AHRQ unveils web-based medical journal: focus on medical errors in blame-free environment - Agency for Healthcare Research and Quality

AHRQ unveils web-based medical journal: focus on medical errors in blame-free environment - Agency for Healthcare Research and QualityThe Agency for Healthcare Research and Quality (AHRQ) has launched a monthly peer-reviewed, web-based medical journal that showcases patient safety lessons drawn from actual cases of medical errors. Called AHRQ WebM&M (Morbidity and Mortality Rounds on the web), the web-based journal ( was developed to educate health care providers about medical errors in a blame-free environment.

In hospitals across the country, clinicians routinely hold morbidity and mortality (M&M) conferences to discuss specific cases that raise issues regarding medical errors and quality improvement. Until now, there has been no comparable national or international forum to discuss and learn from medical errors. AHRQ saw the opportunity to use the web to host an ongoing national M&M conference aimed at improving patient safety by sharing information from anonymous cases.

"The AHRQ WebM&M web site offers the medical community a unique opportunity to learn about patient safety from the experiences of their colleagues across the country and around the world," says AHRQ director Carolyn M. Clancy, MD. "The anonymity safeguards will enable physicians to share their experiences without fear of reprisal. Their involvement will contribute to the education of other providers about how to prevent medical errors and improve patient safety."

Every month, five selected cases of medical errors and patient safety problems--one each in medicine, surgery/anesthesiology, obstetrics-gynecology pediatrics, and other fields, including psychiatry, emergency medicine, and radiology--will be posted along with commentaries from distinguished experts and a forum for readers' comments. Each month, one case will be expanded into an interactive learning module ("Spotlight Case") featuring readers' polls, quizzes, and other multimedia elements and offering continuing medical education credits. Cases are limited to near misses or those that involve no permanent harm.

The web site was developed for AHRQ under a contract to an editorial team at the University of California, San Francisco. The editorial team is led by Robert M. Wachter, MD, associate chairman of UCSF's Department of Medicine and chief of the medical service at UCSF Medical Center. The editorial board and advisory panels include many of the nation's experts in patient safety.

Lucian Leape, MD, a leading patient safety researcher and a member of the AHRQ WebM&M advisory panel, praises the new journal. "To make real progress in patient safety, we have to engage physicians and break down the shame and silence surrounding errors. By presenting real-life cases of medical errors along with dynamic, systems-oriented expert commentaries, AHRQ WebM&M is an ideal way for physicians to learn more about and ultimately improve patient safety."

In its inaugural issue, the web-based journal features cases on a mix-up involving two patients with the same last name in the same hospital room; a mistaken drug administration causing a patient to stop breathing unexpectedly; a procedural mishap requiring emergency vascular surgery; an infusion pump flying into a magnetic resonance imaging machine, narrowly missing a child; and a misdiagnosis of delusions in a man later found to have metastatic brain and spine cancer.