23rd Annual Scientific Assembly

March 16-20, 2017
Hyatt Regency Orlando, Florida

Morbidity and Mortality Case Presentations

Submissions Now Closed - Thank You!

Notification of acceptance or rejection: January 4, 2017

AAEM is excited to provide a proactive discussion of clinical cases which illustrates cognitive errors that will lead to improved patient safety and a reduction in diagnostic error. Graduate physicians are invited to submit their best Morbidity and Mortality cases. Residents are
encouraged to partner with a graduated physician to present the case!


Competition Schedule

Saturday, March 18, 2017 - Celebration 10


Cognitive Bias and System Based Errors as Barriers to the Correct Diagnosis of an Endocrine Emergency
Jonathan M. Rubin, MD FAAEM


When "Don't Just Do Something, Stand There" Fails
Michael Lamberta, MD; Andrew Elan Chertoff, MD FAAEM


Under the Mango Tree
Ayanna Walker, MD; Tracy MacIntosh, MD


An Uncommon Cause of Headache
Jonathan M. Rubin, MD FAAEM


Submission Instructions

Selection criteria includes compliance with this format. Please submit your case as a PowerPoint presentation.

Participant: Senior Resident (if participating) and Faculty

20 minute presentation/five minutes for questions

  1. Brief presentation of the clinical scenario including date, patient volume, objective description of the patient and the family
  2. Communication issues: written, verbal, with patient, family, providers or consultants
  3. Knowledge base issues
  4. Affective bias (factors that made this patient difficult, or conversely, overly rewarding, to work with)
  5. Systems issues, to include ergonomic and information accessibility:
    1. ED
    2. Hospital
    3. Consultant
  6. Teamwork issues: failures, could improvement here have prevented the situation?
  7. Equipment issues
  8. Cognitive issues and bias (see Croskerry papers)
  9. Procedural complications
  10. Which issue was the single greatest contributor to the error in this case?
  11. What could the SYSTEM do better in order to preclude a similar situation in the past?
  12. Questions from the audience


M&M Case Submission Guidelines

Judges will select four cases based on their uniqueness, educational merit and relevance to emergency medicine. Patient identifiers should be appropriately masked, and all documents should be marked as PRIVILEGED and CONFIDENTIAL under one or more of the following federal laws: Health Care Quality Improvement Act of 1986 or Patient Safety and Quality Improvement Act of 2005.


If you have questions regarding submissions, please call AAEM at (800) 884-2236 or email Emily Marx at