Learning from defects to enhance morbidity and mortality conferences.

Sean M. Berenholtz; Theresa L. Hartsell; Peter Pronovost

Commentary

Learning from defects to enhance morbidity and mortality conferences.

June 12, 2009

Berenholtz SM, Hartsell TL, Pronovost P. Am J Med Qual. 2009;24(3):192-5.

View more articles from the same authors.

This article describes the use of a comprehensive unit-based safety tool (CUSP) to improve the effectiveness of morbidity and mortality conferences, meet Accreditation Council for Graduate Medical Education standards, and advance medical education.

PubMed citation

Available at

Related Resources From the Same Author(s)

Reducing health care hazards: lessons from the Commercial Aviation Safety Team.

May 20, 2009

How will we know patients are safer? An organization-wide approach to measuring and improving safety.

September 17, 2010

The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs.

October 16, 2012

Improving patient safety in intensive care units in Michigan.

June 16, 2011

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.

September 20, 2011

Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.

May 25, 2011

A framework for health care organizations to develop and evaluate a safety scorecard.

February 1, 2011

An intervention to decrease catheter-related bloodstream infections in the ICU.

February 17, 2011

Creating high reliability in health care organizations.

January 20, 2010

Board quality scorecards: measuring improvement.

August 10, 2011

Related Resources

Defining a high-quality and effective morbidity and mortality conference: a systematic review.

November 1, 2023

A multidisciplinary model for reviewing severe maternal morbidity cases and teaching residents patient safety principles.

June 18, 2019

The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives.

February 27, 2019

The "Quality Minute"—a new, brief, and structured technique for quality improvement education during the morbidity and mortality conference.

September 24, 2017

Engaging pediatric resident physicians in quality improvement through resident-led morbidity and mortality conferences.

March 2, 2016

Morbidity and mortality conference in emergency medicine residencies and the culture of safety.

December 9, 2015

A systems approach to morbidity and mortality conference.

September 20, 2011

Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety.

March 23, 2011

Learning from mistakes: factors that influence how students and residents learn from medical errors.

February 24, 2011

Morbidity and mortality conference, grand rounds, and the ACGME's core competencies.

February 24, 2011

See More About The Topic

Hospitals

Educators

Morbidity and Mortality Conferences

Residents and Fellows

Learning from defects to enhance morbidity and mortality conferences.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Learning from defects to enhance morbidity and mortality conferences.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site

Submit Your Training

Continue as a Guest

Continue Logged In

Submit Your Training

Continue as a Guest

Continue Logged In

New Users to the PSNet site

Submit Your Toolkit

Continue as a Guest

Continue Logged In

Submit Your Toolkit

Continue as a Guest

Continue Logged In

New Users to the PSNet site

Submit Your WebM&M Case

Continue as a Guest

Continue Logged In

Submit Your WebM&M Case

Continue as a Guest

Already have a PSNet

Account?

New Users