The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety. Issue 1 (January 2016)

• Record Type: Journal Article
• Authors: Frey, Bernhard; Doell, Carsten; Klauwer, Dietrich; Cannizzaro, Vincenzo; Bernet, Vera; Maguire, Christine; Brotschi, Barbara
• Is Part Of: Pediatric critical care medicine. Volume 17:Issue 1(2016)
• Publication Date: 2016-01
• Subjects: adverse events -- error and risk analysis -- medical error -- morbidity and mortality conference -- patient safety -- pediatric intensive care unit; Pediatric intensive care -- Periodicals; Pediatric emergencies -- Periodicals; 618.05
• DOI: 10.1097/PCC.0000000000000550
• Languages: English
• ISSNs: 1529-7535

Abstract

Abstract : Objectives: To present our experience in an interdisciplinary and interprofessional morbidity and mortality conference, with special emphasis on its usefulness in improving patient safety. Design: Retrospective analysis. Setting: Tertiary interdisciplinary neonatal PICU. Patients: Morbidity and mortality conference minutes on 48 patients (newborns to 17 yr), January 2009 to June 2014. Interventions: None. Measurements and Main Results: The authors' PICU implemented a morbidity and mortality conference guideline in 2009 using a system-based approach to identify medical errors, their contributing factors, and possible solutions. In the subsequent 5.5 years, there were 44 mortality conferences (of 181 deaths [27%] over the same period) and four morbidity conferences. The median death/morbidity event-morbidity and mortality conference interval was 90 days (range, 7 d to 1.5 yr). The median age of patients was 4 months (range, newborn to 17 years). In six cases, the primary reason for PICU admission was a treatment complication. Unsafe processes/medical errors were identified and discussed in 37 morbidity and mortality conferences (77%). In seven cases, new autopsy findings prompted the discussion of a possible error. The 48 morbidity and mortality conferences identified 50 errors, including 30 in which an interface problem was a contributing factor. Fifty-four improvements were identified in 34 morbidity and mortality conferences. Four morbidity and mortality conferences discussed specific ethical issues. Conclusions: From our experience, we have found that the interdisciplinary and interprofessional morbidity and mortality conference has the potential to reveal unsafe processes/medical errors, in particular, diagnostic and communication errors and interface problems. When formatted as a nonhierarchical tool inviting contributions from all staff levels, the morbidity and mortality conference plays a key role in the system approach to medical errors.