The surgery morbidity and mortality conference

The history of the surgical morbidity and mortality conference is closely linked to the history of the founding of the American College of Surgeons. Individual persistence in the belief that by looking for individual complications we can improve outcomes for large populations has been the guiding principle of that time-honored tradition of surgical training. However, a more contemporary concern, perhaps linked to societal and generational changes, is that individual responsibility for complications is punitive; the fear or shame results in avoidance of reporting of complications, which in turn fails to bring about the changes needed to prevent further complications. Hence contemporary surgical quality improvement techniques are more focused on process improvement and system-wide steps to prevent an error from every occurring. This chapter explores the history of this transition with examples, case reports, and a review of the key literature and people leading this reform.