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Morbidity and Mortality/Quality Assurance Conference

This conference is held once a month, with alternating formats.  In format #1, clinical cases from the endoscopic procedural suite are submitted by attendings, fellows, and nurses to the Director of Endoscopy for review.  In this format, the Morbidity and Mortality Conference is a multi-disciplinary quality assurance conference.  Faculty, fellows, nurses, and administrators are in attendance as cases are reviewed and commented upon.  Particular attention is given to procedural complications and their management.  In addition, practice issues and systems issues are identified and discussed at the multi-disciplinary level.

In format#2, the physicians identify cases to discuss amongst themselves.  Such cases incorporate elements of sharing experiences, and identifying clinical situations and management decisions which led to adverse outcomes, without a specific focus on procedural complications.  In particular, fellows will be assigned to address specific elements of a case, such as identifying the evidence-base for a particular clinical practice, cost-effectiveness of particular clinical strategies, and root-cause analysis of systems failures which lead to adverse outcomes.

Morbidity and Mortality/Quality Assurance Conference Competencies

Patient Care

Principal Educational Goals

  • To review the competent practice of endoscopic procedures, including indications, contraindications, and management of procedural complications.
  • To consider and discuss patient care management alternatives that may have avoided or reduced the impact of an adverse outcome.

Medical Knowledge

Principal Educational Goals

  • In particular to review sedation pharmacology, drug interactions, principles of conscious sedation, patient monitoring, and the cardiopulmonary medicine involved in patient resuscitation.

Practice-Based Learning and Improvement

Principal Educational Goals

  • Identify knowledge gaps and stimulate further independent study in areas of deficient personal knowledge.
  • Identify systems errors and ways to correct them.

Interpersonal Skills and Communication

Principal Educational Goals

  • To learn to communicate in a respectful and appropriate fashion in a multi-disciplinary large group QA setting.
  • To learn to recognize and manage the interpersonal stresses accentuated in the QA forum.


Principal Educational Goals

  • To recognize how respect, compassion, and integrity is of particular importance in the management of adverse outcomes.
  • To demonstrate sensitivity, respect, and compassion to colleagues subject to review of adverse outcomes.
  • To learn to identify deficiencies in peer performance.
  • To learn the particular principles of QA confidentiality and discoverability issues.

Systems-Based Practice

Principal Educational Goals

  • To learn about management of adverse outcomes through mobilizing various urgent and emergent multi-disciplinary response systems.
  • To learn about those resources and mechanisms for responsible reporting and QA management of adverse outcomes, and systems-based practice review for improved patient outcome goals.