Morbidity And Mortality Review Within The Context Of A Just Culture — Dr Musa Mohd Nordin & Prof Emeritus Dr Azizi Omar

Contemporary health systems conduct Mortality and Morbidity (M&M) reviews as a structured, systematic process for peer review, learning, and Quality Improvement (QI) by examining cases that resulted in an unfavourable outcome, such as medical errors, patient harm or death.

The core tenet of modern patient safety is that the majority of errors are not due to individual incompetence but to flawed systems, processes, and designs.

An effective M&M meeting dissects the sequence of events to identify these system-level “gaps” – unclear protocols, equipment failures, communication breakdowns, staffing issues.

The primary question should be “What can we learn?” not “Who was at fault?” And the most valuable outcomes of M&M review are actionable Quality Improvement (QI) projects: changing a guideline, introducing a new checklist, redesigning a workflow.

The rich, candid, nuanced, and often uncertain discussions that characterise true root cause analysis can only be achieved within the context of a health institution that embraces a “Just Culture”.

A “Just Culture” is the bedrock of a learning health care system, which differentiates between human error, at-risk behaviour, and reckless conduct. It reframes the M&M conference:

• Encourages error disclosure in order to improve the health system.
• Balances accountability with a continuing learning process.
• Supports the emotional recovery of staff after an adverse event.

Instead, the “blame culture” which is pervasive in most public, private, and academic health institutions inhibits rigorous root cause analysis, replaced by sterile, defensive, and unhelpful exchanges which obscures system failures.

By focusing on identifiable individuals, the M&M discussion will naturally centre on the actions of the clinician (the nurse, the house officer, the surgeon) rather than the system failures (the hospital policy, the IT system, the resource constraints) that created the conditions for the error.

The true, systemic root causes remain unaddressed, lying in wait for the next patient.

Extensive research demonstrates that in a punitive environment, error reporting plummets. Clinicians will be reluctant to present cases for fear of direct disciplinary, reputational, or legal repercussions.

Historically, M&M reviews were closed door meetings involving only clinicians directly involved in the case due to the fear of legal ramifications and/or public exposure. This has failed to address the true, systemic root causes and has hindered broader organisational learning.

Best practice and effective M&M reviews are increasingly designed to be open to multi-disciplinary teams, including nurses, allied health professionals, pharmacists and hospital managers.

A wider and select M&M audience is crucial for:

• Fostering a just culture and safety, where it is safe to report and discuss errors without fear of retribution.
• Multidisciplinary feedback with diverse perspectives is essential for a thorough root cause analysis.
• Continuous learning and professional development is enhanced with the deliberations and insights.

Absolutely clear ground rules on confidentiality would ensure strict protection of patient privacy and staff dignity. These includes:

• De-identification of the cases.
• Legal protections that shield the records and proceedings of peer review activities like M&M meetings.

This paper is written with the utmost respect for the Malaysian Medical Council’s (MMC) duty to uphold medical standards and ethical practice.

The intent of the September 23, 2025 Position Paper to ensure transparency and accountability in Morbidity and Mortality (M&M) reviews is acknowledged.

However, its core tenets are fundamentally at odds with established principles of clinical governance, modern patient safety science, and the psychological safety required for effective learning.

We are concerned that its implementation will inadvertently harm, rather than enhance, patient safety, quality care, and professional development.

Dr Musa Mohd Nordin and Prof Emeritus Dr Azizi Omar are paediatricians.