Learning from errors: Implementation of a resident-oriented radiology morbidity and mortality conference as an educational tool

Abstract

Purpose: Our diagnostic radiology (DR) program lacked a formalized, structured process for residents to learn from errors. Prior DR residency Accreditation Council for Graduate Medical Education (ACGME) survey results additionally demonstrated opportunity for improvement in resident evaluation, resources, and patient safety/teamwork. Our project's purpose was to implement and evaluate a new resident-oriented radiology morbidity and mortality (M&M) conference to enhance resident education.

Methods: All DR residents (n = 48) were surveyed regarding a new didactic M&M consisting of quarterly resident-led and faculty-moderated M&Ms. Cases for potential review were collected and stored in a REDCap database via an anonymous survey, from which resident-selected faculty curators would select 4-6 for presentation. Residents presented these cases and the group discussed applicable improvements. An anonymous survey of residents followed each conference. Relevant questions from ACGME survey data were extracted from the two years preceding the didactic M&M and the pilot year.

Results: Before implementation, 86% of responding residents (n = 29; 60% of resident complement) supported the program, 90% expressed willingness to share their own mistakes, and 79% preferred faculty involvement. Respondents favored careful selection of faculty to promote education. At one year, 100% of respondents (n = 17; 35% of resident complement) approved of adding the didactic M&M and endorsed program continuance. All respondents expressed a willingness to share their own mistakes. There was also coincident improvement in ACGME survey data in the domains of evaluation, resources, and patient safety/teamwork.

Conclusion: We designed and implemented a resident-oriented M&M conference that resulted in increased resident confidence and impacted ACGME survey results in evaluation, resources, and patient safety/teamwork.

Precis: Implementation of a structured, resident-oriented radiology M&M conference can increase resident confidence and impact ACGME survey results in the domains of evaluation, resources, and patient safety/teamwork.

Keywords: ACGME survey; Morbidity and mortality conference; Patient safety; Quality improvement; Resident feedback.