SHM Converge Scientific Abstract ePoster Gallery-Effect of MMC on Patient Safety Reporting and Resident Confidence

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This background study evaluated the impact of replacing a traditional morbidity and mortality conference (MMC) with a quality improvement–focused MMC in an Internal Medicine residency program at the University of Arizona College of Medicine–Phoenix. The goal was to create a more open, psychologically safe environment for discussing patient safety events (PSEs) while also improving residents’ engagement with reporting and learning from errors.<br /><br />Before implementation, many residents reported limited knowledge of how to report PSEs, and only a minority supported having MMC discussions about patient safety. Key concerns included limited curriculum time, intimidation, lack of psychological safety, and doubts about MMC usefulness.<br /><br />The new MMC was integrated into the existing noon conference, offered both in person and virtually, and used a combination of traditional discussion and anonymous polling. Residents voluntarily presented morbidity or mortality cases, and the group participated in root cause analysis. Anonymous surveys before and after sessions tracked perceptions in three areas: risk identification and just culture, team cohesion and engagement, and error transparency and risk mitigation.<br /><br />Early results from five MMCs showed increased attendance, from 7 to 21 participants. Most respondents viewed the format positively: 66% recognized better risk identification and just culture, 62% reported stronger team cohesion, and 78% wanted MMC to continue. However, knowledge of how to submit PSE reports declined, and willingness to share adverse events only slightly decreased.<br /><br />Overall, the study suggests that a QI-based MMC can improve participation and support a safer discussion environment, but additional education on PSE reporting may be needed. The authors plan to continue the program, use both polling and traditional discussion methods, and compare future PSE reporting over a longer period.

Asset Subtitle

Leigh Anne Goodman

Meta Tag

Author List Elle M. Newcome, Erin Biringen, Leigh Anne Goodman, Ruth Franks Snedecor

Category Innovations

Concept Morbidity and mortality conference

Concept Safety Culture

Concept Psychological Safety

Concept Quality Improvement

Concept Patient Safety Reporting

Distinguished Non-Finalist

Presenter Organization University of Arizona College of Medicine - Phoenix

Presenting Author Leigh Anne Goodman

Track Quality Improvement

Keywords

morbidity and mortality conference

quality improvement

patient safety events

internal medicine residency

psychological safety

root cause analysis

resident engagement

error reporting

just culture

team cohesion

Morbidity and mortality conference

Safety Culture

Psychological Safety

Quality Improvement

Patient Safety Reporting