Cite this post as:
Scott Weingart, MD FCCM. EMCrit 249 – You Can Either Learn or You Can Blame – Fixing the Morbidity and Mortality Conference with George Douros. EMCrit Blog. Published on June 13, 2019. Accessed on June 9th 2023. Available at [https://emcrit.org/emcrit/fixing-mm-conf/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: June 13, 2019
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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Fascinating discussion, thanks. Despite the lip service, we still have a long way to go creating a hospital culture in which people are not scared to discuss their decision making openly without fear of judgement. In the podcast, Scott brings up the point that someone’s decision resulting in a bad outcome is scrutinized, while the same decision or behavior in a different case that happens to result in a good outcome is given a free pass. Obviously, this is a result of cognitive bias, but how to combat it? One way would be to include in the discussion 10 situations… Read more »
Great podcast, Dr Douros “gets it”. The culture of blame is the antithesis of patient safety and process improvement since it takes the easy way out. Real improvements in patient care requires a culture of reporting, which in turn requires trust from everyone in the organization. To that end our multi-specialty practice in Colorado has partnered with our liability carrier to encourage reporting of unexpected outcomes. Our liability carrier gets more real time notification of potential high risk cases and we analyze the cases (a la Dr. Douros) under their peer review umbrella. This process allows us to avoid punishing… Read more »
This is a great discussion and topic. I just started reading the first recommended book by Sidney Dekker. Have you come across any recent criticisms of the new view of human error? This seems like a very contrasting view and just wanted to know if there is any evidence against this view. Thanks for the great podcast!
Very important topic. We have also struggled with ineffective M&M rounds a number of years ago; here is our journey on revamping the process, and incorporating patient safety and quality concepts to build an easy-to-follow framework for all medical groups to use:
https://emottawablog.com/2018/03/improving-morbidity-mortality-rounds-om3/
This OM3 has been implemented now at many centres across Canada and internationally with great feedback. Check it out!
Great podcast, and thank you for the additional resources. I note that the “Work-To-Rule Strike (malicious compliance)” link is not active. Having just punched the term into a search engine, I’m very keen to be guided towards a good resource to delve further into this topic (beyond W****edia). Cheers!