| The morbidity and mortality conference (M&MC;) 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&MC; 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&MC; 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&MCs.; 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&MC; can therefore provide a context for organizational learning, allowing optimal learning from adverse events. |
