How to face our mistakes: Using the military’s after-action review to improve morbidity and mortality conferences

Nearly three decades ago, David Hilfiker, a family medicine physician in rural Minnesota, authored an essay in the New England Journal of Medicine titled “Facing our mistakes.” In the piece, he chronicles three major medical mistakes he made during his long career practicing medicine. Some of the mistakes are horrifying and others simply tragic, but he is brutally honest and forthcoming—displaying a frank self-reflection that is too frequently absent in the daily practice of medicine.

This lack of introspection is seldom more evident than in American medicine’s morbidity and mortality conferences (MMCs), where dozens of physicians routinely gather to scrutinize a case. A case where a mistake is made is reviewed exhaustively, and the physician who may have misjudged or miscalculated is often viewed as if they are on trial—forced to revisit a painful moment in their careers in front of their colleagues who then have the benefit of hindsight. As physicians, we are often forced to make countless high-consequence decisions—often with limited information—on a daily basis. Our morbidity and mortality conferences, however, suggest that we have failed as a profession to foster an atmosphere in which we feel comfortable confronting the mistakes we make the way Dr. Hilfiker does. I am concerned that this culture impairs honest review of the clinical errors we make.

There is a better way to scrutinize clinical complications and medical errors in a way that fosters a culture rooted in improving systems and avoids leveraging unhelpful critiques and assigning blame. In the 1980s, the United States Army developed a technique called the after-action review (AAR), which members of the military use to this day after major training events to identify strengths and weaknesses and incorporate lessons learned into the next cycle of action. Not only has this tool been used successfully by the military, but it has also been routinely used as a business management tool by scores of Fortune 500 companies. Even the U.K.’s National Health Service (NHS) uses this tool as a way to enhance patient safety and improve the quality of clinical care they deliver. Particularly during times of great stress on health care systems, such as during the COVID-19 pandemic, this tool has helped to promote belonging and cohesion.

The questions comprised in an AAR are the following:

  • What was supposed to happen
  • What actually happened
  • What went well and why
  • What can be improved
  • What do we do next

As is the case in military operations, the delivery of clinical care is a complex endeavor, often occurring under unique circumstances that do not lend themselves to decisions that conform to prevailing guidelines. As a former army platoon leader, I used this methodology to cultivate shared understanding among my unit in dynamic and complex environments, enhance investment in the mission, and gain access to perspectives that I may not have considered from my vantage point. The elegance of this format in its capacity to facilitate an agreed understanding of the multidimensional system lapses that led to a particular undesirable outcome. The questions of an AAR inherently encourage groups to view a clinical event as a complex interplay of stakeholders, imperfect processes, and personalities as opposed to the consequence of one specific cause. In this way, AARs can help to broaden the investigation of a clinical error and create a more comprehensive understanding of the contributing factors.

We are entering a new era of medicine replete with dizzying new advances. Groundbreaking new therapies and technologies that can dramatically improve outcomes for our patients in the future are on the horizon. Yet, even as the landscape of medicine has changed dramatically over the last few decades, the format of our MMCs has not materially changed since its inception in the 20th century and fails to align with the complexity of modern medical practice. Unless we as a profession foster an environment in which clinicians feel comfortable facing often difficult medical mistakes and complications, we will fail to create a health care system that can safely and effectively harness the innovations on the horizon. By using the AAR methodology in MMCs, we can humanize the MMC and create a space for introspection and reflection that not only unearths the systemwide lapses that often lead to an adverse event but also marshals the energy of a deeply invested group of clinicians to enact durable solutions.

Neel Vahil is an internal medicine resident.

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