Morbidity and Mortality Conference in Ophthalmology: Pilot Study on Maximizing Quality while Optimizing Education

Purpose/Background: Discussion of medical and surgical adverse events between peers and learners allows for all members of the learning community to benefit from lessons learned while assessing and resolving that situation. Little is known about the ways academic ophthalmology departments discuss adverse events, or how those discussions impact attending and resident education. This pilot study surveys US academic ophthalmology residency programs using a mixed methods analysis to determine the current frequency, structure, purpose, and outcomes of morbidity and mortality or other quality improvement conferences. Design/Methods: An 25-item electronic questionnaire was e-mailed to 121 program directors with a request to each PD to forward the same 25-item questionnaire to their respective residents. The response period was between May 2023 and July 2023, with two reminders. Questionnaire items were grouped into the following themes: demographics; timing, frequency, and structure; purpose and goals; perceived outcome; and obstacles/areas for improvement. Results: Responses were received from 30/121 (25%) of program directors and 26/1989 (1%) residents. The majority or 31/56 (56%) of respondents’ programs held M&M conferences quarterly, while the frequency range was weekly to quarterly. Residents involved in the patient’s care often were the ones to present (51%) cases which were usually determined by a provider-generated list (53%). Most respondents reported the lack of an anonymous case submission method (75%) and only 31% of participants stated that they had a formalized process for following up on systems issues identified in M&M. The primary obstacle to effective M&Ms was reported to be the fear of judgement/embarrassment or repercussions. Conclusion: There is significant variation in the way complications are discussed in ophthalmology departments across the country. This study demonstrates a near universal need for increased frequency and duration of M&Ms, a formal complication/mistake reporting system, and a formal follow-up on systems issues identified during M&M. These best practices can benefit the culture around discussing complications and increase adoption of M&M conferences in ophthalmology to facilitate better patient safety and outcomes.