Utilizing the Fish-Bone Model to Identify Systems Errors During Pediatric Morbidity and Mortality Conference - Second Annual REACH Medical Education Day

Oct 29, 2026

The presentation describes how to use a Fish-Bone (Ishikawa) model to improve Pediatric Morbidity and Mortality (M&M) conference discussions. It addresses limitations of traditional M&M approaches, including blame-focused perceptions, overemphasis on individual errors, and lack of standardized case review. The session outlines the rationale for creating a non-punitive environment, highlighting system strengths and weaknesses, and supporting change. It also summarizes the quarterly format, audience use of the model, literature integration, and outcomes assessment through standard and M&M-specific evaluation forms.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages28

Reading Time1 h 11 min

AccessFree to download

Background

Morbidity and Mortality (M&M) conference purpose

Risks of traditional M&M approaches

Gaps in current case discussions

Fish-Bone Model

Rationale for system-focused improvement

M&M Conference Format

Quarterly implementation and case dissection

Post-dissection learning emphasis and literature use

Outcomes Assessments

Utilizing the Fish-Bone Model to Identify Systems Errors During Pediatric Morbidity and Mortality Conference INGA AIKMAN, MD, MPH PEDIATRIC CHIEF RESIDENT EAST CAROLINA UNIVERSITY Second Annual REACH Medical Education Day April 20, 2016 Background Ernest Amory Codman “End Result Card” Background 􀁘 Morbidity and Mortality (M&M) conference = venue to discuss medical errors and/ or adverse outcomes. 􀁘 Heterogeneous focus 1 : 􀁘 Unexpected morbidity and mortality 􀁘 Suspected medical error 􀁘 Teaching value 􀁘 The risks of traditional M&M2 : 􀁘 Perception of “blame” 􀁘 Perception of emphasizing individual error Background 􀁘 Gaps: 􀁘 Lack of standardized case discussion process 􀁘 Emphasis on unexpected adverse outcomes 􀁘 Emphasis on individual rather than potential system errors Fish-Bone Model Deis, JN, [et. al](et. al). (2008)“Transforming the Morbidity and Mortality Conference into an Instrument for Systemwide Improvement.” Advances in Patient Safety: New Directions and Alternative Approaches, 2 (08-0034-2) . Rationale |
| Realign and Focus Discussion | | --- | --- | | | | |
| Non-Punitive Environment | | --- | --- | | | | |
| Recognize System Strengths & Shortcomings | | --- | --- | | | | |
| Engender Change | | --- | --- | | | | M&M Conference Format 􀁘 Pediatric Chief Residents conduct quarterly M&M Conferences per academic year. 􀁘 The Fish-Bone Model implemented in 2015-2016. 􀁘 Prompt audience to dissect case via Fish-Bone Model. 􀁘 Identify components that contributed to the adverse outcome M&M Conference Format Continued 􀁘 After dissection of a case via the Fish-Bone Model, 1-2 components were emphasized for learning 􀁘 Literature presented to: 􀁘 Address medical and/ or policy knowledge gaps 􀁘 Explore how systems-based errors were corrected at other institutions Outcomes Assessments 􀁘 Standard evaluations were reviewed 􀁘 M&M Specific Evaluation form was created

FAQs

What problem does the presentation target in traditional Pediatric M&M conferences?

It targets perceptions of “blame” and the tendency to emphasize individual error rather than potential system errors, along with gaps such as inconsistent case discussion processes.

Why is a non-punitive environment emphasized?

A non-punitive environment supports open discussion and helps learners focus on recognizing system strengths and shortcomings instead of focusing on personal fault.

How is the Fish-Bone Model used during the M&M conference?

Pediatric chief residents prompt the audience to dissect a case using the Fish-Bone Model, then identify components contributing to the adverse outcome and emphasize 1–2 learning components after dissection.

Oct 29, 2026

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