AHRQ Web M&M
Online Journal and Forum on Patient Safety and Health Care Quality
This peer-reviewed online journal uses a case-based approach to educate providers and trainees about patient safety. Funded by the Agency for Health Care Research and Quality (AHRQ), the site is a collaborative effort with the University of California, San Francisco School of Medicine.
Morbidity and Mortality Rounds on the Web
AHRQ WebM&M is the new peer-reviewed, Web-based journal on patient safety. Funded by the Agency for Healthcare Research and Quality (AHRQ), the site is edited by Drs. Robert Wachter and Kaveh Shojania, along with a team at the University of California, San Francisco (UCSF), with technical support from DoctorQuality. The site is free and has no advertisements.
AHRQ WebM&M is designed to educate providers and trainees about patient safety and medical errors by using a case-based approach in an engaging, blame-free environment. This site features:
- Cases of medical errors and patient safety issues, with expert commentaries.
- A users' forum.
- Links to patient safety resources.
The 1999 report by the Institute of Medicine (IOM) To Err is Human: Building a Safer Health System concluded that 44,000 to 98,000 Americans die annually from medical errors and created tremendous interest in improving patient safety. Most of the errors cited in the IOM report were due to problems in the health care system rather than individual failures.
Every month in hospitals across the country, morbidity and mortality (M&M) conferences convene for discussion of specific cases that raise issues regarding medical errors and quality improvement. Although M&M conferences have been a staple at most American hospitals for decades, until now there has been no comparable national forum to discuss and learn from medical errors. AHRQ and the University of California, San Francisco saw the opportunity to use the Web to host a national Morbidity and Mortality conference aimed at improving patient safety through analysis of anonymous cases. This concept evolved into the AHRQ WebM&M site.
Every month, the site presents five interesting cases of medical errors and patient safety issues—one each in medicine, surgery/anesthesiology, obstetrics-gynecology, pediatrics, and other fields such as psychiatry, emergency medicine, family practice, nursing, etc.
These cases are submitted anonymously through the Web site. Writers of cases selected for posting will receive an honorarium. Cases will be compelling and provocative, while raising key issues about patient safety and systems improvement.
Examples of cases include:
- Patient mix-up. A man almost received medication intended for another patient with the same last name in the same room.
- Unexplained apnea under anesthesia. A boy undergoing knee surgery stopped breathing after inadvertently being given a paralytic medication instead of an antibiotic.
- Flying object hits MRI. An infusion pump being used for routine sedation in a child undergoing an magnetic resonance imaging (MRI) scan flew across the room and hit the MRI magnet, narrowly missing the child.
- Procedural complications: Learning curve? A woman required emergency vascular surgery due to a complication during routine laparoscopic tubal ligation.
- When "psychiatric" symptoms are medical. An elderly man with delusions and progressive neurological symptoms, initially attributed to psychosis, was found to have metastatic cancer.
One case each month is developed into a Spotlight Case—an interactive learning module that features an expanded commentary, readers' polls, quizzes, and other multimedia elements. For completion of this educational module, physicians can earn CME credit and trainees can receive certification in patient safety. An electronic slide presentation is also available to download for educational use.
Commentaries, Forum, and Resources
Each case is followed by a commentary, written by an expert in the field. Discussants in the first few months include:
- Paul Barach, M.D., M.P.H., Jackson Memorial Hospital, and Director Miami Center for Patient Safety, University of Miami.
- Michael Cohen, Pharm.D., Institute for Safe Medication Practices.
- John Gosbee, M.D., M.S., VA National Center for Patient Safety.
- Mary Hannah, M.D., University of Toronto.
- Lucian Leape, M.D., Harvard School of Public Health.
The commentaries marry an evidence-based approach with observations and analyses, in a lively style that takes advantage of the graphical capabilities of the Internet.
AHRQ WebM&M includes a users' forum, on which readers can post and react to comments about the cases. The site also provides links to other resources and interesting facts about patient safety, medical errors, and health care quality.
Editorial Board and Advisory Panel
The editorial team is guided by an Editorial Board and Advisory Panel, comprised of experts in the relevant patient safety and clinical disciplines. In addition to Drs. Cohen, Gosbee, and Leape, its members include David Bates, M.D., of Harvard Medical School; Marilyn Sue Bogner, Ph.D., of the Institute for the Study of Medical Error; Troyen Brennan, M.D., J.D., of Harvard Medical School; Mark Ebell, M.D., M.S., of Michigan State University; Peter Pronovost, M.D., Ph.D., of Johns Hopkins University; Eric Thomas, M.D., of the University of Texas at Houston; and Albert Wu, M.D., of Johns Hopkins University.
We encourage you to submit cases and to invite your colleagues to do so as well. To submit a case, or for further information about AHRQ WebM&M, including how to register and obtain CME credit, visit the site or contact us at firstname.lastname@example.org.
- Robert M. Wachter, M.D., Editor.
- Kaveh G. Shojania, M.D., Deputy Editor.
- Erin E. Hartman, M.S., Managing Editor.
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the UCSF School of Medicine and the U.S. Department of Health and Human Services, AHRQ. UCSF is accredited by the ACCME to provide continuing medical education for physicians.
UCSF designates this educational activity for a maximum of 12 category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.