The Morbidity, Mortality and Improvement conference is an adaptation of previous Morbidity and Mortality conference (M&M) where a physician would present a case of theirs in which the patient had an adverse outcome. The physician would then be grilled by an audience of their peers and superiors to defend their decisions. Often they humiliated the … Continue reading MM&I Case Instructions
Tag: Quality Improvement
Understanding “Human Error”
Humans make mistakes. Any system that depends on perfect performance by humans is doomed to failure. In fact, the risk of an accident is more a function of the complexity of the system than it is the people involved. Humans are not the weak link in a process. We are a source resilience. We have … Continue reading Understanding “Human Error”