M&M Conference


Case Selection

Cases will be selected by a designated committee from the entire practice population at all sites. Senior residents will be notified at least 2 weeks in advance if they are selected to present a case. Selected cases (inpatient or outpatient) will involve:

  • a poor or unintended outcome which might have been due to or worsened by error or system problems, or
  • "near-misses," where there was an error or misstep in care delivery that could have led to a poor patient outcome, or
    an interesting and unique case that may provide new learning and inquiry


Conference Preparation


Resident Preparation

For each case selected to be presented, the senior resident will work with the resident/fellow/faculty member involved as well as an assigned faculty moderator to develop the case and prepare for presentation. The M&M Template and Case Preparation Guide should be used. Slides/presentations should be sent to the attending of record and the assigned faculty moderator at least 1 week ahead of time for review. Residents should practice their presentation verbally and time it. Uninterrupted presentations should take 5 minutes or less. Although the complication or near miss is the central focus of the oral presentation, the presenting resident should have familiarity with the entire case, which will likely require reading, preparation, and discussion with the attending of record.

Case Moderator

A faculty member will be assigned to each case as a faculty moderator. Moderators will be selected based on their ability to facilitate a discussion about the case (surgical expertise, systems experience, etc). The moderator should work with the senior resident to review and refine their presentation prior to conference. The moderator will introduce the resident’s presentation and will help facilitate the discussion.

Conference Format 

  • Faculty moderator introduction
  • Resident case presentation (5 minutes) – overview of the case, timeline of events, description of how patient care issue(s) caused potential or actual harm, present any good quality evidence-based literature that is applicable, identify the nature of the patient care issue, identify the take-home points, recommend any systems changes that should be considered to prevent this issue from occurring in the future
  • Faculty moderator facilitates discussion of the case and take-home points (10-15 minutes)

Conference Follow-up

After the conference, the presenting resident is responsible for reporting any proposed systems changes via the Online M&M Follow-up Report. The M&M committee will review these at their next meeting and ensure there is a process in place for implementing these changes and following up to ensure that implementation has occurred.