What is The Matrix Program?
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To Department Chiefs, Program Directors,
Educational Administrators and Risk Managers:
For a detailed description of the Matrix Program, please contact
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To understand these Matrix Lessons, the reader must be familiar with the traditional surgical morbidity and mortality conference. This conference is a weekly meeting held in many hospitals. At this meeting the errors and complications of the previous week are discussed. A resident (a postgraduate physician) presents the case to the audience. The floor is then open for comments.
A Matrix Lesson is an essential medical error and complication-reducing point, an experienced medical observation or a trenchant medical insight reduced to a concise lesson statement.
The goal of the Matrix Conference is to analyze error and complication and, in so doing, to plant a seed of patient safety consciousness in all of those who attend. The traditional morbidity and mortality conference has failed its mission. The error and complication-reducing lessons so vital to the safe practice of medicine are often lost in a mish-mash of prejudice, myth and medical anecdote. In many quarters of American medicine, this time-honored weekly assemblage has degenerated into a useless game of shame and blame.
The goal of the morbidity and mortality conference has always been to teach error and complication-reducing lessons. Unfortunately, the conference has come to resemble an aboriginal tribe that never invented a written language. The best minds of the hospital, whetted by spirited debate and passion, often delivered concrete and valuable lessons for physicians - lessons that would help them prevent errors and avoid complications. But no-one ever recorded those lessons for the future.
In an attempt to correct these deficiencies, some progressive departments of medicine have transformed the morbidity and mortality conference into a Matrix Conference. A Matrix Conference is a moderated discussion of a reported complication or medical error. This discussion seeks to define the essential error and complication-reducing points of the presentation. The moderator records them and then distributes them. These essential principles become Matrix Lessons.
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The mechanism for implementing the changes necessary to make this
conference effective is called the Matrix Program. |
Many Matrix Lessons are learned from the practice of medicine outside of the conference. They all intertwine along the highways and byways of the medical center - the patients' room, the hospital corridors, the operating rooms, the doctors' lounge, the residents' lounge and the doctors' offices.
A philosopher once said:
"Experience is a hard teacher because she gives the test first,
the lesson afterwards."
The one hundred lessons that follow are those lessons learned from thirty years' attendance at the morbidity and mortality conference. They are also the lessons learned from one hundred tests administered by a hard teacher - the clinical practice of medicine.
The Matrix Program teaches, re-enforces and perpetuates these lessons in the grand tradition of medical education
If you have any suggestions for new matrix lessons or questions about the Matrix Program, please contact Dr. Leo Gordon at: MatrixPearls@gmail.com
