medical residents underutilize incident reporting systems that feed into M&M conferences.

In August 2017, the Department of Orthopedic Surgery at Cedars Sinai Medical Center launched a web-based, real-time complication reporting platform to encourage incident reporting among orthopedic residents. The mobile application used a HIPAA-compliant, web-based platform (Research Electronic Data CAPture [REDCap]) that allowed residents to report major and minor complications (e.g., unplanned re-operation, infection, medication error, pressure ulcers).

Before roll-out of the mobile app, complications were solicited retrospectively via email on a monthly basis in advance of the M&M conference. From August 2016 to July 2017, there were 54 events reported, with a mean of 4.0 events per month. After the mobile application was launched, there was a significant increase in the number of reported adverse events. In the first year, there were 176 events reported (mean of 14.76 events per month) and 236 events reported in the second year (mean of 19.66 events per month). The AHRQ Patient Safety Culture Survey was administered before and after widespread implementation of the app. Post-implementation, residents were generally more positive about departmental safety culture, particularly how attending physicians regarded their suggestions for improving patient safety.

Related Resources

AHRQ Hospital Survey on Patient Safety Culture. Available at  

Research Electronic Data CAPture (REDCap). Available at