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Book and Media Reviews
January 24/31, 2007


Author Affiliations

Book and Media Reviews Section Editor: Harriet S. Meyer, MD, Contributing Editor, JAMA.

JAMA. 2007;297(4):413-417. doi:10.1001/jama.297.4.416-a

Physicians will recognize “M & M” as a weekly morbidity and mortality conference held on surgical and other services in most US hospitals. At these conferences, problems that occurred on the service during the preceding week are presented and discussed. Corrective measures to prevent recurrence of these problems also are usually considered.

In Cut to the Chase, surgeon Leo Gordon, MD, states his view that “the traditional morbidity and mortality conference has failed its mission.” In the introduction, Gordon writes, “at its best the surgical morbidity and mortality conference is a patient safety conference. At worst it is a useless exercise in shame and blame. . . . ” He proposes that this conference be converted to a “moderated discussion of a reported complication or medical error.” At the conclusion of the conference, the moderator would formally record and distribute the “error and complication-reducing points of the presentation.” To change the culture of these conferences, the name would be changed to “matrix conference.” These conferences would “take the lessons of an error or complication and construct a curriculum of safety around them. These are the lessons that comprise this book.”