Medical errors are the third leading cause of mortality in the U.S., resulting in as many as 98,000 deaths annually.^1,2 Yet open discussions and analyses of the causes of errors occur infrequently.^3,4 Clinicians may avoid these discussions because they fear being perceived as less than competent or they have concerns about disciplinary action and litigation.^5,6 However, unaddressed errors can cause clinicians to internalize feelings of anger, shame, and guilt, making them more likely to suffer from burnout.^6–9 Collaborating to identify and fix the root causes of errors improves quality of care and prevents future errors.⁹ It also provides positive support and useful learning for all team members, particularly those closely involved in the error.⁶

Most errors are the result of bad systems, not bad people. Focusing on assigning blame to individuals does not prevent others in the organization from making the same error in the future. On the other hand, focusing on systems and processes makes errors less likely to begin with, resulting in more meaningful long-term changes.¹⁰

Morbidity and mortality (M&M) conferences have traditionally been the means of addressing medical errors,¹¹ but they have too often focused on individuals rather than systems. In 2019, our department launched a quarterly M&M conference series designed to provide a supportive and nonjudgmental forum for in-depth, structured root cause analysis. The ultimate goal is to identify actionable steps focused on quality improvement and patient safety.^12,13 With almost 300 physicians, 75 residents, and more than 250 advance practice providers spread across 62 sites and four residency programs in three states, we strive to highlight issues and solutions that are applicable to diverse practice settings. As a bonus, the conference series helps our family physicians meet maintenance of certification quality improvement requirements from the American Board of Family Medicine as well as requirements for root cause analysis training from the Accreditation Council for Graduate Medical Education and the Joint Commission.

This article explains our process, provides two case examples, and shares our lessons learned.