Von der Fallanalyse zu Handlungssicherheit: Evaluation der Morbiditäts- und Mortalitätskonferenzen an einem Universitätsklinikum mittels Mixed-Methods-Ansatz

Abstract

Background

Morbidity and mortality conferences (M&MCs) are structured interprofessional meetings to review specific treatment courses and deaths, aiming to learn from errors to improve patient care and safety. They integrate medical education, quality improvement, and risk management. With the rising importance of safety culture in German healthcare, the relevance of standardized M&MCs is also growing. Other examples of safety culture include an open error culture and critical incident reporting systems. This study analyzed facilitating and inhibiting factors of structured M&MCs, their impact on the derivation of improvement measures, and their influence on participants’ professional activities and confidence to act.

Methods

A mixed-methods study involving participant observation and quantitative surveys of all M&MC participants was conducted at Dresden University Hospital. Data from participant observation was analyzed using Grounded Theory approach; correlation analyses supplemented the perceived effects of derived measures.

Results

During the study period (February 2019 to December 2020), 32 M&MCs were visited in 16 departments of Dresden University Hospital (response rate 69.3 %; 400/577 questionnaires). Structured M&MCs promoted systematic case analysis and consistent presentation quality of treatment courses. Derived improvement measures correlated with better understanding of internal departmental processes, increased clarity, and confidence to act.

Conclusion

The study highlights the importance of moderated interprofessional and multiprofessional M&MCs. It suggests that M&MCs can promote learning processes and participants’ confidence to act in patient care, thereby improving the quality of medical care.