Mortality and Morbidity (M&M) or case review meetings are one of the most powerful tools for learning and improving patient safety in Emergency Medicine. When run well, they help identify system weaknesses, support a culture of openness, and drive tangible changes in clinical practice. When run poorly, they risk reinforcing blame, generating little meaningful action, and disengaging staff.

The Emergency Department (ED) presents a unique environment for M&M. High patient turnover, clinical complexity, and time pressures mean that adverse outcomes are often multifactorial and involve several teams. Running effective M&M in the ED therefore requires deliberate structure, psychological safety, and strong links to governance and quality improvement processes.

This article draws on evidence from the BMJ Quality & Safety article “From Error to Improvement: Learning from Morbidity and Mortality Conferences” (Orlander et al., 2002), Royal College of Surgeons guidance, Imperial College’s patient safety education resources, and an NHS trust mortality policy to outline how ED teams can run M&M reviews that genuinely improve care.

1. Purpose: From Individual Error to System Learning

The primary aim of M&M is to improve systems of care rather than apportion blame. Adverse events rarely result from a single mistake. More commonly, they reflect a chain of system vulnerabilities, communication failures, environmental constraints, or cognitive errors occurring within a pressured context.

Well-conducted M&M meetings identify these contributing factors and use them to generate targeted improvement actions. They create a space in which clinicians and other professionals can learn together in a psychologically safe environment.

2. Case Selection: Focusing on High-Yield Learning

Not every death or complication requires full presentation at M&M. Case selection should prioritise those with the greatest learning potential, such as:

• Unexpected deaths or adverse outcomes

• Serious incidents or near misses

• Events illustrating recurrent system problems

• Cases involving interdepartmental or interdisciplinary issues

• Situations where care diverged from guidelines or usual practice

A small panel or governance lead can review incident reports and outcomes to identify suitable cases. Selecting cases purposefully helps maintain the educational focus and ensures that meetings are relevant.

3. Preparation: Building a Clear Picture

Thorough preparation is essential. The presenter or case lead should gather relevant information in advance, including:

• A clear timeline of events and key decision points

• Clinical findings, investigations, and management decisions

• Staffing levels, shift context, and supervision arrangements

• Relevant guidelines or protocols in place at the time

• Documentation and handover records

• System or environmental factors that may have influenced care

Distributing anonymised summaries beforehand allows participants to review the case and come prepared for structured discussion.

4. Structure and Analytical Frameworks

Unstructured discussions risk becoming anecdotal or personal. Using established analytical tools improves rigour and consistency. Examples include:

• Root Cause Analysis for systematic breakdown of contributory factors

• Five Whys technique to explore underlying causes

• Fishbone (Ishikawa) diagrams to map categories such as environment, equipment, human factors, and process

• Human factors analysis to explore cognitive load, communication, and decision-making

The moderator should ensure that discussion remains focused on systems and processes rather than individual blame.

5. Psychological Safety and Skilled Moderation

Psychological safety is essential for honest reflection. M&M discussions should begin with clear ground rules that emphasise respect, confidentiality, and the goal of learning rather than punishment. A skilled moderator, usually a senior clinician, is responsible for maintaining this tone, redirecting unhelpful discussion, and ensuring balanced contributions from all professional groups.

6. Multidisciplinary Participation

Adverse events in the ED typically involve multiple disciplines. Meaningful improvement requires input from all those involved in the patient pathway. This includes doctors, nurses, radiographers, pharmacists, laboratory staff, critical care teams, managers, and others as relevant. Multidisciplinary participation broadens perspectives and supports shared ownership of solutions.

7. Turning Insight into Action

M&M meetings must end with a clear, realistic, and measurable action plan. For each identified issue, there should be:

• A defined action or intervention

• A named person or team responsible

• A timeline for completion

• A plan for how success will be measured

Vague conclusions such as “we should be more careful” achieve little. Actions may include guideline revisions, staff training, workflow redesign, or escalation to governance committees.

8. Feedback Loops and Follow-Up

The most common weakness of M&M processes is lack of follow-through. Actions should be logged in a governance tracker and reviewed at subsequent meetings. Closing the loop by revisiting previous cases demonstrates commitment to change and builds trust in the process. Regular summaries of learning and progress should be shared with the wider department.

9. Institutional Frameworks and Governance

National and institutional frameworks can support ED M&M. The Royal College of Surgeons’ guidance on M&M meetings emphasises structure, confidentiality, and integration into clinical governance, ensuring that lessons inform audit, training, and quality improvement (Royal College of Surgeons of England, 2014).

Imperial College London’s patient safety collaboration provides structured training materials for running M&M meetings, including facilitator guides and templates that can be adapted for ED practice (Imperial College London, n.d.).

Trust-level mortality review policies, such as that from Milton Keynes University Hospital NHS Foundation Trust, describe clear processes for mortality reviews, categorisation of deaths, and escalation, ensuring consistency and accountability (Milton Keynes University Hospital NHS Foundation Trust, 2018).

10. Overcoming Common Barriers

Conclusion

M&M or case review meetings are an essential mechanism for learning and improvement in the Emergency Department. They are most effective when they are structured, multidisciplinary, psychologically safe, and tightly linked to governance and quality improvement processes.

By selecting the right cases, preparing thoroughly, using structured analysis, focusing on systems, defining clear actions, and closing feedback loops, ED teams can turn individual adverse events into meaningful service improvement. This aligns with national guidance, institutional governance frameworks, and international best practice in patient safety.

References

Imperial College London. (n.d.). Morbidity and Mortality Conference Training Materials. Patient Safety Research Collaboration. Retrieved October 8, 2025, from https://www.imperial.ac.uk/patient-safety-research-collaboration/education/training-materials-for-use-in-research-and-clinical-practice/morbidity-and-mortality-conference/ 

Milton Keynes University Hospital NHS Foundation Trust. (2018). Mortality Review and Learning from Deaths Policy. Milton Keynes: MKUH NHS Foundation Trust.

Orlander, J. D., Barber, T. W., & Fincke, B. G. (2002). The morbidity and mortality conference: The delicate nature of learning from error. BMJ Quality & Safety, 21(7), 576–582. https://doi.org/10.1136/qhc.11.4.282 

Royal College of Surgeons of England. (2014). Good Surgical Practice: Morbidity and Mortality Meetings. London: RCS.