Abstract
Background: Discussion of medical and surgical adverse events between peers and learners allows for all members of a learning community to benefit from lessons learned while assessing and resolving the events. The methods by which adverse events are discussed in academic ophthalmology departments and how those discussions impact attending and resident education have received little attention in the published literature.
Purpose: To report the results of our survey of U.S. academic ophthalmology residency programs using a mixed methods analysis to determine the current frequency, structure, purpose, and outcomes of morbidity and mortality (M&M) or other quality improvement conferences.
Methods: An 25-item electronic questionnaire was emailed to 121 program directors with a request to forward the same 25-item questionnaire to their residents. The response period was between May 2023 and July 2023. Two reminders were sent. Questionnaire items were grouped into the following themes: demographics; timing, frequency, and structure; purpose and goals; perceived outcome; and obstacles/areas for improvement. Several participants also attended a focus group to elicit more nuanced qualitative information.
Results: Responses were received from 30 program directors (25%) and 26 of 1,989 residents (1%). The majority of respondents’ programs (31/56 [56%]) held M&M conferences quarterly, with frequency ranging from weekly to quarterly. Residents involved in the patient’s care often were the ones to present cases (51%), 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 fear of judgment, 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.
Received Date
07/08/2024
Revised Date
20/06/2025
Accepted Date
09/07/2025
Recommended Citation
Mudalegundi, Shwetha; Melson, Andrew; Zhang, Alice Yang; and Tu, Daniel
()
"Morbidity and Mortality Conference in Ophthalmology: Pilot Study on Maximizing Quality while Optimizing Education,"
Journal of Academic Ophthalmology: Vol. 17:
Iss.
3, Article 11.
DOI: https://doi.org/10.62199/2475-4757.1322
Available at:
https://www.aupojournal.org/jao/vol17/iss3/11
