Online Journal and Forum on Patient Safety and Health Care Quality
This peer-reviewed online journal uses a case-based approach to educate providers and trainees about patient safety. Funded by the Agency for Health Care Research and Quality (AHRQ), the site is a collaborative effort with the University of California, San Francisco School of Medicine.
Select to download print version (PDF File, 402 KB; Plugin Software Help).
Morbidity and Mortality Rounds on the Web
AHRQ WebM&M (http://webmm.ahrq.gov) is the new
peer-reviewed, Web-based journal on patient
safety. Funded by the Agency for Healthcare
Research and Quality (AHRQ), the site is edited
by Drs. Robert Wachter and Kaveh Shojania,
along with a team at the University of
California, San Francisco (UCSF), with technical
support from DoctorQuality. The site is free and
has no advertisements.
AHRQ WebM&M is designed to educate
providers and trainees about patient safety and
medical errors by using a case-based approach
in an engaging, blame-free environment.
This site features:
- Cases of medical errors and patient
safety issues, with expert commentaries.
- A users' forum.
- Links to patient safety resources.
The 1999 report by the Institute of Medicine (IOM)
To Err is Human: Building a Safer Health System concluded that 44,000 to 98,000 Americans
die annually from medical errors and created
tremendous interest in improving patient safety.
Most of the errors cited in the IOM report were
due to problems in the health care system
rather than individual failures.
Every month in hospitals across the country,
morbidity and mortality (M&M) conferences
convene for discussion of specific cases that raise
issues regarding medical errors and quality
improvement. Although M&M conferences have
been a staple at most American hospitals for
decades, until now there has been no comparable
national forum to discuss and learn from
medical errors. AHRQ and the University of
California, San Francisco saw the opportunity to
use the Web to host a national Morbidity and
Mortality conference aimed at improving patient
safety through analysis of anonymous cases. This
concept evolved into the AHRQ WebM&M site.
Case Reports
Every month, the site presents five interesting
cases of medical errors and patient safety
issues—one each in medicine, surgery/anesthesiology,
obstetrics-gynecology, pediatrics, and
other fields such as psychiatry, emergency medicine,
family practice, nursing, etc.
These cases are submitted anonymously through the Web site.
Writers of cases selected for posting will receive
an honorarium. Cases will be compelling and
provocative, while raising key issues about
patient safety and systems improvement.
Examples of cases include:
- Patient mix-up. A man almost received medication
intended for another patient with the
same last name in the same room.
- Unexplained apnea under anesthesia. A boy
undergoing knee surgery stopped breathing
after inadvertently being given a paralytic
medication instead of an antibiotic.
- Flying object hits MRI. An infusion pump being
used for routine sedation in a child undergoing
an magnetic resonance imaging (MRI) scan flew across the room and hit the
MRI magnet, narrowly missing the child.
- Procedural complications: Learning curve?
A woman required emergency vascular
surgery due to a complication during
routine laparoscopic tubal ligation.
- When "psychiatric" symptoms are medical.
An elderly man with delusions and progressive
neurological symptoms, initially attributed
to psychosis, was found to have
metastatic cancer.
Spotlight Case
One case each month is developed into a
Spotlight Case—an interactive learning module
that features an expanded commentary, readers'
polls, quizzes, and other multimedia elements.
For completion of this educational module,
physicians can earn CME credit and trainees
can receive certification in patient safety. An
electronic slide presentation is also available to
download for educational use.
Commentaries, Forum, and Resources
Each case is followed by a commentary, written
by an expert in the field. Discussants in the first
few months include:
- Paul Barach, M.D., M.P.H., Jackson Memorial Hospital, and
Director Miami Center for Patient Safety, University of Miami.
- Michael Cohen, Pharm.D., Institute for Safe
Medication Practices.
- John Gosbee, M.D., M.S., VA National Center
for Patient Safety.
- Mary Hannah, M.D., University of Toronto.
- Lucian Leape, M.D., Harvard School of
Public Health.
The commentaries marry an evidence-based
approach with observations and analyses, in a
lively style that takes advantage of the graphical
capabilities of the Internet.
AHRQ WebM&M includes a users' forum, on
which readers can post and react to comments
about the cases. The site also provides
links to other resources and interesting facts
about patient safety, medical errors, and health
care quality.
Editorial Board and Advisory Panel
The editorial team is guided by an Editorial
Board and Advisory Panel, comprised of
experts in the relevant patient safety and
clinical disciplines. In addition to Drs. Cohen,
Gosbee, and Leape, its members include David
Bates, M.D., of Harvard Medical School; Marilyn
Sue Bogner, Ph.D., of the Institute for the Study
of Medical Error; Troyen Brennan, M.D., J.D., of
Harvard Medical School; Mark Ebell, M.D., M.S.,
of Michigan State University; Peter Pronovost,
M.D., Ph.D., of Johns Hopkins University; Eric
Thomas, M.D., of the University of Texas at
Houston; and Albert Wu, M.D., of Johns
Hopkins University.
Getting Involved
We encourage you to submit cases and to
invite your colleagues to do so as well. To
submit a case, or for further information
about AHRQ WebM&M, including how to register
and obtain CME credit, visit the site or
contact us at webmm@medicine.ucsf.edu.
- Robert M. Wachter, M.D., Editor.
- Kaveh G. Shojania, M.D., Deputy Editor.
- Erin E. Hartman, M.S., Managing Editor.
CME Credit
This activity has been planned and implemented in accordance
with the Essential Areas and policies of the Accreditation Council
for Continuing Medical Education (ACCME) through the joint
sponsorship of the UCSF School
of Medicine and the U.S. Department of Health and Human
Services, AHRQ. UCSF is
accredited by the ACCME to provide continuing medical education
for physicians.
UCSF designates this educational activity for a maximum of
12 category 1 credits toward the AMA Physician's Recognition
Award. Each physician should claim only those credits that
he/she actually spent in the activity.
AHRQ Publication No. 03-0014
Current as of March 2003
Internet Citation:
AHRQ Web M&M: Online Journal and Forum on Patient Safety and Health Care Quality. AHRQ Publication No. 03-0014, March 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/webmandm.htm
540 Gaither Road Rockville, MD 20850 