The Morbidity and Mortality Conference in Pediatric Intensive Care as a Means for Improving Patient Safety

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. Originally published at: Frey, Bernhard; Doell, Carsten; Klauwer, Dietrich; Cannizzaro, Vincenzo; Bernet, Vera; Maguire, Christine; Brotschi, Barbara (2016). The morbidity and mortality conference in pediatric intensive care as a means for improving patient safety. Pediatric Critical Care Medicine, 17(1):67-72.

The role of morbidity and mortality rounds in medical education: a scoping review

“…). The application of our selection criteria resulted in the inclusion of 67 studies, including eight surveys, four literature reviews, 33 case studies with no comparison or pre/post‐intervention evaluation, nine case studies with pre/post‐intervention evaluations, seven case studies with a comparison, one ethnography study, two qualitative observations and three opinion papers (Table ). Case studies took the form of descriptive programme reviews of an MMR model and related evaluations.…”

“…For patient safety, objectives ranged from tracking errors to training in QI methodology . Specific goals included tracking adverse events, analysing preventable errors, and translating findings to QI initiatives.…”

“…There was significant heterogeneity in how programmes identified and selected cases for MMRs. Many papers described informal processes in which interesting ‘teaching’ cases were brought forward for presentation and were often selected and reviewed by residents in leadership roles or staff physicians . Other MMRs identified cases through formalised data collection of critical incidents, complications and mortality, using methods ranging from chart reviews to error reporting systems .…”

“…A challenge in case selection involved identifying clearly defined criteria for ‘morbidity’ or ‘critical incidents’ . A limited number of studies described initiatives to train facilitators in how morbidity should be defined and appropriate educational cases selected. The level of investigation around cases varied amongst the MMRs studied.…”

The Pediatric Index of Mortality as a Trigger Tool for the Detection of Serious Errors and Adverse Events*

“…Our trigger tool may enhance the discovery of AEs and may be an excellent supplement to other AE identification methods, such as mortality and morbidity meetings (32). However, mortality and morbidity meetings usually focus on the severity of illness toward the end of life, whereas the initial admission factors are less visible.…”