J Healthc Qual. 2024;46(2):100-108. doi: 10.1097/JHQ.0000000000000416. Epub 2023 Nov 21.
The focus of morbidity and mortality conferences (M&MCs) has shifted to emphasize quality improvement and systems-level care. However, quality improvement initiatives targeting systems-level errors are challenged by learning in M&MCs, which occurs at the individual attendee level and not at the organizational level. Here, we aimed to describe how organizational learning in M&MCs is optimized by particular organizational and team cultures.
A prospective, multiple-case study design was used. Using purposive sampling, three cases covering different medical/surgical specialties in North America were chosen. Data collection included direct observations of the M&MC, semistructured interviews with key M&MC members, and documentary information.
The role of the M&MC in all cases integrated two key concepts: recognition of system-wide trends and learning from error, at an organizational and team level. All cases provided evidence of double-loop learning and used organizational memory strategies to ensure knowledge was retained within the organization. A patient safety culture was linked to the promotion of open communication, fostering learning from adverse events.
This study describes three cases of systems-oriented M&MCs that reflected elements of organizational learning theory. The M&MC can therefore provide a context for organizational learning, allowing optimal learning from adverse events.
发病率和死亡率会议（M&MC）的重点已转移，强调质量改进和系统层面的护理。然而，针对系统层面错误的质量改进措施在 M&MC 学习中面临挑战，学习发生在个人与会者层面，而不是组织层面。在这里，我们旨在描述 M&MC 中的组织学习如何通过特定的组织和团队文化得到优化。
采用前瞻性、多案例研究设计。使用目的性抽样，选择了北美的三个涵盖不同医疗/外科专业的案例。数据收集包括对 M&MC 的直接观察、对关键 M&MC 成员的半结构化访谈以及文献信息。
所有案例中的 M&MC 作用都整合了两个关键概念：在组织和团队层面上识别系统范围的趋势和从错误中学习。所有案例都提供了双重学习的证据，并使用组织记忆策略确保知识在组织内部保留。患者安全文化与促进开放沟通、从不良事件中学习有关。
本研究描述了三个反映组织学习理论要素的系统导向 M&MC 案例。因此，M&MC 可以为组织学习提供一个背景，从而能够从不良事件中进行最佳学习。
