Training to Reduce Surgical Errors

An innovative study curriculum is replacing the traditional weekly morbidity and mortality conference at Cedars-Sinai Medical Center (Los Angeles, CA, USA) in an effort to reduce medical errors.

Where once Cedars-Sinai surgeons met at a weekly session to discuss their errors, they now meet at a forum called the M & M Matrix. Here, three different surgical complications are discussed, analyzed, summarized into teaching points, and disseminated via e-mail to all residents and participating staff, who are subsequently tested on the material. This progressive approach, say the instigators, is more effective than sessions where surgical errors are dissected before peers and superiors, and participants spend more time defending their actions than learning from their mistakes.

According to Leo A. Gordon, associate director of surgical education at Cedars-Sinai, the complication-focused curriculum is a much more effective way to teach than the older model. "The M & M Matrix is an evolving concept in resident education, in which the first exposure to a surgical procedure is a complication, rather than a normal recovery,” he said. "This ‘tracing backward' from a surgical complication to normal physiology and surgical recovery makes a profound impression on young surgeons. It has been shown that surgeons who are exposed to errors early in their careers are less likely to make them later.”




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