Organizational Learning in the Morbidity and Mortality Rounds

The morbidity and mortality conference (M) is one of many organizational strategies used to address patient safety and quality of care. Organizational learning theory would suggest that learning from error in the M would be optimized by particular organizational and team cultures. The aim of this study was to describe how adverse events are reviewed in the M using an organizational learning framework. I used a qualitative, prospective, multiple Case study design for this study. I selected three Cases, which were running well-structured M All three Cases displayed double-loop learning and utilized organizational memory strategies to ensure that new knowledge stemming from their reviews was being retained within the organization. The presence of a patient safety culture was linked to the promotion of open communication, thereby fostering learning from adverse events. The M can therefore provide a context for organizational learning, allowing optimal learning from adverse events.M.Sc