The use of a multidisciplinary morbidity and mortality conference to incorporate ACGME general competencies.

Background: The Surgical Morbidity and Mortality conference has long been used as an opportunity for both process improvement and resident education. With recent heightened focus on creating environments of safety and on meeting the Accreditation Council for Graduate Medical Education (ACGME) General Competencies, novel approaches are required. With the understanding that the provision of medical care is an inherently multidisciplinary enterprise, we advocate the creation and use of a Multidisciplinary Morbidity and Mortality conference (MM&M) as a means to establish this culture of safety while teaching the ACGME General Competencies to surgery residents.

Using risk management files to identify and address causative factors associated with adverse events in pediatrics.

We report a retrospective analysis of 84 consecutive pediatrics-related internal review files opened by a medical center's risk managers between 1996 and 2001. The aims were to identify common causative factors associated with adverse events/adverse outcomes (AEs) in a Pediatrics Department, then suggest ways to improve care. The main outcome was identification of any patterns of factors that contributed to AEs so that interventions could be designed to address them.

Cause and effect analysis of closed claims in obstetrics and gynecology.

Background: Identifying the etiologies of real or perceived adverse clinical events and undesired outcomes is an important step in improving patient safety and reducing malpractice risks. Systematic analysis of obstetrics and gynecology-related risk management files allows a more complete examination of ways that human and systems factors may contribute to adverse events.

Objective: To learn the medical complaints of patients who experienced apparent adverse events, the general causes of those adverse events, and the significant specific causal factors involved in obstetrics and gynecology-related risk management cases.