On The Train (Morbidity and Mortality Conference), Sept 24, 2007

I am reading Atul Gawande’s Complications and just stop at the chapter where he described a ritual or culture of sharing mistakes between surgeons at hospitals. Surgeons in any hospitals are working under constant risk of making mistakes and some of them were fatal. According to a Harvard Survey on average surgeons would make one major mistake in their career. They culturally do not talk about these mistakes while on the job but recognized the value of learning from them. What they do is that they will weekly convene in a hospital conference room, have all the mistakes presented and discuss about them. The objective of this is not pointing fingers but about accountability and learning from the mistakes. The process is that each case would be studied and compiled by the resident surgeon and presented to all and they talk about each one of them. In KM speak it is not really just an AAR but more than that. They called this session as Morbidity and Mortality Conference, which is M&M for short. Apart from learning they are using this M&M as a measure to create fear among the surgeons, fear that mistakes are real, culturally to instill balance within the community. This fear factor and accountability would prevent the surgeons being too over confident and damn right cocky.

To quote Gawande,

‘In it’s way the M & M is an impressively sophisticated human institution. Unlike the court or the media, it recognizes that human error is generally not something that can be deterred by punishment. The M &M sees avoiding errors as largely a matter of will - of staying sufficiently informed and alert to anticipate the myriad ways that things can go wrong and then trying to head off each potential problem before it happens. It isn’t damnable that an error occurs, but there is some shame to it. In fact, the M&M’s ethos can seem paradoxical. On the one hand, it reinforces the very American idea that error is intolerable. On the other hand, the very existence of the M&M, its place of the weekly schedule, amounts to an acknowledgement that mistakes are an inevitable part of medicine.’