Morbidity and mortality: learning from a case gone wrong
Table of contents
Thursday, seven in the morning. The auditorium fills slowly, someone projects the timeline of a hospital stay that ended badly, and the resident who was on duty that night knows they will have to explain every decision. In the front row, the preceptors. Behind them, the interns, who still do not know whether the next hour will teach them something or just leave everyone afraid of making a mistake.
NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.
This meeting has an old name: morbidity and mortality conference, or M&M, from morbidity and mortality conference. It exists so that a service can learn from bad outcomes and from errors. This guide shows what the conference is, what studies have found about how it works in practice, and what separates a discussion that teaches from one that only exposes.
Key points
- The morbidity and mortality conference is the meeting in which a service discusses complications, deaths and errors to improve care and train residents.
- In a survey of internal medicine programs in the United States, almost all had the conference, but the goals varied widely from one place to another.
- Trained observers saw that, even when there was an error, it was not always called an error, and leaders rarely admitted their own.
- Discussions without structure tended to slide into blame; structure, preparation and follow-up appear as the points that weigh most.
- The student gets more out of the conference when they read it as an exercise in reasoning, and not as a judgment.
What a morbidity and mortality conference is
A tradition for examining one's own work
The morbidity and mortality conference grew out of doctors' efforts to improve practice by examining errors and bad outcomes, and its modern form has still been little studied outside surgery and anesthesiology (Orlander et al., 2002). The authors of that review describe the conference as a double-edged sword: when it goes well, it serves as a model for learning from error; when it goes badly, it teaches that trying to learn from error is, at best, useless and, at worst, unpleasant (Orlander et al., 2002).
This ambiguity is the heart of the matter. The same meeting can teach critical analysis or teach concealment. What decides it is the way it is run, and not only the patient chosen for discussion.
Three goals competing for the same hour
In practice, the conference usually carries three goals at once:
- Training: showing residents and students how a line of reasoning was built and where it went off course.
- Patient safety: finding system failures that could happen again with another person.
- Quality control: recording that the service reviews its outcomes, often because administration requires it.
All three are legitimate, but they pull the conversation in different directions. A conference designed only to meet a requirement tends to be short and procedural. A conference designed only to teach may forget to change the process that failed.
What sets it apart from other reviews
The routine peer case review, like the one described in the guide to clinical case review for general practitioners, looks at everyday work. The error notebook is an individual student tool. The morbidity and mortality conference is institutional: the whole service looks at an outcome that has already happened, with names, hierarchies and an audience.
What the studies show
Almost all have one, few know what it is for
In a survey sent to internal medicine departments with residency programs in the United States, 295 of 416 questionnaires came back, or 71% (Orlander and Fincke, 2003). Among those who responded, 90% of programs had a morbidity and mortality conference; most met once a month, had a designated leader and discussed three patients or fewer per session (Orlander and Fincke, 2003).
Patients were chosen mainly for an unexpected bad outcome and for teaching value, and to a lesser degree for suspected medical error (Orlander and Fincke, 2003). Two thirds of the services used the conference to meet administrative quality assurance requirements, and the authors concluded that the goals of the meeting did not seem well defined (Orlander and Fincke, 2003).
The error that appears and the error that is named
In a prospective study, trained physicians followed 332 presentations in internal medicine and surgery sessions at four American university hospitals (Pierluissi et al., 2003). Adverse events appeared in 37% of the internal medicine presentations and in 72% of the surgery ones (Pierluissi et al., 2003).
When an error had caused the adverse event, it was discussed as an error in 48% of cases in internal medicine and in 77% in surgery, and it was attributed to a cause in 38% and 79%, respectively (Pierluissi et al., 2003). In both areas, the session leaders rarely used explicit language to say that it was an error and rarely admitted having erred (Pierluissi et al., 2003).
The most useful piece of information for the learner is in that last sentence. If the person leading the session avoids the word error, the audience understands that the subject is dangerous.
What a broad review found
A systematic review of morbidity and mortality sessions in surgery included 59 studies, with a mean methodological quality score of 6.7 on a scale that goes up to 18, which the authors read as average quality (Beaulieu-Jones et al., 2023). The evidence suggested that preparation before the session and follow-up after it, with improvement projects, are as important as presenting the patient concisely and creating a constructive space of accountability (Beaulieu-Jones et al., 2023).
Blame, anonymity and the mood in the room
When the discussion becomes a judgment
In a mixed-methods study in a surgery department, researchers observed 11 sessions over six months, with four different moderators, and the discussion was free, with no standard structure (Abahuje et al., 2024). The central theme was that the low participation of the surgeon in charge and the absence of a system approach led to blame, and blame opened the way to incivility (Abahuje et al., 2024).
In the questionnaire of the same study, 54 of the 147 invitees responded, or 36.7%, and assistant professors had higher scores for negative affect and exclusionary behavior than associate and full professors (Abahuje et al., 2024). The authors' conclusion is direct: structuring the discussion around improving care can create inclusion and more productive conversations (Abahuje et al., 2024).
The effect of anonymity
An academic emergency department tested an anonymous session, in which the names of those involved were not revealed (Jansson et al., 2019). Across 15 sessions, 38 participants answered the questionnaires before and after; the session came to be perceived as less punitive, from 2.08 to 1.76, and the perceived educational value stayed the same, from 4.42 to 4.37 (Jansson et al., 2019). Among the participants, 59.5% preferred that the session remain anonymous (Jansson et al., 2019).
The gain was small, and the perceived focus on individual or system failures also stayed the same in the same study (Jansson et al., 2019). Removing the name helps lower the temperature, but on its own it may be insufficient to change the type of analysis.
Neighboring topics
The session touches on subjects that deserve their own guides: hindsight bias, which makes the outcome seem obvious after it happened; communication of the error to the patient and family; and the suffering of the professional involved, called the second victim. Each of them weighs on the mood in the room, and good moderation keeps all three on the radar.
How to set up a session that teaches
Before: choosing and preparing
The review of team sessions in the perioperative period, with seven studies, organized the elements into three stages (Samost-Williams et al., 2023). Before the session come the choice of patient and the investigation of what happened; during it, a standardized format and a formal moderator; after it, follow-up messages and improvement projects (Samost-Williams et al., 2023).
For the organizer, this translates into simple questions. Why this patient? Who will present, and with what support? Which documents and timelines need to be ready?
During: a reasoning script
A pediatrics residency program structured its sessions so that residents and the audience identified cognitive biases and errors in reasoning (Whitehead, 2021). Over one year, 24 residents presented and identified on average 3.7 biases or errors and 1.7 strategies to reduce biases per presentation; the audience also managed to point out possible biases (Whitehead, 2021).
A script of this kind can follow four questions:
- What was known at each moment, and not what is known now?
- Which hypotheses were on the table, and which one was chosen?
- What mental shortcut may have weighed in? The guide to examples of heuristics in clinical reasoning helps give them a name.
- What process change would reduce the chance of repeating the deviation?
The first question is the one that most protects against hindsight bias. The third connects with the differential diagnosis, because often the problem was a list of hypotheses that was too short.
Then: close the loop
The 2023 review in surgery gave follow-up the same weight as the presentation (Beaulieu-Jones et al., 2023). In practice, this means naming a person responsible for each proposed change and returning to the subject in a later session. Without that follow-up, the audience learns that discussing is enough.
The role of the moderator
The moderator sets the tone. They separate decision from outcome, interrupt personal comments, ask for data when the conversation turns into opinion and, if appropriate, tell of an error of their own. The 2003 study showed how rare this is (Pierluissi et al., 2003), and that is why it carries so much weight when it happens.
How the student makes the most of the session
Read it as an exercise, not as a judgment
The intern usually watches the session like the audience at a tribunal. A more useful stance is to treat the presentation as an open case: stop at each point on the timeline and ask what your hypothesis would be there, with the data available at that time.
Note the pattern, not the gossip
What is worth taking from the session is the type of deviation: a hypothesis nobody considered, a test that was misread, an incomplete shift handover. This record connects with metacognition in medicine, because it teaches you to recognize the same deviation in your own reasoning.
Compare your confidence with the outcome
When you reach a hypothesis before the presenter reveals the outcome, also note how confident you were in it. The guide to calibration of confidence in diagnosis shows why this comparison teaches as much as getting it right.
Ask with care
Questions about reasoning help everyone; questions that sound like an accusation shut the conversation down. "What led to that choice at that time?" teaches more than "why did nobody think of that?". The guide to feedback in clinical cases deals with the same care in another context.
Error as information in NEXO
The best morbidity and mortality session treats error as data. NEXO starts from the same idea on a small scale: with each guess in the case of the day, proximity in ICD-10 across five levels shows how far the hypothesis was, whether in the same chapter, the same group or the same category. The case arrives in up to six clues, and the distribution of correct answers by clue shows at what point you usually close the diagnosis.
The cases are fictional with a real clinical presentation, and the guide what NEXO is explains the whole game. How the modes are unlocked is on the NEXO Economy page.
If you coordinate a medical school, a student league or a residency and want to bring cases for group discussion, see NEXO Closer. Researchers in medical education can propose studies through NEXO Researcher. Doctors who review cases take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.
Frequently asked questions
What is a morbidity and mortality session?
It is the meeting in which a health service discusses complications, deaths and errors to improve care and train residents and students.
What is the morbidity and mortality session for?
For training, patient safety and quality control. A survey showed that these goals are often poorly defined (Orlander and Fincke, 2003).
Should the session be anonymous?
In one study, anonymity slightly reduced the feeling of punishment, without changing the perceived educational value (Jansson et al., 2019). It is a choice for each service.
How do you keep the session from turning into blame?
With structure: a presentation script, a formal moderator, a focus on the system and follow-up on the proposed changes.
What should the student observe?
The reasoning at each point on the timeline, the type of deviation and the way the group talks about error.
How does NEXO handle error?
As information: proximity in ICD-10 across five levels shows how far each guess was from the diagnosis.
Morbidity and mortality session checklist
- Define the objective of the session before choosing the patient.
- Prepare the timeline with what was known at each moment.
- Use a script for reasoning, with hypotheses and shortcuts.
- Name the error when there is an error.
- Separate decision from outcome in the discussion.
- Have a moderator who interrupts blame.
- Close the loop with an owner and a follow-up.
Want to train error as information? Play the case of the day on NEXO.
References
- Orlander JD, Barber TW, Fincke BG. The morbidity and mortality conference: the delicate nature of learning from error. Acad Med. 2002. https://pubmed.ncbi.nlm.nih.gov/12377674/
- Orlander JD, Fincke BG. Morbidity and mortality conference: a survey of academic internal medicine departments. J Gen Intern Med. 2003. https://pubmed.ncbi.nlm.nih.gov/12911649/
- Pierluissi E, Fischer MA, Campbell AR, Landefeld CS. Discussion of medical errors in morbidity and mortality conferences. JAMA. 2003. https://pubmed.ncbi.nlm.nih.gov/14657068/
- Beaulieu-Jones BR, Wilson S, Howard DS, Rasic G, Rembetski B, Brotschi EA, et al. Defining a High-Quality and Effective Morbidity and Mortality Conference: A Systematic Review. JAMA Surg. 2023. https://pubmed.ncbi.nlm.nih.gov/37851458/
- Abahuje E, Yang S, Hu YY, Alam HB, Rosenblatt A, Ballard H, et al. Mixed-methods Assessment of Incivility During Surgical Mortality and Morbidity Conference. Ann Surg. 2024. https://pubmed.ncbi.nlm.nih.gov/37638402/
- Jansson PS, Schuur JD, Baker O, Hagan SC, Nadel ES, Aaronson EL. Anonymity Decreases the Punitive Nature of a Departmental Morbidity and Mortality Conference. J Patient Saf. 2019. https://pubmed.ncbi.nlm.nih.gov/30444742/
- Samost-Williams A, Rosen R, Hannenberg A, Lydston M, Nash GM, Brindle M. Perioperative Team-Based Morbidity and Mortality Conferences: A Systematic Review of the Literature. Ann Surg Open. 2023. https://pubmed.ncbi.nlm.nih.gov/37746600/
- Whitehead A. A Resident Morbidity and Mortality Conference Curriculum to Teach Identification of Cognitive Biases, Errors, and Debiasing Strategies. MedEdPORTAL. 2021. https://pubmed.ncbi.nlm.nih.gov/34765723/