The morbidity and mortality conference: a prolegomenon on its role as an anesthesia risk-management tool.

Although the morbidity and mortality conference (MMC) is an essential component of any anesthesia risk-management program, it has not undergone systematic analysis. All MMC narratives detailing the proceedings at two university centers from June 1988 to June 1990 were examined by content analysis and the unique perspectives of MMC participants were captured. The majority of MMC events were of an educational or informational nature; 32% dealt with patient complications, and 14% involved incidents that could have led to detrimental outcomes. Participant beliefs were ultimately organized into categories describing "the lived experience" of the MMC. These included (1) disclosure of knowledge, (2) correspondence of relationship, (3) teaching conformity to rule, (4) developing a sense of aplomb, (5) preparation for litigation, (6) the ceremony, (7) a quality-assurance mechanism, (8) a personal lambaste function, and (9) an instrument of punitive retribution. The MMC appeared improperly named; "case conference" or "clinical teaching conference" may serve as a more accurate rubric. The MMC played a variety of cognitive and affective roles. Recognition of the nature of the teaching and learning associated with the MMC will allow risk managers to utilize it optimally in achieving envisioned objectives that enhance patient outcomes.