Impact of Morbidity and Mortality Conferences on Analysis of Mortality and Critical Events in Intensive Care Practice

Abstract

Background Morbidity and mortality conferences are a tool for evaluating care management, but they lack a precise format for practice in intensive care units. Objectives To evaluate the feasibility and usefulness of regular morbidity and mortality conferences specific to intensive care units for improving quality of care and patient safety. Methods For 1 year, a prospective study was conducted in an 18-bed intensive care unit. Events analyzed included deaths in the unit and 4 adverse events (unexpected cardiac arrest, unplanned extubation, reintubation within 24–48 hours after planned extubation, and readmission to the unit within 48 hours after discharge) considered potentially preventable in optimal intensive care practice. During conferences, events were collectively analyzed with the help of an external auditor to determine their severity, causality, and preventability. Results During the study period, 260 deaths and 100 adverse events involving 300 patients were analyzed. The adverse events rate was 16.6 per 1000 patient-days. Adverse events occurred more often between noon and 4 pm (P = .001).The conference consensus was that 6.1% of deaths and 36% of adverse events were preventable. Preventable deaths were associated with iatrogenesis (P = .008), human errors (P < .001), and failure of unit management factors or communication (P = .003). Three major recommendations were made concerning standardization of care or prescription and organizational management, and no similar incidents have recurred. Conclusion In addition to their educational value, regular morbidity and mortality conferences formatted for intensive care units are useful for assessing quality of care and patient safety.

Fatores relacionados à ocorrência de eventos adversos em pacientes idosos críticos

“…It is observed in the literature that increasing length of hospital stay before the occurrence of adverse events is a known variable (13,16,22) . A French prospective study in an ICU with 18 beds showed that the most serious AE occurred in elderly patients with greater stay and duration of invasive ventilation (13) .…”

“…A French prospective study in an ICU with 18 beds showed that the most serious AE occurred in elderly patients with greater stay and duration of invasive ventilation (13) . Another study that identified AE in medical records in hospitalized elderly from two wards found a significant difference in length of hospital stay between cases where there was event registries (16) .…”

“…They also noted that the preventable deaths were associated with AE (13) . The literature shows how factors related to the occurrence of adverse events increased nursing workload, hospital costs and length of hospital stay (19)(20) .…”

“…Regarding mortality, a study conducted in the Netherlands, in ICUs of 21 universities found an overall mortality of 31.3%, with a mean age of 83.4 years in this cohort (9) . Studies have shown that, in health care, the elderly are the protagonists in the occurrence of adverse events (AEs) (10)(11)(12)(13) which, according to the World Health Organization (WHO), are defined as incident or circumstance that causes significant and unnecessary damage to the patient (14) . Among the AE, medication administration errors (10,(15)(16) , falls (11,17) unscheduled removal of therapeutic artifacts (10,(15)(16) and pressure ulcers (18) have a higher prevalence and are directly related to nursing care.…”

Ways of improving the quality of simulation-based postgraduate training of physicians

“…Как показывает опыт, обучаемые имеют ограничен-ное представление о том, что происходит с ними, когда они вовлечены в процесс симуляции [8]. Зарубежными исследователями доказано, что наличие визуальных, зву-ковых и тактильных стимулов во время симуляционного обучения, использование видеоповторов и конструктив-ного обсуждения после выполнения задания помогает восприятию новой информации и способствует лучшему запоминанию [9]. Находясь в центре событий, курсанты видят только то, что можно увидеть с точки зрения актив-ного участника, а именно благодаря конструктивному об-суждению после выполненного задания, симуляционный опыт превращается в осознанную практику, которая в итоге помогает обучаемому подготовиться к той или иной ситуации у пациентки.…”