Re-thinking morbidity and mortality
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Sumner Abraham
,
Andrew Parsons
Abstract
Despite the breadth of patient safety initiatives, physicians talking about their mistakes to other physicians is a difficult thing to do. This difficulty may be exacerbated by a limited exposure to how to analyze and discuss mistakes and respond in a productive way. At the University of Virginia, we recognized the importance of understanding cognitive biases for residents in both their clinical and personal professional development. We re-designed our resident led morbidity and mortality (M&M) conference using a model that integrates dual-process theory and metacognition to promote informed reflection and analysis of cognitive diagnostic errors. We believe that structuring M&M in this way builds a culture that encourages reflection together to learn our most difficult diagnostic errors and to engage in where our thought processes went wrong. In slowly building this culture, we hope to inoculate residents with the habits of mind that can best protect them from harmful biases in their clinical reasoning while instilling a culture of self-reflection.
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Research funding: None declared.
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Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
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Competing interests: Authors state no conflict of interest.
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© 2020 Walter de Gruyter GmbH, Berlin/Boston
Articles in the same Issue
- Frontmatter
- Editorial
- Machine learning in laboratory diagnostics: valuable resources or a big hoax?
- Review
- Diagnosis of mast cell activation syndrome: a global “consensus-2”
- Opinion Papers
- Re-thinking morbidity and mortality
- Improving diagnosis by feedback and deliberate practice: one-on-one coaching for diagnostic maturation
- Original Articles
- Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students
- The variability in how physicians think: a casebased diagnostic simulation exercise
- Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method
- Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study
- An estimate of missed pediatric sepsis in the emergency department
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- A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain
- Development of a rubric for assessing delayed diagnosis of appendicitis, diabetic ketoacidosis and sepsis
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- Impact of water temperature on reconstitution of quality controls for routine hemostasis testing
- Development of an algorithm for the identification of leukemic hematolymphoid neoplasms in Primary Care patients
- Establishing a stable platform for the measurement of blood endotoxin levels in the dialysis population
- Brazilian laboratory indicators benchmarking program: three-year experience on pre-analytical quality indicators
- The accuracy of nipple discharge cytology in detecting breast cancer
- Letter to the Editor
- Results of a hospital survey on critical values communication
- Online Only: Congress Abstracts
- The Diagnostic Error in Medicine 13th Annual International Conference
Articles in the same Issue
- Frontmatter
- Editorial
- Machine learning in laboratory diagnostics: valuable resources or a big hoax?
- Review
- Diagnosis of mast cell activation syndrome: a global “consensus-2”
- Opinion Papers
- Re-thinking morbidity and mortality
- Improving diagnosis by feedback and deliberate practice: one-on-one coaching for diagnostic maturation
- Original Articles
- Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students
- The variability in how physicians think: a casebased diagnostic simulation exercise
- Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method
- Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study
- An estimate of missed pediatric sepsis in the emergency department
- Head Computed tomography during emergency department treat-and-release visit for headache is associated with increased risk of subsequent cerebrovascular disease hospitalization
- A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain
- Development of a rubric for assessing delayed diagnosis of appendicitis, diabetic ketoacidosis and sepsis
- Between Web search engines and artificial intelligence: what side is shown in laboratory tests?
- Impact of water temperature on reconstitution of quality controls for routine hemostasis testing
- Development of an algorithm for the identification of leukemic hematolymphoid neoplasms in Primary Care patients
- Establishing a stable platform for the measurement of blood endotoxin levels in the dialysis population
- Brazilian laboratory indicators benchmarking program: three-year experience on pre-analytical quality indicators
- The accuracy of nipple discharge cytology in detecting breast cancer
- Letter to the Editor
- Results of a hospital survey on critical values communication
- Online Only: Congress Abstracts
- The Diagnostic Error in Medicine 13th Annual International Conference
