Buried in the history of every department of surgery is the venerable surgical morbidity and mortality conference. Surgeons know that this mechanism is probably the greatest patient safety tool ever created.

Surgeons also know, however, that this mechanism has been neglected over the years and has been hijacked at times, turning it into a "shame and blame" attending vs. resident game.

As the frenzy of concern over patient safety rises, it's important to give this essential conference a new look. At Cedars-Sinai Medical Center, that new look is called the M+M Matrix.

UNWRITTEN HISTORY
The traditional surgical morbidity and mortality conference has a lethal defect. Despite the experiences and opinions shared, there was never a verifiable way of memorializing great lessons in patient safety.

Most physicians remember that during these conferences, tempers flared, neck veins distended, voices rose. The general give and take was often spirited and enjoyable.

But what happened after the conference? How were these patient safety lessons recorded for the future? The answer is simple: They were not! There was no cycle of education to accompany the shouting and hand wringing. There may have been some fleeting discussions 24 to 48 hours after the conference, but by and large, the lessons disappeared into the ether of daily medical life.

It was as if a culture developed without a written language. Ironically, important lessons, learned over many years by experienced and well-meaning physicians, just evaporated. The system was illogical and ineffective.

MODERN-DAY TEACHINGS
The M+M Matrix concept corrects that lethal defect.

Rather than a "one-shot deal" existing in a vacuum, the Matrix is a weeklong educational effort culminating in a conference that focuses on the essential patient safety meaning of a complication.

The best analogy is that of an upper-level university seminar in patient safety. We all remember those seminars, usually held weekly by the professor. They were focused on a particular problem and were aimed at people who had a working knowledge of the basics of the field.

And just like that upper-level university seminar, the Matrix conference requires preparation, participation and yes, examination.

Here's how the Matrix program works: Complications are submitted to the Matrix moderator. The Matrix moderator is a physician who has as one of his or her primary responsibilities the organization and implementation of the Matrix program.

That individual selects two or three cases for discussion. There is a delicate balance in this choice among educational value, staff interest and frequency of the complication.

Once those cases are selected, an appropriate resident is designated to present each case. Working with the moderator, the resident outlines the case and highlights the specific error- and complication-reducing points. This discussion results in an evolving PowerPoint presentation.

The days of schlepping to the library, making notes on file cards and producing overhead transparencies are over. Residents with honed computer and Internet skills can easily put together presentations highlighting the complications.

The conference convenes and cases are presented.

The moderator tightly channels the discussion to those particular error- and complication-reducing points of value. At the end of the presentation, a list of "Matrix Points" is developed. These points represent the best effort of the conference to instill safety measures in all who attend.

The moderator then constructs a Matrix--an outline reflecting the discussions and the background material assembled for that discussion. This Matrix is distributed via e-mail. At the end of the year, these e-mails are collated and printed in a bound volume. When a new staff member arrives or when a resident prepares for board exams, these bound volumes represent a year's worth of patient safety efforts.

Part of the Matrix program is the administration of written examinations for the residents. The short-answer essay examinations are based on the previous quarter's discussions. These are graded and reviewed by the moderator in an ongoing patient safety effort.

Those who support the Matrix concept are convinced that exposing residents to patient safety measures early in their careers will make them safer physicians. For the staff, the Matrix represents an ongoing patient safety curriculum running parallel to their practices. Further, with the advent of videoconferencing, podcasts and remote transmissions, Matrix conferences may soon be available to any interested physician.

Although originating within the department of surgery, the Matrix concept is adaptable to most medical disciplines. As the demand for patient safety escalates, such a resource will be a vital part of every department and every physician's practice.

Leo Gordon, MD, is a general surgeon who currently serves as the associate director of surgical education at Cedars-Sinai Medical Center in Los Angeles. Dr. Gordon received his MD from Northwestern University and has been on the medical staff at Cedars since 1979. He is the originator, moderator and coordinator of the M+M Matrix, a patient safety educational curriculum for residents and physicians. For more information about the Matrix program, contact Dr. Gordon at Leo.Gordon@cshs.org.

CHARTS
The M+M Matrix is an organized approach to instilling patient safety lessons in residents and physicians. The chart below and the other two charts on the next pages outline the process.