Anonymity Decreases the Punitive Nature of a Departmental Morbidity and Mortality Conference

J Patient Saf. 2019 Dec;15(4):e86-e89. doi: 10.1097/PTS.0000000000000555.

Abstract

Objectives: We sought to analyze the effect of an anonymous morbidity and mortality (M&M) conference on participants' attitudes toward the educational and punitive nature of the conference. We theorized that an anonymous conference might be more educational, less punitive, and would shift analysis of cases toward systems-based analysis and away from individual cognitive errors.

Methods: We implemented an anonymous M&M conference at an academic emergency medicine program. Using a pre-post design, we assessed attitudes toward the educational and punitive nature of the conference as well as the perceived focus on systems versus individual errors analyzed during the conference. Means and standard deviations were compared using a paired t test.

Results: Fifteen conferences were held during the study period and 53 cases were presented. Sixty percent of eligible participants (n = 38) completed both the pretest and posttest assessments. There was no difference in the perceived educational value of the conference (4.42 versus 4.37, P = 0.661), but the conference was perceived to be less punitive (2.08 versus 1.76, P = 0.017). There was no difference between the perceived focus of the conference on systems (2.76 versus 2.76, P = 1.00) versus individual (4.21 versus 4.16, P = 0.644) errors. Most participants (59.5%) preferred that the conference remain anonymous.

Conclusions: We assessed the effect of anonymity in our departmental M&M conference for a 7-month period and found no difference in the perceived effect of M&M on the educational nature of the conference but found a small improvement in the punitive nature of the conference.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Attitude of Health Personnel
  • Congresses as Topic / organization & administration
  • Emergency Medicine / standards*
  • Fear
  • Humans
  • Internship and Residency / methods*
  • Learning*
  • Medical Errors / prevention & control*
  • Medical Errors / psychology
  • Morbidity*
  • Mortality*
  • Organizational Culture
  • Patient Safety*
  • Physicians / psychology
  • Shame