Cedars-sinai surgery dept. implements innovative surgical training tool to reduce medical errors

LOS ANGELES, CA Mention Morbidity and Mortality Conference to most surgeons and watch flickers of painful memories play across their features. Many surgeons view these weekly hospital meetings where ones surgical errors are dissected before peers and superiors as humiliating ordeals where participants may spend more time defending their actions than learning from their mistakes. However, Cedars-Sinais Department of Surgery has transformed its weekly Morbidity and Mortality Conferences into an innovative educational study curriculum the M & M Matrix. This progressive approach for reviewing surgical errors provides a forum where complications are discussed, analyzed, summarized into teaching points, and disseminated via e-mail to residents and participating attending staff, who are subsequently tested on the material.

According to Cedars-Sinais Associate Director of Surgical Education Leo A. Gordon, MD, FACS, Cedars-Sinais M & M Matrix is a significant departure from the old conferences, which were characterized by heated oral discourse. In hospitals across the country, Morbidity and Mortality Conferences often result in tempers flaring and fingers pointing and the lessons are often left at the door, he said. In Cedars-Sinais conferences, we take a systematic look at three different surgical complications, summarize the points, set them in print, and distribute them to residents and participating attending staff as study guides on which they will be tested.

Dr. Gordon offered a hypothetical example of a 19-year-old male who develops a pulmonary embolism after undergoing surgery for multiple gunshot wounds to his pelvis. The M & M Matrix on this case would be called Pulmonary Embolism Following Surgical Procedures for Trauma, said Dr. Gordon. At the conference, the moderator would lead a methodical discussion on how and why this complication occurred. The subsequent study matrix would include a summary of the discussion along with curr

Contact: Beverly Antel
Cedars-Sinai Medical Center

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